A coven of nine veterinarians united around a table to break bread and suck down wine is never a too-pretty experience once the evening winds down and talk of veterinary disaster cases overwhelms the menu. (Halibut crusted with Indian spices accompanied by heirloom tomatoes in a spicy yogurt sauce and peppery smashed potatoes—with an almond panna cotta for dessert, in case you’re wondering.)
Despite the delicacies, the conversation held sway: Amazing tales of pets whose conditions devolved into frustrating, gut-wrenching nightmares only a veterinarian could properly commiserate with. To wit, last Saturday night at my house was like our own little morbidity and mortality rounds.
Vets can be weird. To co-opt a phrase, we’re “…demented, but social.” Only a group like this could do justice to serious patient misadventures in which mistakes were made, things were learned and ideas could be shared in a non-threatening and respectful environment.
(Trust me, as pet owners you want vets to get together on Saturday nights to write dinners off their taxes and discuss your pets. How else can veterinarians learn from their mistakes if they can’t comfortably discuss them?)
Interestingly, most of the mistakes we were discussing didn’t have much to do with miscalculating doses and fudging diagnoses, as you might expect. They largely centered around our verbal, emotional and ethical pratfalls when it comes to client communication.
In most of these cases, end-of-life decisions were the focus. How veterinarians handle client communication during these crucial last visits can make the difference between serious suffering and the “beautiful death” described literally in the Greek-rooted word, “euthanasia.”
And most veterinarians can relate fantastic stories about having gone about it all wrong. For example, when we deal with owners whose religious beliefs preclude euthanasia; or when we prevaricate and fail to put our foot down (when a good stomping is all that stands between extreme suffering and death).
I have my share of these tales, but it seems my specialist friends beat me, hands down, when it comes to discussing death in detail—in all the wrong ways.
Now, that’s not because I’m any better at it. It’s simply the result of two factors:
1) I have a long-term relationship with my clients. I know them. I have a handle on what I can and can’t say to them in sensitive situations. My specialist buddies don’t have the benefit of such niceties. They’ve likely only just met the client.
2) Specialists spend more of their time dealing in more complex cases general practitioners are more likely to refer for more specialized treatment. Let’s face it—these pets are more likely to be very sick. And they’re more likely to die.
My friends are mostly in these unenviable positions. They’re frustrated by some owners’ unwillingness to admit defeat on behalf of their suffering pets. They’re frustrated by many owners’ denial that suffering is present, more so if it’s an understandable denial borne of grief and/or a failure to recognize irrefutable evidence of pain and suffering.
The more cynical among you might assume that veterinarians are primarily motivated by a drive to keep their patients alive—if for no better reason than because it’s how we make money. But none of the vets I know is THAT cynical. Prolonging an animal’s suffering—with no treatment in sight—is wrong, regardless of how the owner sees it.
So what’s a vet to do?
Interestingly, most of us agreed that recusing ourselves from the case is the ideal approach. As in, “I will not be a party to this. I feel strongly that you must make a decision to euthanize or hospitalize for alleviation of extreme pain and suffering. Home care is NOT acceptable. Find yourself another veterinarian if you want to continue to allow her to suffer.”
My lung cancer case last month was a perfect example of the scenario this approach was built for: A client with a dog in severe respiratory distress refuses to accept that euthanasia is the right approach. She wants to take her dog home “to die with dignity.” I respectfully disagreed that “dignity” could be preserved in the face of all that suffering when more humane alternatives are available. Nothing short of a morphine drip and an oxygen cage could have helped this dog—if that.
I should have refused to help her at all. I should have made my case more strongly. I should have said, “My ethical duty is to your pet and I will NOT help you prolong her suffering.” But she would have taken her dog home anyway, right? Maybe not. I wonder.
After Saturday night’s dinner I feel differently about cases like this. Sure, a vet’s job is to help an owner make their own decisions about a pet’s life. But I’d no more euthanize a healthy, happy, well-adjusted animal (an area where I’m comfortable refusing my services) than involve myself in prolonging an irrevocably suffering animal’s life.
Sometimes it takes a good meal and a group of like-minded colleagues to bring home the obvious.
Add Comment23 Comments
nice ...............
thinks
tay September 22nd, 2008 10:32:00 AM
With one of my dogs, I was probably guilty of delaying a day or two. The vet did recommend euthanasia due to liver cancer that had spread. I wanted my dog to die naturally, and there weren't overt signs of pain (which my vet did say wouldn't necessarily be there). No pain management was recommended. I DID have trouble accepting euthanaisa (this was my first experience with it), reasoning we wouldn't find it acceptable (or I wouldn't) for a person. But when I did see signs of suffering, I called the vet immediately and he came out for a house call and euthanized the dog. Yes, I know it was inconvenient for him, and I was probably wrong, but these decisions are very difficult when one loves an animal.
On the other side of a coin, I had a dog who at 13 was diagnosed with bone cancer. She underwent amputation of a front limb and chemo, and did rather well for about a year. One day, she couldn't walk and was unresponsive. I took her immediately to the vet. She prescribed anitbiotics on the off chance that the symptoms were due to an infection, but said it was more likely the cancer had spread to the brain. She told me to take her to the UCD vet hospital if things deteriorated in the night. Unfortunately, they did (she had a seizure), and I brought her to the hospital, expecting her to be euthanized. In this case, the UCD vet DIDN't want to euthanize her--he rcommended all sorts of tests, even though he acknowledged there wouldn't be any treatment. I rejected the tests, and the next morning I talked to my own vet (and she was euthanized).
I guess I am saying this can cut two ways--the vets may also delay, for whatever reason. (UCD is a teaching hospital, and the vets probably pursue treatment vigoroulsy, almost at all costs.) I'm not blaming anyone (not even myself)--but these cases are complicated emotionally (and sometimes medically).
Arlene September 22nd, 2008 11:57:00 AM
My dog Julie died in my arms today.
She chose to spare me of the decision of when to let her go, and simply went herself, and while I'm crying all day today, I'm grateful to her that, just in line with her sweet and loving character in her life, she was so in her death, saving me from the decision I know since yesterday that was getting very close.
Sorry- I wanted to say more. But I'm crying too much right now.
Xslf September 22nd, 2008 01:53:00 PM
Xslf: So sorry. I've been reading your Julie stories in my email inbox. It's such a sad story. you did everything you can for her.
Dr. Patty Khuly September 22nd, 2008 03:38:00 PM
Arlene: You're right. Some vets are programmed to do everything possible. Some are even *required* to do everything. me? I just give a choice whenever there is one. But I believe that if the pet can't be made comfortable enough not to suffer simple aches and pains then...it's time.
Dr. Patty Khuly September 22nd, 2008 03:40:00 PM
Dr. Khuly,
Recently I heard from someone that euthanasia is actually a horrible way to die. This person preferred to shoot his dogs. He said that first it paralyzes the pet and then it suffocates them. I've worked at a vet's office for year. How did I miss that little tidbit? Please tell me that isn't true...
Kelly September 22nd, 2008 09:40:00 PM
Kelly: Your friend is sadly misinformed.
When it was time to let one of our precious Labradors go our Vet came to our home to help us.
My girl went gently to sleep in my arms. We should all be so lucky when our time comes to go so peacefully.
Elizabeth - From Nova Scotia September 23rd, 2008 07:04:00 AM
I've heard this about euthanasia, too, usually from people who had one bad experience. I don't know how it's done in the US, ut around here the animal is injected with an overdose of a narcotic to put it to sleep (with weak or small animals, that's often enough to kill them) and then the vet injects the actual euthanasia drug that will stop the heart, directly into the heart. Some vets don't bother with the first injection and then euthanasia can be a painful, slow death - but that's not standard and definitely frowned upon to say the least. I always ask new vets how they euthanize.
Sometimes animals try to breathe in reflex after the euthanasia injection, which looks and sounds horrible, but they don't feel anything due to the narcotics injection.
Xslf, I'm sorry about Julie *hugs*
Jennifer September 23rd, 2008 08:42:00 AM
Most people are shocked at how peaceful our modern veterinary methods for euthanasia can be. A lot of this depends on the individual veterinarian *and* technician present, but the two-injection method is a very peaceful way to die--especially if it's performed in a home setting.
Shooting your pet? If you know exactly where to shoot I'll not disagree that it's fast. But most of us wouldn't consider it peaceful. And I'd never recommend it. Modern vet methods are designed to be foolproof. You can't convince me that a gun to the head in the hands of the average person is foolproof. Moreover, it's considered illegal in most places.
Dr. Patty Khuly September 23rd, 2008 08:46:00 AM
I have been involved in many euthanasias, and I feel I can attest to the fact that it is typically quite peaceful. With the first injection to calm the animal, the dying process is very quick and seemingly painless.
I was present at two euthanasias of my own cats and countless euthanasias of clients. With my own cats, I had the feeling that they knew I was helping them. Especially my Bear cat. He had a tumor in his mouth that was growing rapidly. He seemed to know that the vets were there to help him. He wasn't super friendly with anyone but me, but he came over and laid down on the lawn with us and let them pet him. It was calm and as peaceful as I could have wished for.
Tammy September 23rd, 2008 01:02:00 PM
We had to euthanize our dog Wolfie this weekend. He was my mom's till I took him about 8 months ago because she didn't feel she could deal with his chronic health conditions.
He had recently taken a bad turn, but after 3 days of hospitalization for kidney failure (at $3k) the vets gave me hope he might stabilize at home. Nonetheless, when I brought him home, he didn't seem comfortable, and we were struggling with the euthanasia decision in spite of his improved numbers at discharge.
Then, as we convened to discuss this, he had a grand mal seizure.
I had planned to have it done at home where the vet would have used two shots, but after the seizure he was very distressed/agitated. Since we were trying to make the euthanasia decision anyway already, it tipped the balance. But due to the urgency of the situation, I ended up taking him into the hospital that night to do it, which I had not planned to do.
The place where we had it done used only the one shot, not two.
I was previously accustomed to seeing the two shot protocol.
After the vet told me his heart had stopped and left the room, he gasped not once, but three times. deeply.
It was extremely disturbing to me.
I was really not prepared for three deep gasping breaths. One maybe but three makes it seem like he wasn't dead and was struggling to breathe.
I am very disturbed by it. I wish I could rest assured that he was not conscious, but no matter what anyone says, I will always wonder. After all, no one has come back to tell us how this feels.
Although this hospital is one of the better ones in the area, the bedside manner of the technician that night left MUCH to be desired. I asked her to stop stroking Wolfie as they were injecting the solution. I had him in my lap and I was touching him the way he liked to be touched. She started stroking him in this hard, rapid way and he was already agitated. He did not like being there and he does not like the smell of strange people, much less to be touched in a rather cold and rapid way. He is a nervous little dog to begin with. I asked her to stop touching him and she gave me an offended look and left the room.
It was awful.
Maybe her feelings were hurt but at that time she should be thinking of OUR feelings, not hers.
It only strengthens my resolve to have this done at home whenever possible in the future. With the 2-shot deal (telazol first). I know the telazol stings but the one shot thing -- it seemed more violent.
This is all to say that when to euth is a very personal decision, and very often horribly heartbreaking no matter what.
I don't think anyone should judge anyone else.
Lots of vets think "Oh, they should put that pet down" and roll their eyes when you are out of sight, but nonetheless when speaking to you, foster hope for more decent time. His regular vet had expressed an opinion that she would have euthed him long ago due to his reduced quality of life. I didn't, because he was still eating eagerly, sleeping comfortably, and barking at the cats. He still (most of the time) had normal stools. Yup, he was blind and deaf and dealing with something neurological, but his neuro status had not seemed to change much in the 8 months I had him and he did not seem to be in distress until recently, which is why we took him in to the ER place. I admit that although she thought he might have a brain tumor, I believed it was unlikely since I never saw seizures in those 8 months, and he was not declining rapidly neurologically. I now believe she was probably right.
Whether or not to end life, and when to do it, is always a very excruciating decision, and pretty much no matter when you do it, or what decision you make, you are going to feel guilty. If you do it too soon, you will feel guilty. If you do it too late, you will feel guilty. If it didn't go "perfectly" you will feel guilty.
I just don't think anyone should judge anyone else on this issue.
It doesn't help that vets don't necessarily agree. One says: I'd euth him over quality of life. The others say: "Oh, his numbers have come down and we believe you can stabilize him at home, and he feels better."
Unless there is acute suffering and death is on the horizon, it isn't really such a clear cut decision, and it is -- after all -- irrevocable.
My bar is this:
"Is there one good day left?"
If I know for sure that there will never be comfort, the absence of pain, or any enjoyment, and nothing but decline on the way to death, then I feel I can do it. I can't just euthanize a reasonably comfortable animal who still likes to eat because his quality of life is pretty low. My quality of life will be low someday too, when I am in a wheelchair. But if I awaken and hear the birds and enjoy the sun on my face, and my dinner tastes good to me . . . and of course, someone is keeping me clean (which we can usually do for our animals . . . )
Maybe there is still one more day left with something to look forward to.
I know there weren't any more of those days for little Wolfie, but still, even knowing that, it was heartbreaking, and not the way I'd hoped to do it.
Even mercy killing is a very difficult act for many of us.
Stefani September 23rd, 2008 03:53:00 PM
Arlene, Glad you said it first.
I can't imagine any reputable or ethical vet being "required" to do anything, except be honest regarding condition and what options are available with likelyhood of recovery
Barbara A. Albright/New Hampshire September 23rd, 2008 07:22:00 PM
I wasn't aware that Telazol was used routinely for euthanasia procedures - something about that disturbs me. Maybe it's because the only time I really see Telazol used is for chemical restraint of otherwise fractious animals - my understanding is that it's mostly a dissociative/tranquilizer, and it doesn't do much for pain or for stress levels. I always thought the "two-shot method" utilized acepromazine and pentobarbital - anyone else familiar with this method or am I mistaken?
anna September 24th, 2008 04:47:00 PM
anna, I'm glad you brought that up. I think on a previous post, acceptable traquilizers were mentioned and I forget what that list was. I only had one dog pre-tranquilized and that was with ketamine. The only thing that was left to be desired about that euthanasia, was the young vet pronounced him dead while his chest was still "breathing quietly". It wasn't a comfortable "moment".
Dr. K., I, too, have seen what is termed "terminal gasps", and surely there must be a physical reason why this sometimes happens and it could be explained to help Stefani. In my elderly dog's case, he happened to have "stomach torsion" and "ascites".
Or could it be due to rapid injection of the pentobarbital?
Barbara A. Albright/New Hampshire September 24th, 2008 06:11:00 PM
I heard that ketamine was a paralytic and just makes it impossible for them to move, which means they could be in distress and you wouldn't know it. I heard telazol actually put them to sleep. Who to believe?
I did have valium to give him before hand, which is good. He was tired and not as anxious as he otherwise would have been. He would have been entirely freaking out without the valium on board, but still, it is not the same as being able to have him "asleep" first. He was still aware enough to be whimpering and shaking and upset about being at the vets and being handled by strange people.
And those three labored deep breaths really bothered me.
I agonize a lot over the method of euthanasia. Spend a lot of time thinking about the "perfect" way.
I don't want them to feel anything or be aware, but there is no method that I am entirely sure allows that.
Stefani September 25th, 2008 11:43:00 AM
Let me explain the drugs used in our euthanasia cocktails:
Telazol (tiletamine and zolezepam combo) is like valium and ketamine used together. With ketamine there's more pain control involved--but not much. Both drug combinations are commonly used as the first drug in the so-called "two injection protocol."
Ketamine and tiletamine are both dissociative anesthetics. Both burn a bit when given IM (intramuscularly). Neither hurt going in the vein, though (as I prefer to administer them). Both are used to induce anesthesia in routine veterinary practice. Neither is a paralytic (as is used in the human penal system for capital punishment). Both make the animal unresponsive and unconscious in the way extremes of valium might.
When used before the euthanasia solution, we usually administer overdoses of these drugs, making the animals' torpor and unconsciousness even more profound and irrefutable.
Furthermore, the barbiturate solution used as the second drug is also administered as an overdose. Even when administered alone, it does not hurt. It was a standard drug for induction of anesthesia in humans and animals for a long time and we know that pain is not associated with its administration.
The same cannot be said of the way humans receive lethal injection. We know now that the drugs used in human lethal injection CAN hurt if administered improperly. But there's no reason to assume that any part of the euthanasia protocol in animals is painful.
Animals DO move involuntarily after death--less so with the two drug protocol because of the profound muscular depression that accompanies the deep lack of consciousness when telazol or ketamine/valium are used.
Humans receiving lethal injection receive pancuronium (or some version of this paralytic drug) so that they don't move at all after death. That's done because it disturbs humans to see any movement after death. But involuntary motor activity after death IS typical. It does NOT mean that pain is being felt, as brain waves are not present at this time. It's merely the result of electrical conduction left over in motor neurons.
I know this is more info than you asked for but I felt it was necessary to explain why we do what we do. I hope it gives you more confidence in how we do things. I'm certainly one of those people who believes that the two injection protocol is extremely humane.
Dr. Patty Khuly September 25th, 2008 03:06:00 PM
Thank you very much, Dr. K. Some of us are very concerned with quality of death as much as quality of life!
A friend of mine also employs "ace" as a pre-euthanizing tranquilizer. As far as the involuntary movements, I believe that also can be variable, though not sure of the physical mechanics why.
There is a huge difference witnessing involuntary movements "post-unconscious" and that of "conscious" and though perhaps disturbing to see post-death, none-the-less, one can mentally digest it without emotional/mental harm.
Having only one pet euthanized via the 2-step method, I can say that the "transition" to death was a bit longer and perhaps 'peaceful' may be the right word? At the same time, a kind vet explained that some animals don't do well with the disassociative drug---delerium, etc.
The majority of my pets have passed quickly and peacefully with the one-step humane barbituate overdose (sodium pentobarbital combination solution)
Barbara A. Albright/New Hampshire September 25th, 2008 04:46:00 PM
Barbara: that's why we always pair the dissociative anesthetics with benzodiazepines. It lessens the stress associated with a dissociative state. However, the large volumes most vets employ in the case of euthanasia seem to allow animals to skip any of the intermediate anxiety this might cause, anyway.
Dr. Patty Khuly September 26th, 2008 04:59:00 PM
I'm a few months late on this discussion but I have to respond to Stefani. I was also deeply disturbed and somewhat traumatized after the recent euthanasia of our 15 and a half year old terrier, who I think had about 5-10 deep agonal breaths (my mother says it was only 3 or 4, I remembered 12), with eyes wide open. I had never seen human or animal death before, and even though I was prepared for a gasp, I wasn't prepared for several of them. I reached over and stroked his chest and felt what seemed like an irregular heartbeat or possibly muscle twitches, also disturbing. It bothered me to think, what if he was conscious and scared? But in spite of this troubling emotional reaction to what I saw, I can reason that the way the drugs act on the central nervous system, it would not have been possible for him to have been conscious at that point. That is what I basically believe (and hope). The vet who performed the procedure said there is research data to this effect--if anyone with knowledge wants to point me to such data, it might comfort me. But basically I am comforted by watching funny videos of the dog when he was alive and remembering the way he lived and not the few moments of death that were disturbing to me. I also struggled with guilt over the decision--not because the dog had great quality of life (he was blind, deaf, demented, had cushings disease, hind leg weakness, and the last staw--a nerve problem affecting his ability to bear weight on the front leg so he was unable to stand at all). What left me with lingering guilt was that he was very happy right before the procedure, lying comfortably being fed and scratched and grinning. Some would say that is how it should be--and I think I can see it that way--but in some ways it would have ben easier if he had been in pain and death would be more clearly a relief.
Sarah February 27th, 2009 11:58:13 PM
Oh, I just realized, especially since this is a Vet Stress discussion--I should clarify, I am not saying the Vet performed the procedure wrong or that pet euthanasia is actually designed to be horrific and cruel...I just meant that as a lay person witnessing it, your mind plays tricks on you, like what if something went cosmically wrong in the universe that day and he was both anaesthetized and conscious at the same time, etc...(I added this clarification just in case 6 months later anyone is still reading this page...)
Sarah February 28th, 2009 09:07:11 PM
Thanks for your sharing.Maybe you are interested in Abercrombie and Fitch.
AF September 18th, 2009 01:31:55 AM
Thanks for the information
Online Marketing | Electronics Gadgets | Travel Guide | etips solution | Kerja Keras Adalah Energi Kita
adis October 18th, 2009 06:52:08 AM
tiffany jewelry
tiffany cuff links
TIFFANY October 26th, 2009 04:14:23 AM
Add Commment