How I approach… A meaningful euthanasia appointment

Introduction – A quality euthanasia

Euthanasia has evolved to include more elements than the medical act itself. It is a procedural experience wherein the owner is invited to be present and say goodbye in a manner that matches the bond they hold with their pet. The patient’s comfort in the last moments of life is especially important, and veterinary teams are now introducing more and more effort to the process in order to reduce fear, anxiety, and stress. A quality euthanasia appointment begins early with client preplanning and team preparations; once everyone is gathered, the 14 essential components of good euthanasia (Table 1) are completed to ensure a smooth delivery of the procedure. These components are a template for the veterinary team to follow every time. Performing euthanasia correctly is good for animal welfare, protects the mental health of clients and the veterinary team, and maintains trust in the veterinary profession to care for patients in their time of need. In the Greek language, euthanasia means “good death” and with adequate training, it may be successfully completed by anyone licensed to perform the procedure. I appreciate the dedication it takes to achieve it and the emotional toll it can have on the veterinary team, but when done well and for the right reasons, euthanasia has the potential to be one of the most rewarding and meaningful interactions the team has with the patient and client, and a driver towards compassion satisfaction 1.

Table 1. The 14 essential components of good euthanasia. 

© Courtesy of CAETA

Preplanning with clients

Helping clients to prepare for the euthanasia of their pet often begins well in advance of the appointment. They need discussions around if and when to euthanize, including what options they have before euthanasia is considered necessary. Help with decision-making is one of the most important things veterinarians can do for their clients 2. Beyond when to euthanize, clients often have questions related to who can be present, what will occur, and where they can gather for the procedure (Table 2). In this preplanning stage, it is appropriate to involve everyone on the team who can help clients get the information and answers they seek. This increased understanding about euthanasia reduces regret and fear of the unknown. Even those clients who have been through the procedure before benefit when preplanning for their next pet.

Table 2. Questions for clients as a part of euthanasia preplanning.

Euthanasia details may be included on the practice website and handout materials, along with the options clients should consider ahead of time. While it is uncommon for euthanasia to be listed among a veterinary website’s services, clients benefit knowing that the hospital or mobile service provides it 3. An online form or direct conversation with a staff member can collect information to ensure the owner’s wishes are met. This includes asking the client if they prefer to be present for the euthanasia procedure; while not all will want to remain for the duration, clients do want the option 4. Euthanasia preplanning discussions and appointment specifications can be noted in the patient’s medical record 5,6.

Payment may be collected before the appointment begins, with the understanding that it may be refunded if the appointment is canceled or repurposed for another form of medical support. If there is no existing veterinarian-client-patient relationship established, the appointment may be scheduled as a quality-of-life assessment, which allows the clinician to better decide if euthanasia is warranted. Collecting monies for euthanasia services can feel uncomfortable due to the emotional nature of the appointment, but it is a medical procedure that deserves payment, and ideally all financial matters are handled before the appointment begins.

Many patients will be more comfortable with the use of pre-visit pharmaceuticals (PVPs) such as sedatives and anesthetics 7. These provide a calmer experience when dosed appropriately for the patient’s temperament, breed, and situation. I prefer to use a combination of drugs, typically given orally well in advance of the appointment, followed by additional calming approaches, such as keeping the pet with familiar items and people. A popular PVP combination is the “Chill Protocol” 8 (Table 3). I tend to double these doses before euthanasia to impart even deeper effects, however higher doses or layering on other sedation drugs is commonplace 9.

Table 3. The chill protocol for canine and feline patients.

Beginning the appointment

Before the start of any euthanasia, the staff can prepare the room with items that convey softness and comfort (Table 4). Additional support aids include incontinence pads, towels and blankets, and the area should be quiet and free of distractions. Established patient records may be reviewed and medical supplies readied.

Table 4. Hospital comfort room elements.

The appointment officially begins when the owner and patient arrive at the hospital, or the veterinarian arrives at the home. For the former, staff may greet them at the vehicle or door to the clinic and safely guide them to the euthanasia room (Figure 2). Many patients and clients are physically and/or emotionally compromised, so assistance is necessary. Once settled into the space, the staff member should take a few moments to establish rapport, learn everyone’s name and show affection to the patient. This fosters trust during the emotional visit, and bonds everyone together. If the patient is physically struggling (e.g., dyspnea, severe pain), a timely procedure is required. 

I like to advocate for one staff member to be with the client and patient throughout the entirety of the appointment. In this way, personnel such as technicians or the veterinarian may enter and exit the space as needed while one person always remains connected to patient and client needs. This staff member is referred to as the euthanasia attendant and may even be the veterinarian themselves. The euthanasia attendant will review the procedure along with the client’s wishes for deceased pet aftercare and any special requests, all of which should be recorded in patient records 6. Proper consent for euthanasia must be obtained, including a clear understanding by the client regarding what euthanasia means. I recommend the term euthanasia be clearly defined on the consent form (e.g., “humanely terminate life”). If payment was not collected before, it is preferrable to do so before the medical procedure begins to allow owners to exit before euthanasia begins (if they wish) and to avoid talking about money after death. Before the medical procedure, it is kind to provide grief support literature to show empathy and understanding around the significance of the loss (Figure 3).

The euthanasia procedure

When the patient, client and veterinary team are ready to proceed with the euthanasia, the first step will be to review what is going to take place in very simple terms. Clients like to know what to expect, and this should be communicated in a manner that conveys compassion and not in terms that elicits worry or fear. I like to describe the procedure in pieces as I proceed rather than tell them everything that may happen from the start. The second step is to give pre-euthanasia sedation to the patient in the room with clients present (Figure 4). These typically include alpha-2 agonists, benzodiazepines, opioids, phenothiazines, and dissociative drugs. A combination of drugs can be given subcutaneous or intramuscular depending on what the clinician feels is best, based on patient signalment 7. Before the sedative injection, I ask if the patient is sensitive anywhere on the body so I can avoid it. The patient will then quickly succumb to sleep with their owners nearby, further reducing anxiety. The goal is to keep the patient in the euthanasia room for the duration of the appointment, and everything for the procedure, including intravenous catheter placement, is carried out in the room with anyone who wishes to be present, including the euthanasia attendant who monitors the patient as the sedative takes effect. 

Once the patient is in deep sleep or completely unconscious, a towel or incontinence pad may be placed underneath to catch bodily fluids. The veterinarian may then decide how best to administer the euthanasia solution. The most common drug used for companion animals is pentobarbital sodium, although some countries may use an alternative. Pentobarbital works on the brain to facilitate death and may be administered in a variety of ways to elicit its effects. I choose the technique (e.g., intravenous, intracardiac, intrahepatic, intrarenal, intraperitoneal) that is most likely to facilitate a rapid death with the least amount of complication. When administering drugs intravenously, it is considered best practice to first place an indwelling intravenous catheter to prevent accidental extravasation of euthanasia solution into nearby tissues. Importantly, intraorgan injections require the patient to be unconscious to avoid pain 10 and offers an alternative to intravenous injections where the veins are difficult to locate 11 (Figure 5). Regardless of where in the body the solution is given, it is courteous to offer the client private time with their pet, through a useful phrase like “She is ready for the next medicine to be given to help her to pass (die). Would you like some private time before I proceed?” In this manner, the client knows it is time for the actual euthanasia and that the veterinarian will move forward as soon as everyone is set.

After administration of the euthanasia solution, the veterinarian will need to pronounce the patient deceased. This is done by auscultating the heart and monitoring for active signs of death (e.g., slight body stretch, agonal breath, urination/defecation). If the heart continues to beat longer than expected, another dose of euthanasia solution should be administered in the same location, or the veterinarian may give the injection into another area with better blood perfusion 11. Unless the client has been told exactly how much drug or number of injections will be given, the veterinarian may continue administering whatever is needed until cardiac arrest. 

Post-euthanasia support

As mentioned during the procedure, offering privacy for the client and patient gives them time to say goodbye on their own terms. Following death, owners appreciate more privacy, and offering them a handheld doorbell device which can be used to alert staff when they are finished and ready to depart the hospital may be appreciated 12 (Figure 6). I also like to make a memorialization gift for them to take home; they can see it being made and be part of the moment, which many clients appreciate 2, and children may get involved too (Figure 7) 13.

When the client is ready to exit, the euthanasia attendant may walk them out. A private exit is preferred over the busier, more public front door. If the deceased patient will be taken home for burial or to the pet cemetery, the staff may respectfully prepare the body for transport (Figure 8). Clients should be informed of the dangers of some euthanasia solutions (e.g., pentobarbital) and of the importance of proper body handling 14. Many deceased patients will remain at the hospital for the local pet crematory to retrieve for their aftercare services. Veterinary staff are encouraged to prepare the deceased body in the same room as euthanasia; this helps prevent possible disease transmission into the rest of the hospital and reduces visual exposure to death more than necessary. The body should be stored in a respectful container and cooler space. Clients do not like refuse bags and prefer dedicated designated cadaver bags, caskets, and blankets/shrouds 15. Whatever is selected should be acceptable for the client to view.

Handling challenges

Euthanasia is a medical procedure commonly witnessed by owners and which will pose challenges for a variety of reasons. Patients are often physically and/or emotionally compromised, making interactions with them more delicate. There are times when the pre-euthanasia sedation drugs do not appear to work, or when the euthanasia solution itself is not eliciting the desired rapid effects. The general rule is to give more drug until adequate results are seen. I avoid drawing attention to any technical difficulties and simply adjust accordingly, silently continuing without causing the client concern. A meaningful euthanasia appointment includes the veterinary team conveying compassion, confidence, and control. Clients appreciate knowing the staff have everything in hand and that their pet is pain-free and peaceful 4. When challenges arise, one of the best ways to maintain control of the appointment is to remain physically calm (e.g., taking deep breaths, relaxing core muscles).

A technically challenging euthanasia appointment may be labeled a dysthanasia, i.e., when the euthanasia method fails to deliver a pain-free experience for the patient, and the client and/or staff endure added emotional stress. This must be addressed 16; in such situations the veterinarian, practice manager, or veterinary social worker/grief counselor may consider reaching out to the client afterwards to discuss what happened, even if what appeared to be a painful reaction by the patient was involuntary or part of active dying, with no pain perceived at all. Talking through the appointment is beneficial to the mental health of everyone. The veterinary team is encouraged to hold monthly “euthanasia rounds” to discuss procedural elements and generate improvements when appropriate 17 (Figure 9).

Conclusion

Endings matter. Veterinary professionals should feel proud when performing a technically strong euthanasia procedure while simultaneously caring for the emotional needs of the owner and staff. Variation during euthanasia is fine, but consistency is better, and the team can provide more consistency by creating standard operating procedures that include all 14 essential components of good euthanasia. Finally, while the focus of this article is on the hospital euthanasia setting, an honorable mention is given to the benefits of home euthanasia – more meaningful appointments may be conducted in the home environment or pet euthanasia centers independent of the hospital. Regardless of the patient’s signalment, where euthanasia is performed and who is present, it is important to always focus on what is best for the patient and loved ones.