Delivering Bad News & Euthanasia Decision-Making: Raising a Difficult Topic
By Jane R. Shaw, DVM, Ph.D.
Assistant Professor, Argus Institute, College of Veterinary Medicine and Biomedical Sciences, Colorado State University
Veterinarians are obligated to both the pet and the client to initiate and facilitate euthanasia discussions when they know that death is near. End-of-life discussions clarify the client’s wishes regarding the pet’s death, help minimize regrets about how the pet’s death was handled, enable the client to make decisions ahead of time, and allow the client to cope with the death of their pet.
The SPIKES model is based on a six-step protocol for delivering bad news.
1. Create a supportive setting
Ensure privacy, attend to client and patient comfort, minimize distractions, allow for time, sit down at the same level with the client and invite supportive individuals.
Identify who should be present for the conversation.
- “I am wondering if there are other persons who care about Max, who may want to take part in this discussion.”
Take time to establish initial rapport with the client, using open-ended questions, compliments, and empathy statements.
- “How is Max doing?” and “How are you doing?”
- “I am glad that you brought Max in, so that we could address this problem.”
- “The last 24 hours have been really tough.”
2. Understand the client’s perspective
Establish what the client knows about the pet’s illness.
- “What are your concerns regarding Max’s condition?’
- “What do you think is causing Max’s illness?”
- “Tell me in your own words what you understand about Max’s cancer?”
Determine the client’s desire for information. People have different ways of coping with bad news.
- “Some clients like to know a lot about their animal’s illness and others prefer the basic facts. What would you prefer?”
Understand the client’s perspective and values on end-of-life care.
Ask about the client’s previous experiences with euthanasia, using open-ended inquiry.
- “I am wondering whether you have had previous experiences with making a euthanasia decision. What factors came in to play in making that decision?”
- “I am wondering whether you have been present at a euthanasia procedure in the past. Tell me about that situation.”
Explore religious or spiritual beliefs that may impact a euthanasia decision, using open-ended inquiry.
- “Some clients have religious or spiritual beliefs that guide the euthanasia decision. I am interested in how these beliefs might guide your decision-making process.”
3. Ask permission to provide information (Invitation)
Ask permission to share the information with the client.
- “I am wondering if it is alright with you if I discuss some of the specifics regarding Max’s illness.”
Obtain the client’s permission to discuss euthanasia.
- “I am wondering whether it would be alright with you if we took a few minutes to discuss the option of euthanasia.”
- “Although we may not be facing this decision soon, I would like to ensure that that we prepare ahead of time.”
- “We can hope for the best in Max’s care and we also need to plan for the future so that we can ensure Max’s quality of life.”
- “It can be helpful to work through some of the details ahead of time.”
4. Provide the explanation (Knowledge)
Deliver the bad news in stages.
Provide a warning shot.
- “Mary, I have some news that may be upsetting for you to hear.” (Pause)
- “Mary, I have some difficult information to share with you regarding Max’s condition.” (Pause)
- “This is one of the most difficult decisions a client faces in caring for their pet.”
- “Making this decision on Max’s behalf is not easy. I wonder if it sometimes feels overwhelming?”
Give information in small easily understandable pieces. Avoid use of technical jargon and define medical terms. Share only 1-3 sentences at a time and use supplemental tools, such as written materials or audio-recordings. Pause and check for understanding prior to proceeding.
- “The cancer has spread to Max’s lungs. This will continue to make it very hard for Max to breathe and will eventually cause his death.” (Pause)
Ask for the client’s permission to continue to disclose the details of the medical condition.
- “Would you like me to tell you more about Max’s condition now?”
- “This is a lot of information and we can talk about it in stages and take one step at a time.”
- “Would you like to talk more when you can bring a friend with you?”
Provide accurate and detailed information about the animal’s condition. Give information in small, easily understandable pieces, pause and check for understanding prior to proceeding.
- “Max is probably feeling like you do when you have a bad virus. It probably hurts to move and it looks like it is difficult for him to get comfortable. His body temperature is high and he is having difficulty breathing.” (Pause)
- “Since I haven’t seen Max for three weeks, I have noticed some changes in him. He has lost more weight and muscle tone and seems less responsive. He seems to be experiencing some pain. While I can give him more medication for his pain, his body is declining due to the cancer.” (Pause)
Check for the client’s understanding, using open-ended questions.
- “What questions does that leave you with?”
- “What additional information may be helpful to you?”
- “Tell me how you understand the choices for Max’s care.”
- “What do you think are the most important points to present to your family?”
Provide instructions on how to monitor the pet’s condition.
- “Mary, things to watch for in Max are a decrease in his appetite and interest in drinking water, reduced activity level, difficulty breathing, such as panting or increased effort, and a lack of interest or responsiveness to you and his daily activities.”
Ask for the client’s permission to continue to disclose the details of the euthanasia procedure.
- “I am wondering if it would be alright with you if I were to walk you through the euthanasia procedure we use at our clinic.”
- “There are several details and decisions in relation to the euthanasia procedure. I am wondering if you would like to discuss them now.”
Review key decisions
- “Who would like to be present during the euthanasia?”
- “Where would you like the euthanasia procedure to take place?”
- “Who would you like to conduct the euthanasia procedure?”
- “Would you like to consider an autopsy?”
- “What are your plans to care for Max’s body?”
- “Would you like a clay paw print or hair clipping?”
- “Would you like a ceremony to honor Max?”
Avoid the phrase “nothing more can be done,” and reframe using the phrases “supportive care” or “palliative care.”
- “We will provide supportive care to Max to make his life as comfortable as possible.”
- “We will continue to provide palliative care for Max’s symptoms and to treat his pain.”
5. Empathize with the client
Throughout the conversation acknowledge, validate and normalize the client’s emotional responses.
Use silence, empathetic statements, and display compassionate and caring non-verbal cues (i.e. sit close to the client, caring facial expressions, gentle and calm tone of voice, slow pace of speech, leaning forward, and use of touch).
- “I'm right here for you. Take your time.”
- “I imagine how hard this is for you to talk about. This news is overwhelming.”
- “This is a lot of information to absorb and it came unexpectedly.”
- “It sounds like you are making decisions in Max’s best interest.”
- “I want you to know that I fully support your decision and will do my best to honor your wishes for Max.”
- “You have taken such good care of Max throughout his illness. I can tell how much you love him.”
- “I bet it is hard to imagine life without Max. I can see how close you are to him.”
- “It’s quite common for clients in your situation to have a hard time making these decisions. It feels like an enormous responsibility.”
- “Of course, talking about this makes you feel sad. It’s normal.”
6. Summarize, plan follow-up, and offer support
Summarize what has been discussed.
Negotiate a plan for treatment or follow-up.
Identify client support systems.
- “I am wondering who else cares for Max and will support you in making decisions.”
Provide information on support services (i.e. grief counseling and support groups).
Provide brochures, handouts, booklets, etc. that discuss end of life issues.
Supporting Clients at Time of Euthanasia and Beyond
Pet owners' responses to pet loss are often as emotional as the grief responses accompanying the loss of a human friend or family member. Bereaved pet owners report disruptions in their lives, work roles, and other relationships due to their feelings of grief.
It is appropriate to educate your clients about grief before, during, and after their pets' deaths. The basic content of your educational synopsis should be adapted according to each loss situation. Information about euthanasia procedures or helping children with grief, for example, can be included when appropriate.
Argus Institute: Offers a variety of resources to assist you in guiding your clients through the process of euthanasia and assist them in their grief.
- Shaw JR, Lagoni L. End-of-life communication: Delivering bad news and Euthanasia-decision making. Vet Clin Small Anim 37:1; 95-108, 2007.