The Companion Animal Euthanasia Training Academy (CAETA) invites you to consider the following fictional euthanasia case and reflect on how to proceed. After reviewing the case, read the questions and consider your answers before continuing to CAETA’s suggestions. This case is designed to test your knowledge of companion animal euthanasia and be a conversation starter among your veterinary team. Case outcomes are enhanced when following CAETA’s 14 Essential Components of Good Euthanasia.

Euthanasia Case: Nugget the old horse

Nugget, a 27-year-old gelding, is being euthanized at a local animal sanctuary. He has been losing weight over the past few months, appears uncomfortable walking, and has developed a tooth abscess, making day-to-day life more unpleasant. The veterinarian travels to the sanctuary to perform euthanasia in Nugget’s pen, with the plan to bury the body in a neighboring field in the designated animal cemetery. The sanctuary owners inform the veterinarian that Nugget has been harder to handle lately, likely due to the growing pain in his hooves and mouth. They request pre-euthanasia sedation, which the veterinarian agrees to, administering a dose of xylazine. Nugget begins to quietly relax after a few minutes. The veterinarian places a jugular intravenous (IV) catheter, allows the owners to approach for final goodbyes, then requests they stand back at a safe distance. Around 60 mls of pentobarbital euthanasia solution is rapidly administered through the catheter, and the veterinarian prepares to guide Nugget down to the ground. After 3 minutes, Nugget remains standing with soft, steady breathing. The veterinarian assures the owners that he is doing fine and that the sedation may be slowing down the euthanasia solution’s uptake, which can happen. After 10 minutes, Nugget is still standing. Another 60 mls of euthanasia solution is given, and while Nugget’s head is hanging lower, he remains standing after 5 more minutes. The owners are becoming frustrated and ask if Nugget doesn’t want to die. They have euthanized many horses and have never had it take this long. The owners ask to approach Nugget to comfort him, but the veterinarian feels it is too risky. The veterinarian reassesses the catheter’s placement and decides it is best to replace it in another location for a third dose of pentobarbital. This is done, and Nugget immediately collapses to the ground, taking a few final breaths before peacefully passing away. The entire event from sedation to cardiac arrest lasts 30 minutes.

Discussion Questions

1. Nugget was given xylazine to relax him before euthanasia. Was this the right approach, and did it impact his response to the euthanasia solution?
2. Nugget took around 30 minutes to die from pentobarbital administration. How long is it acceptable to wait for drugs to take effect? 
3. The sanctuary owners expressed significant concerns about how the euthanasia was going. What should the veterinarian do to comfort them during the procedure, as well as after the appointment?

CAETA Euthanasia Case Suggestions

1. Xylazine is a common sedative used in horses for relaxation and easier handling. If the horse will benefit from it, it is always the right approach to facilitate a more gentle euthanasia experience. The subsequent drop in blood pressure may have slowed the euthanasia solution’s time to reach the brain (where it elicits its effects) however, this was not the main issue in this case. Death took a long time because the IV catheter was improperly placed. Xylazine was given to calm Nugget and ideally make the IV catheter placement more straightforward, but it was placed subcutaneously, which can sometimes happen. This is dramatically slowed the pentobarbital uptake to the brain.
2. Waiting for drugs to take effect is required, but knowing how long to wait is perhaps an art form for veterinary teams. Because pentobarbital can be given to standing horses, properly administered euthanasia solution should cause a rapid onset of death that is obvious. Practitioners monitor the patient for signs of change, such as ataxia, collapse, respiratory arrest, and eventual cardiac arrest. It is well known that horses and other livestock may remain standing for several minutes before succumbing to the lethal effects of pentobarbital; therefore, waiting a few minutes is acceptable. If the veterinary practitioner starts to have concerns that the drug is not reaching the brain, they should promptly administer another dose. Doing so decreases safety, however, and places the veterinarian and other potential handlers at risk of injury if the horse moves quickly and unexpectedly. In Nugget’s case, the pentobarbital was most likely being placed outside the vein, leading to prolonged physical changes. The veterinarian may have thought the xylazine was causing this and felt compelled to wait longer before administering a second pentobarbital dose. The first dose was also below the recommended volume of 85 mg/kg or 1 ml per 4.5kg (standard in the United States). Waiting 30 minutes for euthanasia to complete is a long time in horses and is best avoided.
3. The veterinarian kept the owners at a safe distance and talked to them while euthanasia was conducted, which was wise. The owners expressed concerns and even asked to approach Nugget again, indicating their growing discomfort with the procedure. Euthanasia practitioners have an obligation to explain what euthanasia will look like even to those who have witnessed it before. While the veterinarian may have had the trust of the owners at the beginning of the appointment, they needed to foster that throughout by maintaining rapport and keeping communication open. The veterinarian could have better described why Nugget was standing after 10 minutes and the reasons behind waiting to give more drugs. As long as enough euthanasia solution is available, more can be given to effect. This said, burial was planned for Nugget’s aftercare, and this veterinarian, knowing that pentobarbital is best kept out of the environment, may have been inclined to give Nugget the lowest effective dose. When owners express concerns, veterinary personnel will need to acknowledge the concerns, do what they can to alleviate them, and thank clients for allowing them to proceed as they feel is best based on the patient’s needs. Afterwards, medical records should be very detailed and explain what occurred from start to finish, including any events that could lead to the appointment being labeled as a dysthanasia. It is also helpful to follow up with owners the next day to see how they are feeling about things and address any lingering questions they may have.

This case highlights the following Essential Components: E=Establish rapport, S=Safe space to gather, A=Avoid pain and anxiety, H=Helpful and compassionate personnel, and D=Deliver proper technique. These examples are just a few of the ways euthanasia can be enhanced. Consider what else might be done to ease the client’s emotional burden and support the patient’s needs for a gentle death. The Companion Animal Euthanasia Training Academy is here to elevate your euthanasia expertise.