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End-of-Life Care: Taking Care of Ourselves, Clients, and Patients

Katherine Goldberg, DVM, Whole Animal Veterinary Geriatrics and Hospice Services, Ithaca, New York

January / February 2018|Web-Exclusive

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Full disclosure—as I write this piece, I am involved in a case that is stressing me out and testing my boundaries.

I worry about my patient, a dog that would have been euthanized weeks ago if she lived in my house. I worry about my client, who is so exhausted and overwhelmed that yesterday she had an altercation with the FedEx driver over the whereabouts of her dog’s compounded medications. (She blocked his truck with her car until he searched through all the packages, at which point he threatened to call the police.) I worry that my colleague, a brilliant veterinarian and skilled acupuncturist, will never agree to see one of my patients again if I keep referring her cases like this. I worry I will not meet the deadline for this article because, with my patient’s acute decline, all the best-laid plans with my schedule are now out the window.

I know all cases are not like this one,  but these cases certainly have an impact. I also know these cases are superb for learning and teaching. So perhaps this is the appropriate landscape as I write about taking care of ourselves, and each other, when end-of-life care is bringing us down. 

Calling All Upstreamists 

In both his TED talk and his book The Upstream Doctors, Dr. Rishi Manchanda tells a story of 3 friends who discover a child flailing and struggling to swim in a river.1 They look around and see many children who need help. Initially, they jump into the river and rescue the children one by one, but more children keep coming. One friend starts focusing on the children most at risk of drowning, while another builds a raft in hopes of rescuing many children at once. The third friend swims upstream, away from the 2 others, who ask, “Where are you going? There are more children to save!” She replies, “I’m going to stop whoever or whatever is throwing these children in the water!”1

The third friend, in a healthcare context, is the upstreamist (ie, the person who understands that sickness begins where we live, work, and play and prioritizes the mobilization of resources to change the system).1 The upstreamist considers her professional duty not only to prescribe a chemical remedy but also to tackle sickness at its source.1 I am a strong advocate for upstream thinking regarding veterinarian wellbeing because I see familiar patterns playing themselves out over and over again.

Learning the System

Euthanasia and end-of-life considerations are predictable stressors for veterinary professionals. If I asked you to recall your most recent “awful” case—the one that drove everyone nuts and made veterinary nurses cry—chances are good an end-of-life scenario was involved. Counseling is important, and destigmatizing help-seeking and increasing the availability of support are essential initiatives, but if we know specific situations contribute to distress, what can we do to modify them upstream? If we look at veterinary end-of-life care as a system, where in the system can we intervene to optimize emotional wellbeing? Are there cultural practices within the veterinary profession itself that deserve a closer look?

The Gift of Euthanasia 

The veterinary profession has decided euthanasia is the way companion animals should die. No empiric evidence shows that euthanasia is right or good or better than any other way of attending to death in animals, but a dominant paradigm of veterinary practice says this is the way it should be done. To effectively spread the message of euthanasia as a gift and to participate in it over and over again, those who provide euthanasia must become unquestionably convinced of its positive power. This occurs in veterinary school. 

However, the pet-owning public does not universally accept euthanasia, so it is no wonder euthanasia decisions are a primary contributor to veterinarians’ moral stress. Opposition to euthanasia is rarely absolute, but the circumstances under which euthanasia is acceptable are typically more nuanced for clients than veterinarians. Given the complex and value-laden nature of intentionally ending life, a bit of questioning does not seem unreasonable—why, then, is this such a challenge for veterinarians? We have all heard or said it ourselves: What’s wrong with these people? Why won’t they euthanize? 

I have come to see this as a system with a design flaw: Veterinarians are trained in preemptive euthanasia (ie, euthanize before things get bad), whereas clients often wish to hold on until it is absolutely clear that euthanasia is reasonable. This setup is fundamentally bad for everyone involved, including the patient.

Altering the Lens

To be clear, I am in no way opposed to euthanasia. I think it is an essential tool, and, when appropriate, the best step we can take to alleviate animal suffering; however, euthanasia also may contribute to the suffering of those who choose it on a pet’s behalf.2-9

We do ourselves a disservice by promoting euthanasia as a one-sided gift. Anyone who says death without euthanasia is inherently inhumane is forgetting that the majority of people in the United States die without lethal doses of life-ending medications. Certainly, it may be argued that more can be done to improve the human dying experience, and, of course, there are critical differences between end-of-life considerations for people and animals. But, it is important to recognise that people have a wide variety of experiences with chronic debility, serious illness, and end-of-life decision-making for the humans in their lives, and they remember these experiences when they make decisions for their pets. For example, my client attended to the final care and dying experiences of both her parents, and she feels that she knows what she is doing with her dog.

Altering the lens through which the veterinary profession views euthanasia is a substantial act. Consider how a parent of a child who uses a wheelchair is likely to receive a euthanasia recommendation for a dog with impaired mobility. I suggest we rethink euthanasia from something we must or should consider to something we might or could consider.

By changing euthanasia from a recommendation to a reasonable option, we can begin to overcome our veterinary end-of-life system’s design flaw and reach common ground. This approach can benefit clients by improving empathic communication and patients by improving the resulting care. Most importantly, perhaps, and the reason for this column, the approach benefits veterinarians, who engage in these tough conversations continuously.

Going Downstream

In a survey of ethical dilemmas encountered in veterinary practice, veterinarians ranked “client wishing to continue treatment despite poor animal welfare/quality of life” as the most stressful dilemma.10 In the “euthanasia is the only and best option” model, this dilemma is particularly distressing. Why? Because the veterinarian and client invariably become engaged in a conflict in which the veterinarian is trying to persuade the client to euthanize. In the “euthanasia is just one option among many options” model, the veterinarian is disengaged from the role of persuading the client to do anything; innovative care planning also expands once euthanasia is no longer the single focus. I suggest we remind ourselves that euthanasia is a late-stage option that follows many other decisions. Euthanasia itself is not an upstream initiative. Spending time and energy trying to change things we have no control over (eg, client preferences) is often easier than learning how to solicit those preferences and work within them, but it is not useful.

Conclusion

Understanding client goals and preferences is the upstream initiative that will help improve end-of-life care, whether dying occurs via euthanasia or not. This process also helps clarify what we can and cannot control, and this is good for our wellbeing. For example, despite my currently elevated stress level, I know the goals-of-care conversation I had with my client was invaluable in soliciting her goals, fears, and preferences, and I know the patient’s care plan is consistent with them all, while still prioritizing patient welfare. The client is responsible for her preferences and decisions—I am not, although I am responsible for communicating if, and when, I believe we need to chart a different course.

Acknowledging euthanasia’s many challenges, accepting that clients may not always want what we are offering, recognizing the associated emotions for all involved, establishing and maintaining boundaries, and embracing nonjudgment are all forms of self-care for veterinarians. May we give ourselves permission to focus on these initiatives and encourage our colleagues to do the same.

References and Author Information

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