11 End-of-Life Conversations

“Life is meaningful because it is a story. A story is a sense of a whole, and its arc is determined by significant moments,  the ones where something happens, peaks of joy and valleys of misery are part of how the story works out as a whole. That whole, both a story and a life, depend crucially on how it ends.”

-“Being Mortal: Medicine and What Matters in the End” by Atwul Gawande

The veterinary care team has the ability to make the end matter.  The veterinarian’s role in humane euthanasia encompasses the medical skill and the supportive client communication.   While the medical aspect is straightforward, the heart of a veterinarian’s role lies in communication with the client that enables more confidence in decision making. Research indicates that one of the factors contributing to client grief was the perception of the professional support provided by the veterinarian. The manner in which the veterinarian provides care for a client whose pet has died has the potential to alleviate or aggravate grief. ^[1]

From the initial conversation about quality of life to the moment of euthanasia and aftercare of the body, veterinarians must guide pet owners with empathy, clarity, and respect. End-of-life animal care most often involves a series of events and discussions, each presenting a unique set of communication challenges, that are different from client to client. As with all of our difficult conversations, there are specific skills you can learn and apply to facilitate productive discussions.  End-of-life communication in veterinary medicine includes delivering bad news, monitoring and assessing quality of life, euthanasia decision making, discussing the euthanasia protocol and body care options, and providing grief support, education, and resources. ^[2] It is important to note that these steps are critical for all conversations, regardless of species.  Although the specific decisions and factors considered may vary between companion animals and production animals, the overall progression of the case discussion and communication skills required remain the same.

End-of-life conversations with clients begin with humane euthanasia offered among the spectrum of options discussed for the patient, and this is often the most challenging component of the series. Applying specific communication skills will help clinicians navigate these difficult conversations. Establishing a setting where communication is appropriate (ex. a private exam room vs the clinic lobby) is a critical first step. Using open-ended questions to explore the client’s perception around the pet’s quality of life and illness as well as the client’s thoughts, feelings and experiences are a key tool that can be applied to initiate the conversation and provide a direction for the conversation. The veterinarian’s ability to deliver information is greatly enhanced when incorporating the techniques of chunk-and-check, and ask-tell-ask to provide the client with large volumes of information in a manageable format. Checking for client understanding using open-ended questions allows the veterinarian to tailor the amount and type of information according to the client’s preferences. This improves the shared understanding, as well.  Reflective statements can also be very valuable as a way to not only communicate active listening, but also as a way to offer pause and help the clients reflect themselves.  Throughout the interaction, it is critical to offer empathetic statements and nonverbal cues that validate, acknowledge and normalize the client’s experience and emotions.  Summarizing the decisions and next steps is also a very important component to confirm the client’s decisions and comfort level with their decision.  Continued client education and conversations to share the process and protocol for humane euthanasia will follow the decision–making discussion.

It is also helpful for veterinarians to understand normal grief responses and processes as grief is a spontaneous response to loss and the normal way to adjust to endings and change. ^[3]

It may be helpful to remember that grief intensity varies by disruption to attachments, circumstances surrounding the loss, and the amount of available support, not species of the deceased.  In veterinary medicine, grief can be triggered as soon as a potential loss is sensed by the client.  This is called anticipatory grief and may significantly affect the way a client processes, copes, and makes decisions.  The intensity and length of client grief may also reflect the skills and support of the veterinary team. ^[4]

Considering the ADOBe framework you have learned to apply to difficult conversations, we can see above how awareness (see graphic) plays an impactful role in this facet of our practice, embracing discovery with our client using open-ended questions, offering empathy and compassion.

Extending the system is a key component of a holistic approach to end-of-life client communication.  A referral to outside/additional resources is appropriate when the veterinarian observes an intense emotional reaction, a client having prolonged difficulty making treatment or end-of-life decisions and/or the client’s life circumstances involve isolation, multiple recent losses, or few social supports.  Starting with a statement that normalizes the client’s difficulty and then suggesting outside support that may be useful. That communication could sound like:

  “Some people find it helpful to talk with someone who understands what you are going through…”

  “I know of someone who may be able to help you sort through your options/feelings.” 

Veterinarians serve not only as medical professionals but as compassionate partners in honoring the human-animal bond at life’s end.

Additional training and resources are available from the large organizations that support veterinary medicine including the AVMA Guidelines for the Euthanasia of Animals, AAHA End-of-Life Care Guidelines as well as ongoing continuing education and client communication training.

“A good death does honor to a whole life”   

                                                                -Petrarch