Equine practitioners dedicate a significant portion of their practice to ensuring and restoring the wellbeing of their patients. However, patients do reach the end of their lives while in your care—whether through acute injury, chronic illness, or aging—and the skill with which you navigate end of life decision-making with clients can make all the difference between a grateful client and a disgruntled one. It is increasingly apparent that communication and support around decisions to euthanize are some of the most important interactions in veterinary practice. Client decisions around euthanasia are also fraught with emotional, financial and sometimes social pressures, making professional guidance all the more critical.
The Difficulty with End of Life Discussions
While studies on equine practitioners’ experiences with end of life situations are scarce, useful data has emerged from research on small animal practitioners. One study from small animal practice indicated that finding common ground—and shared goals—can be relatively easy in euthanasia discussions, but it is far more difficult to explore clients’ feelings and expectations around animal illness and death, particularly where geriatric patients are involved.1
Small animal veterinarians often feel ill-prepared and uncomfortable communicating with owners of terminally-ill patients,2 as these conversations often involve breaking bad news, handling intense emotions, and working through concerns about patient suffering. This is especially true when clients request treatment that is unlikely to result in a good outcome. Concerns about futility abound in both small animal and large animal practice, and this can lead to moral distress and job strain.3
Understanding the Client Perspective
Counteracting these challenges requires developing additional skills around end of life communication. Practitioners who are well-equipped to negotiate these discussions will feel more comfortable, more effective and less stressed. Grounding our skills in an understanding of the client experience means remembering a few things. First, clients must release hope in order to accept the likelihood of their horse’s death. This is sometimes easier when a horse is in a clear and acutely life-threatening crisis—especially when those crises are dramatic. It can be much more difficult when the core issues are aging and/or chronic, life-limiting conditions. Remember that clients are often looking for the one thing that will show them that meaningful survival is possible (not necessarily probable).
Second, clients must determine what is unacceptable for the horse to experience (otherwise known as the “no go zones”). Rarely do clients have a clear idea of what they are not willing to do for a horse—and what is not okay for a horse to experience in the short and long term —unless they have a lot of experience navigating end of life issues. This kind of clarity is important, though, because it determines under what conditions a client will assent to euthanasia. For instance, if a client is not comfortable with their horse experiencing unmanageable pain, educating the client about what unmanageable pain looks like and the limits of veterinary treatment will be an important starting point.
Keep in mind that with chronic illness and/or slow deterioration, clients might become desensitized to the “new normal” of an ill or aging horse. This desensitization can make it difficult for clients to recognize when the horse’s condition is either unlikely to improve in a measurable way, or when the horse’s condition will only deteriorate from here onward. The perspective of well-informed outsiders can be useful here, as those who do not see the horse daily might see subtle shifts in the horse’s condition that might otherwise go unnoticed by clients and other providers of routine care.
Last, research in human medicine indicates that good deaths are collaboratively constructed through careful communication about patient needs and family/caregiver goals.4 Family members, especially those attached to patients that cannot advocate for themselves, report that what they want most from their medical team is help managing patient symptoms, clear and cooperative decision-making around the continuation or cessation of active treatment, and to be well-informed about how the end of life will look. They also want to feel that medical professionals respect and affirm the importance of their relationship with, and care of, the patient.
Communication Strategies for End of Life Conversations
With all of the above in mind, here are some tips for navigating core challenges in end of life discussions:
1. Begin with a “warning shot” and a pause. Statements such as “I’m afraid difficult decisions are ahead” or “I have some significant concerns about your horse’s condition” allow the client to orient his or her brain to the gravity of the situation. Pausing for a moment or two allows the owner to shift gears and cognitively prepare for that conversation.
2. Be direct and simple in your language. Few clients understand veterinary vernacular and know how to accurately apply the medical information they are given, so using simple descriptors is important. Using the “chunk and check” approach can help make complicated conversations easier for clients to digest: break your message into small chunks (what we know, what needs to happen now, and what happens next), then double check for client understanding.
3. Tailor your message to the phase of illness. Clients often struggle to make sense out of emergencies that take a horse from healthy and functional to life-threatened in what can seem like the blink of an eye. With acute injury/illness, focusing on the most severe aspects of patient presentation is key. Chronic illness and aging, however, require a focus on the most meaningful changes in a patient’s condition, especially those indicating that we’ve reached the terminal phase of illness. In the terminal phase, clients must release hope for restoration and begin planning for death.
4. Explore the client’s expectations and emotions using high yield, open-ended questions. Some examples include:
- “What is your understanding of your horse’s condition at this time? What does this mean for you?”
- “Have you thought about what will happen if his/her condition progresses beyond what you can safely/effectively manage?”
- “What is acceptable for you to gain more time together? Will this change if he/she doesn’t improve?”
- “What do you need to know or understand in order to make a decision you can find peace with?”
5. Identify client goals and common ground. Clarifying a client’s goals for the horse, and the owner’s partnership with the horse, is critical because each client must understand if goals are realistic given the horse’s condition and prognosis. Additionally, goals must be weighed against treatment requirements, management issues and financial restrictions. Once client goals have been explored, identify for the client where his/her goals and your goals as a clinician meet.
6. Provide no more than three options for how to proceed (especially when euthanasia is one of those options). Humans struggle when faced with too many choices, and this is particularly true in times of overwhelm. Limiting choices to two or three options, then making a clear recommendation among those options, helps clients narrow the field. Highlighting the choice that is both congruent with client goals and the most likely to result in the best possible outcome (even when that outcome is cessation of suffering) is most likely to result in client adherence. If continued/palliative care is chosen, providing the client with a timeline for re-evaluation will provide you and the client with a chance to re-assess down the road in a prescribed way.
It goes without saying that there are many barriers to sound decision-making, and we need to explore these barriers, as well. Remember that lay beliefs about horse health and care can significantly influence client decisions, and clients might receive more medical information from peers than from professionals.5
Social pressures within a barn environment, particularly when other stakeholders are connected to the horse, can also confound end of life decisions. When dynamics are complicated, it is useful to focus on the factors that horse owners tend to prioritize in medical decision-making: horse pain and suffering, likelihood of resolution with treatment, severity of condition, financial restrictions, horse age and temperament and length of recovery.6
Take-Home Message
End of life discussions are often quite challenging for practitioners. When done well, however, they can be both effective and rewarding. By following a few guidelines, we can optimize patient care while also providing the information and support necessary for producing sound client decisions. Remember:
- Start with a ‘warning shot,’ then allow the client to re-orient.
- Be direct and simple with your language.
- Tailor your message to whether the issue at hand is acute or chronic.
- Explore the client’s expectations and emotions. This is the root of compassionate care!
- Identify client goals and look for common ground.
- Limit options and make a clear recommendation. DINGBAT
References
1. Noguiera Borden, J.; Leandra, L.; Adams, C.; Bonnett, B.; Shaw, J.; Ribble, C. (2010). Use of the measure of patient-centered communication to analyze euthanasia discussion in companion animal practice. Jrnl Am Vet Med Assoc, 237: 1275-87.
2. Dickinson, G.; Roof., P.; Roof, K. (2011). A survey of veterinarians in the US: Euthanasia and other end-of-life issues. Anthrozoos. 24(2):167–74.
3. Moses, L.; Mallowney, M.; Boyd, J. (2018). Ethical conflict and moral distress in veterinary practice. Jrnl Vet Int Med, 32(6): 2115-2122.
4. Steinhauser, K.; Christakis, N.; Clipp, E.; McNeilly, M.; McIntyre, L.; Tulsky, J. (2000). Factors considered important at the end of life by patients, family, physicians, and other care providers. Jrnl Am Med Assoc, 284(19): 2476-82.
5. Scantlebury, C.; Perkins, E.; Pinchbeck, G.; Archer, D.; Christley, R. (2014). Could it be colic? Horse-owner decision making and practices in response to equine colic. BMC Veterinary Research, 10: S1. Available at: https://doi.org/10.1186/1746-6148-10-S1-S1. Date accessed: 05 May 2019.
6. Bowden, A.; Burford, J.; Brennan, M.; England, G.; Freeman, S. (2019). Emergency Conditions in Horses: Opinions and Decision Making of Livery Yard Owners. Vet Evid, 4(2), May. ISSN 2396-9776. Available at: https://veterinaryevidence.org/index.php/ve/article/view/199/298. Date accessed: 06 May 2019. doi:http://dx.doi.org/10.18849/ve.v4i2.199
