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Bereavement: how we, our staff, and our clients face it.

Death: we all face this emotional event in different ways, and so do our clients. Given the fact that veterinary hospitals deal often with grave illness, as well as with euthanasia, veterinary professionals encounter bereavement on nearly a daily basis. While some people cry when coping with death, others are stoic and do not show their feelings. Veterinarians and their support staff regularly face both emotional clients dealing with grief and their own feelings about death. Some veterinary institutions have regimented protocols about how they deal with grieving clients and euthanasia, while other places have poor or suboptimal practices regarding pet death. To stimulate thought about how our profession might deal with these emotionally charged events, I have asked 5 veterinarians from different geographic locations and varied backgrounds to describe how their institutions deal with pet death and euthanasia. The participants are Thomas Edling, DVM, Vice President, Veterinary Services, Petco Animal Supplies, Inc, Tucson, AZ, USA; James Harris, DVM, Mayfair Veterinary Clinic, Sandy Bay, Tasmania, Australia; Larry Linnetz, DVM, Chippens Hill Veterinary Hospital, Bristol, CT, USA; Lauren Powers, DVM, Carolina Veterinary Specialists, Huntersville, NC, USA; and Paul Welch, DVM, Forest Trails Animal Hospital, Tulsa, OK, USA. I am hoping that by hearing their responses, we will all rethink the way that we handle both grieving clients and veterinary employees and become a bit more sensitive in our actions. We must all remember that our reactions to pet death can have a longlasting impact on the parties involved; thus, it's critical for us to think about how we handle delicate situations regarding death and euthanasia in advance.

Laurie Hess, DVM, Dipl ABVP (Avian) Associate Editor

Question: What is your practice's policy regarding euthanasia? Is there a protocol that you follow?

Dr Edling:

In private practice, I did not perform any convenience euthanasias. If an owner no longer chooses to care for his/her animal, we would work to rehome the animal but would not euthanize it. If the animal was terminally ill, and euthanasia was a humane way to end the animal's suffering, I would anesthetize the animal and give a lethal injection.

In the corporate setting, we do not allow convenience euthanasias. All healthy animals are found homes. If an animal in our care is ill, it is provided veterinary care until it is healthy and found a home. The only animals in our care that are euthanized are those that are terminally ill. If an animal in our care must be euthanized due to a terminal illness, we work with a local licensed veterinarian who follows AVMA guidelines appropriate for the species. When an animal has been purchased and has an owner, the owner must work with his/her veterinarian on these issues.

Dr Harris:

I provide euthanasia service. We require knowledge of the patient and the condition involved. We do not perform "convenience euthanasias." Clients make an appointment for this service. We ask ahead of the appointment for the client to decide about whether or not he or she wants to be present, about special requests, and about choice of the disposition of remains. Euthanasia is provided by an intravenous injection if the patient is large enough. Small patients are administered intramuscular injections.

Dr Linnetz:

I will only euthanize birds if there is a serious medical condition that is not amenable to treatment, or the cost of treatment is exceeds the owners ability to pay. Often, if the condition is treatable, but the owner is unable to pay, I will treat the animal pro bono and then adopt the bird out (with the owner's consent, of course). Injured wildlife is often brought in, too, and if the injury is severe, the bird is euthanized at no charge.

Our protocol for euthanasia is essentially the same for all species. The bird is sedated, either with intramuscular medication (midazolam, often combined with butorphanol), and then intravenous pentobarbital is given. If the intravenous route is not available, then an intracoelomic injection is given in the liver region. I generally discourage the owner from witnessing the euthanasia, but if the owner is insistent, the bird is sedated, and the pentobarbital is injected.

Dr Powers:

We must be assured that there is a medically appropriate reason for the euthanasia or a very serious behavior problem for which all alternative options have been discussed, explored, and ruled out. We provide witnessed and nonwitnessed euthanasia services, although we discourage witnessed euthanasia for birds. We always heavily sedate or anesthetize all patients prior to euthanasia. If a bird has an intravenous or intraosseous catheter in place, we administer propofol, followed by sodium pentobarbital, intravenously or intraosseously. If a catheter is not in place, we gently manually restrain birds (in order to prevent flailing) and mask-induce with gas anesthesia, followed by intravenous administration of sodium pentobarbital.

Dr Welch:

Fortunately, in my practice, at least with pet birds, euthanasia has rarely been needed. It is primarily offered or requested when a bird has a condition, such as a tumor, in which the patient continues to do poorly or has a grave prognosis. Our practice does, however, handle hundreds of wildlife cases each year with birds, from robins to eagles, and euthanasia is a fact of life with these cases. Unfortunately, I often have to euthanize these birds due to the severity of their injuries or the inability to be release them back into the wild, and over the last 30-plus years, I have had to euthanize a lot of birds.

I have found that the gentlest method of euthanasia is to draw up sodium pentobarbital solution in a syringe and then put on a new 25 gauge needle on to the syringe. While holding the bird gently in a towel, I inject in the upper abdomen near the liver. If the owner is in the room, I let him or her hold the bird until it quietly expires. If the bird is wildlife, I set it in a cage after injecting it, and it quietly pass away. I rarely, if ever, have an episode of excitement or stress with this method.

Question: What choices do you offer clients regarding the pet's remains, and how are these choices explained to the client?

Dr Edling:

In private practice, I offered the options of giving the animal's body back to the owner, burial with a licensed provider, or cremation. In all instances, I also offered a necropsy. I personally explained all options to the owner and worked with the owner to help him/her fully understand the options and all steps of the process, including costs.

In the corporate setting, we do not work with clients or owners and their pets' remains. When an animal in our care is euthanized, the remains are either cared for by the veterinarian that euthanized the animal or by a licensed individual/service in accordance with local and state laws.

Dr Harris:

We explain all the choices available to the client: home burial, country burial, cremation with the ashes scattered, or a dedicated cremation with the ashes returned. There is no fee if the clients take the remains, but they are advised that the remains must be placed an appropriate depth underground. All the other choices have a cost, and those discussed with the client.

Dr Linnetz:

The owner has a choice of taking the remains for home burial (in which case we place the bird in a small coffin box), having the bird cremated (either private or group) and then having the ashes returned, or burial (either private or group) by the service we use. Our receptionist discusses these options with the client in a private area before the euthanasia is performed.

Dr Powers:

Clients have the choice of taking the pet home right away, leaving the pet at our facility for pickup by a cremation service, or having us hold the pet for 24 hours while they make a decision. We have a standardized "after care" form that explains the client's options. We have a contract with a local pet cremation service that visits our facility virtually every day of the week. Clients can seek out an alternative cremation service if they like, but they have to make all the arrangements themselves. I warn clients that there may be local ordinances that regulate pet burial. I also warn clients about secondary pentobarbital poisoning and advise them to bury their pets so that no other animals are able to access their remains.

Dr Welch:

Owners have the option of taking the body home, having the city health department pick up the body, or cremating the body and having the ashes returned to them or scattered at the crematory's memory garden.

Question: Does your practice contact the client after euthanasia?

Dr Edling:

In private practice, I personally called every owner after euthanasia and sent a condolence card. In the corporate setting, we do not work with clients or owners and euthanasia.

Dr Harris:

Clients are contacted following this service. A condolence card with a handwritten message is sent. If the client is alone, single, or appears to be at risk, I personally phone them the evening of the service.

Dr Linnetz:

After each euthanasia, the pet's footprint is inked onto thick paper, which is cut into an appropriate size and then inserted into an envelope along with a sympathy card. The attending veterinarian writes a personalized note to the owner. I will often call the owner days later just to check that the owner is okay.

Dr Powers:

Yes. We almost always send a sympathy card to the client after a pet is euthanized. I will often call clients within the next day or two if I know them well or if I am worried about their well-being, just to check in and express my sympathies again. We offer polymer clay paw prints at no cost to the client.

Dr Welch:

The owners are generally present during the euthanasia; however, if they are not, I call them afterwards.

Question: Does your practice offer bereavement counseling?

Dr Edling:

I did not offer bereavement counseling in private practice, and we do not offer it in the corporate setting, either.

Dr Harris:

As 1 am a certificated grief and bereavement counselor, I do offer counseling. We also have a list of social workers and psychologists who provide this service, and clients are offered a list of names and contact numbers.

Dr Linnetz:

We do not, but the receptionist hands out a card with counseling companies available.

Dr Powers:

No. But we often make available a list of veterinary schools and other organizations that provide grief counseling to clients for pet loss (ie, Pet Loss Support-Grief Counseling services listed on the Important Resources for Veterinarians provided by the AVMA). We also provide copies of AVMA client brochures on pet loss. In addition, we refer clients that have lost a pet bird to Lafeber Wings of Compassion (http://www. lafeberwingsofcompassion.com/).

Dr Welch:

Not officially, but I visit with people a lot concerning issues like this, and I always make myself available if they want to talk about things.

Question: Do you offer at home service for euthanasia?

Dr Edling:

In private practice I offered full-service at-home euthanasia. In the corporate setting, however, we do not offer at home euthanasia, but many of the local veterinarians we work with do offer at home euthanasia.

Dr Harris:

The practice offers home euthanasia service. This has to be arranged with all the decisions made ahead of the service.

Dr Linnetz:

Not often, but I have done so in the past. Dr Powers:

On occasion, but this is not common at my practice.

Dr Welch:

We offer this for dogs and cats, but this has never been requested from my avian clients.

Question: Do you train your staff regarding euthanasia and client grief?

Dr Edling:

In private practice, I did not have a formal training program for my staff, but we did talk through the specific steps of euthanasia and discussed client grief, especially prior to working with a client with whom we knew euthanasia was an option. In the corporate setting, our employees are not trained in euthanasia and client grief, as we do not work with clients or owners and euthanasia.

Dr Harris:

Staff are trained. Clients have all the needed paperwork ready to sign. Fees are paid at reception, and the clients and pet are taken to the consulting room. Staff are advised of the service and do not joke, laugh, or speak in loud voices while the clients are in the practice.

Dr Linnetz:

Yes. We will put up a sign on the outside of the exam room saying that a euthanasia is being performed, and our staff knows not to laugh or make noise outside the room. The technician who is helping me with the euthanasia will offer kind words afterwards such as, "We are very sorry for your loss." The receptionist will often try to make sure there are no disturbances in the waiting room.

Dr Powers:

Our staff does receive training on euthanasia practices but not specifically for helping clients understand and manage their grief.

Dr Welch:

No, but our clients generally know our staff well, and they all stay in contact, either in the clinic or over the phone.
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Title Annotation:Round Table Discussion; dealing with bereavement among veterinary professionals
Publication:Journal of Avian Medicine and Surgery
Article Type:Discussion
Geographic Code:1USA
Date:Mar 1, 2016
Words:2214
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