When Quality of Life Scales Aren’t Enough; Counseling clients who can’t let go

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As a pet patient reaches the natural end of its life, clients face the difficult decision of continuing care or opting for euthanasia.  They seek guidance for what’s best for their pet. In veterinary medicine, there are multiple Quality of Life (QOL) assessment tools that have been created to open dialogue around what the pet is experiencing and the presence of comfort or discomfort.   These tools have proven very effective; however, they are often not enough to completely guide the client on the best course of action.  Instead, there are strategies to implement that should help veterinary professionals better navigate these emotional conversations, and ultimately reduce patient suffering while protecting the mental health of clients and the veterinary team. Such strategies include conversation timing, supportive phrases, and ethical principles.

It’s possible you’ve told clients there is nothing more that can be done, to take their pet home and keep them comfortable, and perhaps that they will even know when the time is right to euthanize.  During the end-of-life (EOL) experience, clients often don’t know what their options for care are and most will be ill-prepared to comprehend the extent of their pet’s physical and/or emotional suffering.  Clients often have a difficult time understanding what pain looks like and how to determine if natural death is approaching. Watching their pet decline can lead to negative emotions such as fear, anger, and despair. The veterinary team’s role is to educate on what is normal or abnormal for the dying patient and to give guidance on the best path forward.

Counseling clients begins by establishing rapport and trust.  It is important to acknowledge the human-animal bond and offer praise to the client for being willing to have such a difficult conversation.  This is a significant moment in the life of the client and pet, and finding trust during this time will improve the conversations ahead.

There are numerous QOL scales available in veterinary medicine.  They include:

·  The HHHHHMM Quality of Life Scale: Dr. Alice Villalobos

·  How Do I Know If It’s Time?: Ohio State University

·  Considering Your Pet’s Quality of Life in the Midst of Disease: Colorado State University

·  Quality of Life Scale: Lap of Love

·  QOL Calendar App: Grey Muzzle Organization

·  VetMetrica by NewMetrica

These scales are designed to monitor a patient’s physical and mental state over the course of time, usually during advanced age-related changes or following the diagnosis of a life-limiting illness.  They are quantitative and generate a value that determines if a patient’s life is pleasant or unpleasant, comfortable or uncomfortable, and ultimately if life is worth living.  This remains highly subjective however, and QOL scales may only take the conversation with clients so far. Scales are assessment tools that add structure to the EOL conversation and create a baseline for clients to work with.  They can be completed daily, weekly, monthly or even yearly depending on the seriousness of the condition(s). Multiple family members can do them and compare answers to guide decision-making. QOL scales, while useful, still fail to capture the full extent of the client’s household dynamics, previous experiences, and the complexities of what it may take to care for the patient’s health needs.  With pets as such an integral part of the client’s life and wellbeing, many cannot imagine saying goodbye even if the QOL scale indicates suffering.

Early in disease progression, palliative care may be possible to maintain a better QOL for patients. Discussing care options with clients is important, especially before the concept of euthanasia is broached.  Veterinary teams have an obligation to fully comprehend medical approaches to non-curative comfort care, and to bring them to the attention of clients.  In doing so, premature euthanasia can be avoided, and patients given the chance for continued life.  Euthanasia can be more thoroughly discussed when palliative care options have been exhausted and the pet is reaching unavoidable suffering. Counseling clients becomes very important at this stage.

When starting the honest discussion about suffering and death, it’s helpful to review the patient’s file, set aside personal biases and any judgment, and create space for open-honest communication.  Inform everyone how the goal is to understand how the patient is feeling now and what is expected in the very near future. Establish rapport and use good communication skills to create safe dialogue around such a sensitive topic.  If euthanasia is not expected at the time of the conversation, the pet does not need to be present.  Much of the time will be spent listening to the client.  After they have shared their perspectives, it will be time for the veterinarian to share their professional opinion on the best course of action, which may or may not be for euthanasia.

It’s common to discuss the daily successes and challenges for the pet, and for the client to rank how well they feel the pet is doing.  They should consider the physical, emotional, and social wellbeing of their pet, as well as the QOL of all caregivers.  If it becomes clear the client does not believe it is time for euthanasia, they should be asked under what circumstances would it be appropriate. Are there factors preventing a decision to be made, either for further palliative medical support or for euthanasia? If so, the veterinarian will need to learn what these factors are and address them head on.

Questions may be asked to the client to understand more deeply what their pet may be experiencing as its state of health declines, and what makes life worth living.

Are they able to breathe comfortably?
Can they eat and drink independently?
Can they move about with comfort and independence?
Can they eliminate with dignity and comfort?
Are they able to have a restful sleep?
Can they still groom and scratch where it itches?
Is there a reasonable level of control over their environment?
Can they still partake in their usual routines?
Do they have a good level of mental stimulation and engagement?
How are they coping with the stress of failing health and this new normal?
Do they still have the same level of interaction with the family?
Do they still enjoy relationships with other animals?
What is the personal bottom line for your pet?
What makes their life worth living?
At what point would life no longer be worth living?
If your pet could speak to you, what do you think they’d say?

Suffering can mean different things to different people.  It does not always equal pain, but that’s what many think of when they think of suffering.  A very simple definition of suffering is anything that denies us our true self, and that can further be divided into physical or mental suffering.  The question that must be asked becomes ‘Is suffering bad enough that death is warranted?’.  If the answer is yes, the veterinarian can justify advocating for euthanasia.  If not, the veterinarian may advocate for more palliative care.

If euthanasia is something the veterinarian feels is necessary, based on the client’s inability to continue with care and the clear suffering or risk of suffering experienced by the patient, the veterinarian can recommend euthanasia as a viable course of treatment.  Clients may be counseled about the difference between how humans and animals experience their world. They may also appreciate knowing what the veterinarian would do if they were in their shoes. It is a time for honest communication, with focus on realistic expectations.  The veterinarian may share from previous experiences and what they understand about the natural course of disease progression.

The following is a list of some phrases used during client interactions to illustrate the severity of the patient’s health, and natural decline towards death:

“The world she once knew is closing for her.  She only has this one tiny part of the life she
              once loved.”
“She looks very tired.  She’s not enjoying life anymore.”
“She appears ready and may be waiting for you to be ready too.”
“We need to make a decision for her. She is suffering.”
“She’s dying.”

Some phrases used to promote euthanasia decision-making (when palliative care can no longer be provided):

“Many feel it’s better to say goodbye a day too soon than a moment too late.”
“Imagine looking back a year from now. How will you feel about the decision?”
“You are giving him the final gift of a peaceful passing.”
“What if your pet had an advanced medical directive form in front of him. What do you think he would choose?”

These conversations are very complex and require the time and space for honest, direct yet compassionate intentions. They are not easy and are full of emotion and often confusion on what’s going to be best for all involved. Confidence is important as one advocates for the pet patient’s physical and emotional health as death approaches, either naturally or through euthanasia. Keep in mind there will be circumstances when euthanasia is not possible. Proportionate or continuous palliative sedation may be provided as the alternative. Beyond the recommendations mentioned here, the Companion Animal Euthanasia Training Academy encourages further communication and emotional intelligence training to prepare veterinary professionals for all manner of end-of-life discussions.

Written by Dr. Lianna Titcombe and Dr. Kathleen Cooney, CAETA Master Instructors

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Dr. Kathleen Cooney

DVM, CHPV, DACAW resident Founder, Senior Director of Education for the Companion Animal Euthanasia Training Academy