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by Cherie T. Buisson, DVM, CHPV
Certified Hospice and Palliative Care Veterinarian
Originally published on DrAndyRoark.com

Today I spent the afternoon at a family dinner for my brother’s birthday. Gatherings with my family are always unique. My sister-in-law and I are both veterinarians, so if a meal doesn’t involve a conversation about poop or vomit, someone is off their game. This particular meal qualified in both categories.

On the dinner table was a pile of papers. My parents were redoing their health care surrogate paperwork. In our family, this isn’t the slightest bit weird to do at a birthday dinner (it’s one of the few times you can count on us all being in one room).  My mom told us the story about my grandfather instructing the family that upon his death, their second job was to cry and mourn him.  Their first job was to get to the bank and empty all his accounts before his death notice hit the newspapers. We’re a practical bunch.

I noticed that my mom’s chosen surrogates were my dad and me. My dad’s paperwork was blank. As he was filing it out, he hollered down the table at me, “Your mom picked you. Do you want me to pick your brother to make it fair?”
I answered through a mouthful of apple pie and ice cream, “I’m more likely to pull the plug on you. You decide.”

He picked me.

I make my living having uncomfortable conversations. This is ironic because I avoid conflict whenever possible. I hate arguments, debates and disagreements. When I first became a hospice veterinarian, I was extremely uncomfortable talking about euthanasia. Now, it’s the subject I’m most comfortable talking about. Why? PRACTICE.  Every veterinarian knows that the more you do something, the better your skills. Conversations about end-of-life care are the same way. Whether you’re discussing a DNR order for a sick pet or bringing up the subject of euthanasia, the more comfortable you are, the more comfort you can give the family.

This isn’t rocket science. You don’t need a book to tell you what to say. Talk to your team and ask them what comforts them most to hear at the end of their pet’s life. Ask yourself what words bring you peace during a difficult time. Say those words to your clients. Listen and look for your clients’ reactions. Adjust what you say based on that.

Remember that for the most part, the decisions they are making are being made out of love. Even if they can’t afford their pet, they likely still love them. I would rather see a client euthanize a treatable pet than shame them into going home pretending to follow my instructions and letting that pet suffer.

Here are a few of the difficult discussions that we need to get comfortable having:

1) Risks of anesthesia. Don’t let surgery become so routine that you forget to educate your client. There’s no need to scare the pants off them, but they need to be aware of the risks and sign that they understand them. Have you ever read the paperwork before you had surgery? It’s terrifying but necessary. Let’s lay out the reasonable risks and explain them to our clients. Don’t just hand them a piece of paper that they sign without reading.

2) DNR. This is especially important for elderly and very sick pets who will be left with you. If you can’t get in touch with the owner, what should you do? Even boarding pets need to have a plan in case the worst happens.  I had a patient become agonal while the owner was away. The pet sitter called me for help. Because she had taken the time to talk with the owner and had written permission to do whatever was necessary, I was able to euthanize him and end his suffering without worrying what the owner would think when she found out.

3) Hospice care and euthanasia. Get comfortable explaining the different options of referral, aggressive treatment, conservative treatment, palliative and hospice care, and euthanasia. If the client gets upset, explain that you must offer all the options to make sure you’re doing right by the family. It is their choice to eliminate options, not yours.

4) Overweight pets. Your job is to educate the owner. If the client is overweight, that is none of your business.  You’re not fat shaming anyone by telling them their pet is overweight – you’re being a good doctor! Handle it sensitively, explain the risks and talk to them about diet and exercise for their pet.

5) Dental disease. While some clients are going to let their pet’s teeth rot right out of their head no matter what you say, some will do so out of sheer ignorance if you don’t educate them. Some are terrified about anesthesia. If you say the pet needs dentistry and they make a face, ask them flat out: “What it is about dentistry that bothers you?” If the owner refuses dentistry, treat the pet medically for pain. Sometimes just realizing that you feel the pet’s pain warrants medication is enough to make them reconsider. A little gabapentin can go a long way towards providing quality of life to a painful patient.

6) Wishes for the pet if the owner is incapacitated. If the owner is physically or mentally ill and will eventually be unable to care for their pet, have them make a plan and put it in writing so their loved ones know what to do for Scruffy. So many pets are foisted on hospice workers, veterinary teams and unsuspecting relatives because there was no plan in place.

7) Owners who can’t medicate or handle their pets. This is especially problematic in feline medicine. If we can teach clients to give a pill early on, we’ll all be so much happier. Giving Pill Pocket samples to clients at their kitten visit is a good way to introduce easy ways to medicate. If a client can’t or won’t medicate a sick pet, we need to be upfront that euthanasia will likely be necessary earlier because of it. I’ve met several clients who said they couldn’t medicate their cat. When I dug deeper, I discovered they’d never even tried!

8) Pain management isn’t negotiable. It is now beneath our standard of care to fail to provide pain control for our patients. Explain to clients that you and your team will not allow pets to suffer. If they don’t want pain medication for surgery, they’ll have to have surgery elsewhere. Make sure you spend some time in pain management seminars at conferences. Every time I go, they transform the way I practice.  We can extend both quantity and quality of life if we educate ourselves about pain.

Sit down with your staff and develop scripts for all of these scenarios. Roleplay. Change your intake forms to reflect the choices your clients have for care while their pet stays at the clinic. Create checklists for anesthesia discussions that both clients and clinic staff initial.

If a client declines a particular diagnostic test before surgery, type in and highlight on the intake form that they declined the test and understand that it may increase the risk of anesthetic complications.  Have them initial the highlighted area. Never be afraid to decline to do surgery or anything else that makes you uncomfortable.  It’s your license after all. Sometimes we have to take risks in order to provide for the comfort of the patient, but if your gut says “Don’t Do It” then don’t!

Clear, compassionate communication is by far the best way to protect your patients, your clients and your license.  I once thanked my Dad for his excellent handling of the “facts of life” discussions when I was a kid. He snorted and told me his heart was pounding and he had sweat rolling down his back the whole time. I never would have known. His outward calm made me less uncomfortable and made listening easier. Force yourself to practice talking about things that are awkward. Eventually, the awkwardness will go away. Until then, approach uncomfortable conversations with confidence and wear a lab coat – hopefully it will help hide the sweat!