13 Aug 2024
Caroline Allen argues why this difficult and emotional topic needs to be part of the wider clinical discourse.
Caroline Allen
Job Title
Image © Valeriia / Adobe Stock
We need to talk about death. Euthanasia is one of our most commonly performed procedures in vet practice, and yet compared to articles about skin disease or diarrhoea, it is rarely a topic of journal articles or papers in practitioner-read publications. In fact, it often feels as though it has been left unsaid or even avoided.
When a case study is reported and the outcome is euthanasia, how often are we given an explanation of the thinking that led to that point, or is it just a passing reference after all the “interesting stuff” was tried?
This lack of visibility risks euthanasia feeling like something we should be avoiding; that it is failure if we get to a point where euthanasia is recommended. The author believe this is entirely wrong and that we risk severe welfare harm if we do not understand and embrace euthanasia as one of our most valuable interventions, and a vital welfare tool – much more than any MRI scan, new test or advanced surgical intervention.
She is delighted that the BVA Animal Welfare Foundation, of which she is a trustee, ran a session on euthanasia at this year’s Discussion Forum (13 May) discussing this vital topic.
Entitled, “Better a day too early than a day too late”, this session brought together experts on this topic to dig into the welfare and ethical factors we should be considering when we think about euthanasia.
The author has read so many articles and been to so many lectures over the years on the ideal approach to heart conditions, or liver disease, but these are only going to affect a relatively small proportion of our patients. In contrast, death is going to happen to all our patients at some point.
In many cases, vets can influence how that death takes place. We are in a unique – and arguably privileged – position to be able to end suffering, but our role in ensuring an animal has a good death is about far more than the euthanasia consultation. When and how we talk about death and euthanasia can have a significant impact on the views of owners, and the outcomes for their animals.
It is important to remind ourselves that this puts us in a significantly different position to our human colleagues. It is interesting, and perhaps quite short-sighted, that we do not seem to have really stopped to consider this difference as we have followed our medical colleagues down the line of more and more advanced and complicated procedures aimed at prolonging life.
The fact that euthanasia exists as a tool for us should have enabled us to better discuss the welfare benefits of some of these advanced procedures, but this does not seem to have been the case. It is distressing to see animals put through procedures that cause significant welfare compromise, chasing a diagnosis that is almost certainly going to be incurable and life ending.
The author knows that some colleagues working with research animals question why pets do not receive the same protections as lab animals when it comes to invasive and “experimental” procedures, and I am inclined to agree with them.
It is especially concerning when some “advanced” procedures seem to have become accepted and celebrated in public discourse without ongoing outcome data being shared so we can all learn from this.
We know that every animal is going to die; it’s just a question of how that will happen.
The options are limited and somewhat overlapping, but essentially fall into the following categories:
Euthanasia: literal translation being a “good death”. There is some debate about whether euthanasia should be limited to situations where an animal’s life is ended for its own benefit; that is, to relieve suffering. This is a useful distinction. After all, we don’t talk about euthanasia of farmed animals when they go to slaughter.
“Natural” death sounds nice and it is what owners often express they wish would happen. However, given this tends to involve multi-organ failure, plenty of scope for suffering exists. The type and degree depends, of course, on the cause, but we know that in many cases, the animal will probably suffer some adverse experiences such as pain, nausea or weakness. Studies in humans have shown that this is sadly still the case at times in human care1.
Palliative care does exist2 in the veterinary sector, but it is somewhat different from that seen in people, in that the time of euthanasia is an important consideration. This can cause confusion and may be why there hasn’t been more discussion of what palliative can could and should look like; that is a shame.
As long as it is performed competently, euthanasia is often considered a welfare-neutral procedure from the animal’s perspective, as a dead animal cannot suffer. Where this statement has been challenged, it is on the basis that euthanasia deprives animals of positive future welfare, so it is important to consider how any proposed treatments might bring about improved welfare, but also importantly what welfare costs will be borne in the interim3.
Clearly, euthanasia is not always a “good thing”, and it’s important when performing euthanasia regularly that we understand the balance of factors. It is not the intention of this article to get into a deep ethical discussion around euthanasia, but to provide a more practical discussion. Reviews exist for those who would like to read more4.
We frequently weigh up the different diagnostic and treatment options that are available for a particular condition or presentation. How often do we have euthanasia on that list?
Waiting until all other options have been exhausted before euthanasia is considered may mean a delay, ending up in a situation where euthanasia takes place at least “a day too late”. It can also mean that we miss the opportunity to start to prepare the owner.
Where the narrative is often that euthanasia is sad and bad, it is helpful to look at the risks of not performing euthanasia where it may be indicated.
As we can see in Table 1, risks exist on both sides of the decision, but it is the situation of a “day too late” that risks animals suffering.
| Table 1. Considerations when deciding on the right time to perform euthanasia | ||
|---|---|---|
| Risk of performing the euthanasia “a day too early” | Risk of performing euthanasia “a day too late” | |
| Animal factors | Ethical issue of denying a “life worth living”. The animal misses out on a range of positive experiences. | The animal suffers. Suffering may be physical related to the health condition or treatment, but may also be psychological, related to some element of the condition – this can be a physical or behavioural condition. It can also be related to the treatment; for example, repeat visits to the vets, administering of medication or restriction of exercise. Remember that animals cannot predict future benefits in the same way people can, so this suffering should not be justified as “worth it” in the same way we might in a human who can rationalise their suffering to some extent. The question that then arises is how much suffering should we allow? There is no easy answer, but it is critical to minimise suffering that occurs as the result of a treatment plan. If the plan does not have a good chance of resolving suffering then this line of action should be reconsidered. |
| Owner | Loss of pet and associated emotional and psychological impacts. Grief. Guilt. Anger. Noting that these will all occur at the point that the animal dies, which is inevitable. These may be worse if the owners feels they lost their pet “too soon”. |
Caregiver burden5,6. While we often think about the implications of the euthanasia decision on owners, we rarely consider the significant implications that can result from not euthanising. Owners can suffer from caregiver burden and a heavy toll can come from knowing their beloved pet is unwell and deteriorating, as well as the practical factors that come from owning an unwell pet. |
| Veterinary team | Team members may struggle from moral injury if involved in (or even aware of ) euthanasia that goes against their own moral or ethical code. This is typically discussed in the literature as when vets are forced to carry out “convenience euthanasia” or euthanasia of healthy animals7. However, in an industry where it can sometimes feel that euthanasia is failure – especially if the “gold standard” approach has not been followed8 – a risk of moral injury may exist, even if the outcome is best for that animal in its own particular context. This is one reason why a contextual care approach is recommended by the author8,9. |
Moral injury may equally result from an awareness of animal suffering that cannot be alleviated. A common concern raised by vets is what to do when owners refuse advice that their animal requires euthanasia to avoid suffering. While these situations should always be treated with great empathy and sensitivity, it is important to be aware of the law in this area and the fact that the Animal Welfare Act means it is an offence to allow an animal to suffer unnecessarily. The author profoundly disagrees with the use of “disclaimers” signing off a suffering animal back to the owners, as this is not compatible with the law. |
| Some (not exhaustive) additional considerations depending on the setting – for example, for charities | ||
| Wider impacts on people/other animals | Impacts on people and animals with a relationship to the euthanised animal. | In the case of animals considered to be at a high risk of aggressive behaviour, and where that risk cannot be appropriately treated/managed, then a risk to wider society exists. Many situations are not clear cut, and it can be easy to misinterpret behaviour. Animal behaviour is a specialist subject and this is not covered in veterinary training. Where possible, involvement of a certified clinical animal behaviourist is invaluable. However, where this is not possible, it is not unreasonable for vets to take a precautionary approach. |
| Reputational impact | Risk of negative stories on social media if someone disagrees with the euthanasia decision. | Keeping a suffering animal alive also risks criticism and makes it more difficult to advocate for the best welfare outcome in other scenarios. |
| Resource issues in a shelter setting | In shelters, high levels of euthanasia can have significant impacts on team well-being and can impact on volunteers, reputation and fund-raising. | Keeping animals in care that are not rehomeable means that shelter capacity and other resources are not available to help more animals in need. This risks reducing the impact and effectiveness of the organisation in tackling the wider problem of animal abandonment/neglect, and so forth, and could also impact on reputation, fund-raising and so forth. |
The situation is often complicated by the fact that several involved parties ecist – primarily the animal, the owner and the vet. These interests may not be compatible.
Managing these tensions often proves to be stressful for vets, but it is important to remember our oath ends: “ABOVE ALL, my constant endeavour will be to ensure the health and welfare of animals committed to my care”, and that the law – specifically the Animal Welfare Act – codifies the vet’s role in ensuring that animals do not suffer unnecessarily.
Like many tricky topics, communication is vital. While we have all heard stories of owners upset by euthanasia being mentioned too soon, probably just as many people are upset about it being mentioned too late.
If the topic becomes something people in the practice team are confident to talk about then it should be less likely to be taken the “wrong way” by clients. If euthanasia is mentioned openly in many different contexts then it doesn’t have to be awkwardly raised when financial issues occur, which can add to feelings of anger and guilt.
Contextual care tells us many reasons exist as to why a particular treatment course may or may not be suitable – not just finances.
Measures can be taken to help make the topic easier to broach. These include:
In the second part of this article, the author will discuss some of these tools and provide more detail around the legal framework that exists within the Animal Welfare Act.
