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 on to CAETA’s suggestions. This case is designed to test your knowledge of companion animal euthanasia and be a conversation starter among the veterinary team. Case outcomes are enhanced when following CAETA’s 14 Essential Components of Good Euthanasia.

Euthanasia Case; Tommy the edematous dog

Tommy, an 11-year-old beagle with Cushing’s disease, is being euthanized due to gradual decline over the past 2 years. Tommy has the classic symptoms of the disease including a swollen belly and edema in his legs. The family has elected euthanasia in the hospital with their favorite veterinarian, a relatively new graduate with a compassionate bedside manner. The family of 5, all of whom are heavily bonded with Tommy, arrive at the hospital and carry Tommy into the euthanasia room. He is weak and looks very frail. Three of his four legs are significantly swollen, all of which have skin lesions and crusting. The vet provides Tommy with a pre-euthanasia sedative combination of dexmedetomidine, butorphanol, and acepromazine. When Tommy is sleeping, the vet looks over the legs to find a good vein to inject the euthanasia solution (pentobarbital) into but is having trouble. They attempt to place a butterfly catheter in the one leg with the least amount of edema, but no blood is found. The vet sits back to contemplate their next steps and is trying to decide what to tell the family as to why things are taking longer than expected.

Discussion Questions

1. The vet has minimal euthanasia experience and is walking into what can be a challenging euthanasia appointment. In what ways can they prepare themselves for the procedure beforehand?
2. Tommy has significant edema making veins hard to locate. What steps can the veterinarian take to increase the likelihood of success?
3. The vet wants to tell the family why they are having difficulty finding a vein but doesn’t want to draw attention to it. What can they do to reduce concerns and build trust?

CAETA Euthanasia Case Suggestions

1. The vet can review the case ahead of time and reflect on the physical challenges that may present. Advanced Cushing’s disease will lead to thin skin, distended abdomen, peripheral edema, muscle wasting, and skin crusting from both infections and calcium deposits. If the plan is to euthanize via a leg vein, they should think about which veins to try first, second, and third. It may be necessary to avoid the leg veins altogether and instead attempt an intraorgan injection. Such techniques can be quickly reviewed through CAETA’s blogs and books. They will also want to think about the best way to give pre-euthanasia sedatives to patients with sensitive skin. Small needles and avoiding open skin wounds will help. The vet may consider giving oral medications to sedate patients who are painful. 
2. We are told that the veterinarian has given Tommy a pre-euthanasia sedative combination of dexmedetomidine, butorphanol, and acepromazine. These drugs are less painful when injected, compared to drugs with a low pH like ketamine, tiletamine, or midazolam, however they won’t do much to improve blood pressures or venous access. If the veterinarian wants to improve the likelihood of quickly finding a vein, they should consider adding ketamine or tiletamine to the sedation protocol. These are dissociative drugs that increase cardiac output and should help with peripheral blood pressures. And since ketamine or tiletamine are technically anesthetic drugs, at adequate doses they will render Tommy unconscious and make him ready to receive an intraorgan pentobarbital euthanasia injection if a vein cannot be found. To further increase the odds of finding a vein, the vet or supporting technician should clip the fur to visualize the injection area, use a good tourniquet to occlude blood flow, and have extra catheters at the ready.
3. The large family is very bonded to Tommy and wants to see him well cared for. There may be an expectation that euthanasia will be quick so the veterinarian can start the appointment sharing the goal of moving ahead with whatever Tommy needs. The veterinarian may say something like “Thank you for inviting me to care for Tommy. He is so special and such a dear friend to everyone. Tommy’s comfort is important to me and I’ll proceed based on his physical needs. This is his day and we will take things at his pace.” When the veterinarian cannot easily locate the vein on the leg with the least amount of edema, they can simply move forward with an intraorgan injection once the patient is anesthetized. While they can give a detailed description of why the legs have edema and that the veins are hard to locate, the family will be more concerned about saying goodbye to Tommy. In this instance, less information is more beneficial than explaining too much. The veterinarian may inform them with simple details such as, “Tommy is ready for the next medicine to help him to pass. I’m going to give the medicine here (placing a hand over his chest area for example) and he will pass immediately or within just a few minutes. He knows you are right here with him and that he is very loved.” As long as the veterinarian has enough euthanasia solution for an intraorgan injection, they can proceed to give it where they think they will have the greatest success, and in Tommy’s case, this is likely the heart. The family can be there for every part of the procedure.

This case highlights the following Essential Components: D = Deliver proper technique, N = Narrate the process, S = Safe space to gather, A = Avoid pain and anxiety, U = Use pre-euthanasia sedation/anesthesia, H = Helpful and compassionate personnel, I = Inclusion of loved ones. 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.