Pet Loss BEST PRACTICE GUIDELINES For Veterinary Teams (PDF)

Pet Loss BEST PRACTICE GUIDELINES For Veterinary Teams Angie Arora, M.S.W., R.S.W. Kirsti Clarida, R.V.T. Maria Londono Forero, B.S.W. Margaret Steffan, B.Sc., V.T. Daniella Zamora, V.T. First Edition June 2020  CONTENTS CONTENTS 2 INTRODUCTION 3 END OF LIFE PRE-PLANNING 5 END OF LIFE DISCUSSIONS AND DECISIONS 7 HOSPICE AND PALLIATIVE CARE 11 EUTHANASIA AND DEATH 13 Location and Environment 13 Support Factors 16 Dysthanasia 17 AFTERCARE AND MEMORIALIZATION 18 Aftercare Decisions 18 Aftercare Process 20 Memorialization 20 CLIENT SUPPORT AFTER LOSS 21 COVID-19 IMPLICATIONS 24 RESOURCES 27 IMAGE CREDITS 29 2  INTRODUCTION Through a collaborative partnership, Seneca College and VCA Canada are pleased to share this set of best practice guidelines. Funded by Seneca Innovation, the project involved the completion of a literature review, data collection from 310 pet owners who shared their experiences interacting with veterinary teams, and a consultation with leading industry experts. The culmination of this work has resulted in the Pet Loss Best Practice Guidelines for Veterinary Teams. Seneca College and VCA Canada understand that pet loss is a form of disenfranchised grief in that it is not widely acknowledged by society and consequently, grief is highly stigmatized and clients are often left isolated. Those mourning the loss of their pets require compassionate care and while research has demonstrated that the veterinary industry is up for the task, there is a systemic gap in formalized training. Clients expect that their loss will be understood and care will be provided accordingly. Coupling this with the constant exposure to death can lead to issues of burnout and compassion fatigue for staff. As a reactionary and preventative measure, the following set of guidelines will address these interrelated issues. Skills acquisition is considered a strong buffer to compassion fatigue and so the more equipped staff feel in supporting clients within their scope of practice, the less likely they are to experience compassion fatigue. When staff are equipped, they are more likely to provide clients with meaningful care thus ensuring everyone’s needs are met. Therefore, the Guidelines emphasize the importance of the Veterinary-Client-Patient Relationship (VCPR) and “bond-centered” practice, with a particular emphasis on the Veterinary-Client Relationship once the pet has passed. For the purpose of these Guidelines, ‘pet’ will be used to refer to the animal in lieu of ‘companion animal’ or ‘patient’. ‘Client’ refers to the pet owner as represented in the veterinary-client relationship. We acknowledge that other terms such as ‘pet parent’, ‘caregiver’, and ‘owner’ may also be used in literature and practice. The use of ‘pet’ in our project is not meant to minimize emotional attachment, but rather allow for role clarity. In addition, ‘veterinary teams’ or ‘veterinary professionals’ are used to encompass the different roles of staff involved in care, including veterinarians, veterinary technicians, veterinary assistants, receptionists, and practice owners/managers. The Guidelines will follow a Start, Stop, Continue approach based on information collected from the project. The findings reveal that there are many areas of practice in which the veterinary industry is providing a high quality of care to its clients, and these practices will be encouraged to continue. 3  In some instances, new practices will be suggested to begin, and unhelpful practices will be discouraged. Before we begin, it is important to note overarching themes which emerged as they set the tone for the following guidelines. First, clients who have experienced the loss of a pet other than a cat or dog, do not appear to receive the same level of care compared to clients who have lost a cat or dog. When we are referring to pets throughout this document, we are referring to all species; regardless of the type of pet they have lost, all clients deserve the same level of empathy and compassionate care. Second, humane treatment of their pets is an important factor shaping clients' decisions. Clients expect that their pets will be treated in humane ways, all the way from end of life discussions to after the pet has died. When this compassionate care does not occur, it can affect their grieving process. Therefore, the Guidelines will focus on ways in which veterinary teams can provide families with bond-centered care during end of life and euthanasia, and client-centered care once the pet has passed. 4  END OF LIFE PRE-PLANNING While some resources exist, it cannot be overstated that there is no one-size-fits all approach to supporting clients through their pet’s end of life. The Companion Animal Euthanasia Training Academy offers ‘The 14 Essential Components of Companion Animal Euthanasia’ as one option to guide veterinary teams through euthanasia appointments. We want to extend the approach to include service after death for the client and their families. Therefore, to better understand clients’ perceptions of the situation and assess each client’s individual needs, it is suggested that veterinary practices adapt an End-of-Life Pre-Plan to guide the process. By utilizing such a plan, clients will be provided with a sense of control during a time that can feel quite helpless. In addition, this will help veterinary teams better understand how to support their clients by allowing for meaningful discussion that still stays within the scope of the team’s practice. Our End-of-Life Pre-Plan recommends the following headings, understanding that not all sections will apply to every client situation: Guidelines in this document will suggest practices to consider under each of these headings, which clinics and hospitals can then adapt for integration into their own template. 5  END OF LIFE DISCUSSIONS AND DECISIONS End of life discussions often present very challenging times for both clients and veterinarians. It is a sensitive time that requires a high level of compassion and attention to detail on the part of the veterinary team. Current research validates that veterinary teams do an excellent job displaying empathy and understanding to clients’ situations. Dedicating time to counsel clients, review treatment options, answer questions, and listen to client concerns makes a big impact on the memory of their pet’s death. In contrast, not receiving compassionate care can negatively impact a client’s grieving process. Coined by Alisha Matte, ExplorEEEER is a framework to approaching end of life discussions to elicit pet owners’ needs and wishes. This approach is designed as a conversation checklist assigning the veterinarian’s role as an explorer. The steps in an ExplorEEEER conversation are: Experiences Expectations Emotions Lifestyle Elements Relationships Client’s past and current experiences, expectations, emotions, lifestyle and relationships all impact the ways in which they will experience their pet’s end of life and grieving process. The following guidelines will provide opportunities to actualize elements of this framework through a bond-centered approach to end of life discussion and decision-making. While all efforts should be made to plan these discussions as early as possible, we recognize that plans can change. For those clients whose loss is imminent, it is equally important for veterinarians to provide them with information on what to do should their pet pass unexpectedly and to prepare to engage in these discussions after death should the client require. 6  List euthanasia as a client service to improve the understanding that providing compassionate end-of-life is afforded the same care as other treatments. i. Expand your listing to share the clinic’s approach to euthanasia (e.g. private room, end of day for privacy, pre-payment options, etc.) ii. Include aftercare options (cremation, aquamation etc.) and links to providers for more information. iii. List pricing options (and details) as you would other services. iv. Include resources for client care and support that are being provided in-house and by referral (ie. Veterinary Social Work). Schedule time to have end of life discussions which can allow for more opportunity to explore client concerns and minimize the feeling of being rushed for both parties. i. The conversation should be held in a private environment with as little distractions as possible. i. Having the conversation with the client/family in their home could be of benefit. This would be of particular relevance for mobile veterinarians. ii. Initiating this discussion early in the prognosis can provide the client time to consider how they would define a positive end of life experience. iii. Provide resources for the client to access (print, online) after the discussion. It can help them to confirm or correct memories of the discussion after it occurs. iv. Clients having experienced a previous loss tend to feel more confident in options that exist based on memory. It is recommended that all options be discussed regardless of the client's previous experiences so they understand any new options that may exist for the pet and the client. Maintain forthright, open communication with clients and be prepared to listen to their concerns and questions. i. Create a non-judgemental environment to discuss end of life decisions as guilt and shame are common themes described by clients. ii. A pros/cons approach to treatment plans can help clients understand the impact of the options being presented. iii. Clients may be unable to process prognosis or treatment information during the initial receipt. Where possible, share printed or written materials for reference and be available for a follow-up discussion to review concerns should the client require. iv. Consider pre-booking a telephone or in-person follow-up communication to answer questions and review options at the end of the initial appointment. 7  Prepare the veterinary team for delivering difficult information to clients, particularly as it relates to the pet’s diagnosis and prognosis. It can be emotionally taxing, especially in the absence of tools on how to approach such difficult conversations. i. Veterinary teams are encouraged to consider building their own self-reflection and self-management strategies so that staff are empowered to manage their own thoughts, emotions and reactions during challenging situations. The Crisis Prevention Institute provides insightful information and training on how to be mindful of one’s own reactions, maintain rational detachment, be attentive, use positive self-talk, recognize one’s own limits, and debrief. The more aware staff is of their own emotions and thoughts, the better they will be able to provide compassionate support to others. ii. A particularly useful model for delivering challenging news in an empathetic and patient manner is the SPIKES Six Step Approach, developed by Robert Buckman (originally created for human medicine). The SPIKES Protocol for Delivering Bad News to Patients* Step Description of Task Setting Establishing patient rapport by creating an appropriate setting that provides for privacy, patient comfort, uninterrupted time, setting at eye level, and inviting significant other(s) if desired. Perception Elicit the patient’s perception of his or her problem. Invitation Obtain the patient’s invitation to disclose the details of the medical condition. Knowledge Provide knowledge and information to the patient. Give information in small chunks, check for understanding, and frequently avoid medical jargon. Empathize Empathize and explore emotions expressed by the patient. Summary and Strategy Provide a summary of what you said and negotiate a strategy for treatment or follow-up. *From Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology: description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer. 1999;86:887-97. Baile et al.’s protocol was adapted from Buckman R. How to Break Bad News: A Guide for Healthcare Professionals. Baltimore: Johns Hopkins University Press, 1992. Source: Shaw, J.R., & Lagoni, L. (2007). End-of-Life Communication in Veterinary Medicine: Delivering Bad News and Euthanasia Decision Making. Veterinary Clinics of North America: Small Animal Practice, 37(1), 95-108. Doi: 10.1016/j/cvsm.2006.09.010 8  Clients are looking for reassurance to help ease their decision-making process. Reassurance can come in many different forms while still staying within professional scope of practice, medical ethics and personal morals, and should be ongoing throughout the end of life experience. Expressions of compassion and empathy by the veterinary teams makes a strong, positive impact on the client’s grief. i. Approach conversations with authenticity and a genuine intention to be present for the client. ii. Use paraphrasing statements to ensure the staff understands what the client is saying, offer opportunities for clarification, and reinforce that what the client is saying is important. iii. Validate clients’ feelings where possible. iv. Speak in non-judgmental ways so that the client is afforded a safe space to express themselves. v. Address any personal and systemic challenges that arise for the client so these factors can be considered in the decision-making process (e.g. emotions related to previous loss experiences, relationship changes, finances, social support network etc.). vi. Embody a mentality where euthanasia is seen as a partnership between both parties (once the veterinary professional and client agree to the euthanasia). With this, there is a commitment to ensuring that the procedure is carried out to the best possible standard so that the pet has a ‘good death’ which can more positively impact both the client and the veterinarian. vii. Include a Veterinary Social Worker as this may support both the client and the veterinary team in these discussions. Consider a referral to this resource if not available in the clinic. Integrate quality of life assessments as they can be a reflective tool to engage clients in end of life discussions. Consider:: ⚀ Ohio State University: How Do I Know When It’s Time ⚀ HuMANE Care Quality of Life Assessment Aid ⚀ JOURNEYS: A Quality of Life Scale ⚀ Lap of Love Quality of Life Calendar ⚀ Quality of Life (HHHHHMM Scale) By engaging clients in this type of assessment and allowing them to garner more insight into their pet’s quality of life, it can assist their decision-making process and potentially alleviate intense feelings of guilt during the grieving process which often emerge when people begin to second-guess their decisions. Address caregiver fatigue and burnout as it can profoundly impact the end of life experience for all parties involved. i. While Veterinary Social Workers are well suited to facilitate these discussions with clients, the absence of social workers should not preclude veterinary teams from providing clients with support. During end of life discussions, dedicated time should be allocated to discussing clients’ quality of life. To learn more about caregiver burden and things to consider in your discussion, resources such as PetCareGiverBurden.Com can be helpful. Consider offering hospice and palliative care to clients be it in-clinic or through referral where available. 9  HOSPICE AND PALLIATIVE CARE Clients may have preconceived ideas about what hospice and palliative care mean. For some, the terms may be interpreted to be the pet’s ‘death sentence’ and may be perceived as ‘giving up’ on the pet. Therefore, educating team members about the nature of veterinary hospice and palliative care would be a starting point to empowering them to begin these discussions with clients. Veterinary teams may need to explain both options in the context of veterinary medicine to ensure the client understands the scope of services available and can make an informed decision for their pet. The following guidelines may support this discussion: Consider the setting in which these conversations occur and the tone that shapes them. i. Where possible, facilitate these conversations earlier in the treatment planning process. Experience shows that the earlier the information is presented, the more receptive clients tend to be. ii. While not always possible, clients may find engaging in such conversations feels more comfortable at home than in a clinic where there are many distractions. If this is not possible, facilitate these conversations in as quiet and safe a room within the hospital as possible. iii. It is encouraged that clients have these conversations with veterinarians they have established a relationship with, as that can ease some of the pressure of having the conversation. iv. Shift the focus. Emphasize on the journey of maintaining the pet’s quality of life instead of the steps towards death. i. For example, what can be done to address each symptom in the moment? Could it be pain control? Release from strict diet? ii. Each specific recommendation will reduce the situation from a large and overwhelming end to smaller more manageable steps forward. 10  Deliver a more nuanced definition of palliative care (e.g. ongoing kidney disease treatment can be considered a form of palliative care). i. Explore the impact of hospice or palliative care on both the quality of life and longevity. ii. Be as specific as possible (e.g. medications, travel or visit frequency etc.) about what might be considered in palliative treatment. iii. Focus on the opportunities to alleviate symptoms of disease or pain through these services. iv. Be open about palliative care options that can also include humane euthanasia. Provide print and/or digital information about hospice and palliative care services. i. Consider training team members in end-of life care or hiring specialists into the practice. Having this skill set in-house can greatly improve client communication in this area. ii. Prepare a list of hospice and palliative care resources in your region including contact information of service providers, websites, videos, and online groups. This will help clients understand the viability of hospice and palliative care as an option for their pet. Provide clarity and details for clients to determine how to interpret changes in their pet at home since clients may struggle to understand the presentation of symptoms. i. Provide clients with a list of changes that would indicate when the veterinarian should be consulted as this will provide a higher level of reassurance for clients. ii. Consider the client's capacity to interpret medical information. Delivering information about prognosis and unique disease processes at their level of understanding can reassure and relieve future guilt the client may experience. 11  EUTHANASIA AND DEATH The client experience during euthanasia and pet death can overshadow compassionate efforts made during pre-planning and after care. The event is emotionally complicated and many clients are not truly prepared for the sensory overload of sights and sounds during a euthanasia. It can also overshadow any previously positive relationships built between the veterinary team and the family. Secondary stress in veterinary team members tending to the patient and client is another potential outcome of euthanasia. While the client is experiencing one death, the negative cumulative effect on team members experiencing multiple deaths cannot be understated. To mitigate the potential distress to the client, pet and veterinary team, pre-planning details around the moment of euthanasia is strongly encouraged. Every effort should be made to engage in these discussions as early as possible. To facilitate the discussion, consider the following recommendations. Location and Environment Where the euthanasia occurs can have a profound impact on both the client and pet. For the client in particular, memories of the final moments are often replayed as part of the grieving process and therefore it is the veterinary team’s responsibility to help foster as supportive and comforting an environment as possible. To do so, the following guidelines can be considered. Engage in discussions with clients to determine their needs during the euthanasia process regardless of where the euthanasia takes place. For example: i) Ascertain if the client wishes to remain present or not, without making assumptions or passing judgment. ii) If the client wishes to be present, determine the level of detail the client wishes to receive during the euthansia process and communicate accordingly to stay within the client’s comfort level. iii) Discuss euthanaisa location options and preferred settings (e.g. at home, in-clinic, outdoors, sounds, lights, smells). iv) Discuss payment options so clients can choose when to pay (e.g. days before appointment, day of appointment, after appointment) v) Consider a time of day that the euthanasia will occur that works for both the clinic and client. vi) Suggest clients consider who will be present during the euthanasia. Collect contact information should the practice be required to connect with these contacts on behalf of the client should an emergency arise. vii) Larger practices should specify that clients identify preferred veterinary professional(s) to be present 12  Explore clients’ interests for at-home euthanasia and respond accordingly. There appears to be a growing interest as it can ease some of the challenges of euthanaisa by providing familiarity to both the client and the pet. i) Recognizing a range of expertise in the practice of at-home euthanasia, the following are in order of preference: a) Consider referral to a hospice and palliative care veterinarian prior to euthanasia service. This affords the client and pet an opportunity to build a relationship with the referral practice. b) Referral to a hospice and palliative care veterinarian during end of life discussion. The absence of a pre-existing VCPR between the client and this specialized practitioner should not minimize the benefit this service can bring to euthanasia. c) Consider referral to mobile services offering in-home euthanasia. d) Consider the option to include at-home euthanasia as a service. ii) Referring veterinarians are encouraged to have a conversation with the receiving veterinarian (with the client’s consent) to discuss specifics that may support care (e.g. aggression issues in the pet). iii) Ways in which this at-home euthanasia can be offered at an affordable price needs to be explored to ensure that it remains a viable, compassionate option without compromising service quality. Create a calm, quiet and tranquil environment when euthanasia takes place in the clinic. Consider the entire visit from the moment the client arrives to when they leave. This includes ensuring: i) Offer a calm and separate area to the client and pet immediately upon arrival to the clinic thereby avoiding the common waiting area. ii) Plan the euthanasia to occur in a space that does not appear sterile or cold (like an examination room or a room where the pet was previously treated), but rather a comforting and quiet space with privacy, seating, and the option for dimmer lighting. iii) Veterinary staff should keep the pet with the client for the entirety of the euthanasia procedure rather than taking them out of the room for any purpose. This allows the client to be with their pet for every one of their last moments. iv) Avoid or reduce interruptions. These last moments can shape the trajectory of a person’s grieving process. v) In the event that the client cannot be with their pet, facilitating a process whereby the pet is with someone familiar who loved them and/or provided them compassionate care is the next best option. vi) Consider using a battery-operated candle at the front desk to signify a pet is passing, with a sign or plaque encouraging all to speak softly and with respect during this difficult time. vii) Avoid or reduce loud noises, noxious smells, or other animals/people in the clinic as some pets may be reactive to these stimuli. Both the client’s and the pet’s comfort should be taken into account given the high-stress nature of euthanasia. viii) Remind clients to bring home comforts with the pet (blanket, pillow, bed, snacks or meal). Familiarity with their surroundings improves client perception of their pet’s comfort. 13  Clients may experience difficulties leaving their pet after the euthanasia has occured. Veterinary teams play an important role in helping to assure clients that their pet’s body is treated with respect and dignity through both direct and indirect ways. i) Wrap the pet’’s body in warm and comforting material. Using a soft blanket is preferable to a used towel. Encourage clients to bring a familiar blanket from home that they are willing and comfortable to part with. ii) Where resources permit, there should be a team member on standby to stay with the pet as the client leaves. This can help provide the client with some comfort as they leave the practice. iii) Confirmation that the pet’s body will be handled with respect, care and dignity after the client has left can help alleviate some of the difficult emotions clients may be experiencing. Communicate what will be done with the pet’’s body should the client inquire: What is the body going to be carried in? Where is the body stored and for how long? How is the body moved to the crematorium? When will the body be moved? ⚀ There is indication spending time with the body may be beneficial for both the client and other pets processing the loss. Consider options for clients to remain with the body for a short period of time. ⚀ For in-home euthanasias, a delayed pick-up could be made available. ⚀ For in-clinic euthanasias, veterinary teams could allow clients to take the pet home, with an agreed upon time for the pick-up. ⚀ In any setting, it is the responsibility of veterinary professionals to dissuade any stigma or judgement associated with clients who choose to remain with the body. Consider the cultural practices associated with remaining with the body of a loved one for some. 14  Process billing and finances in sensitive and compassionate ways. For example: i) Clients have the option to pay prior to the euthanasia. Where possible, the billing could be addressed days beforehand. ii) Consider billing clients for the costs days after the euthanasia. iii) The cost of euthanasia should not be lowered if that affects the overall quality of care and service. However, options should be made available to affordable euthanasia to avoid suffering (e.g. Humane Societies may offer euthanasia and communal creation at lower cost). Clients have a right to be informed of all options so they can make an informed decision. Support Factors Familiarity is an important variable to the pet loss experience. At a time when things can feel very overwhelming and out of the client’s control, the more that can be done to keep familiar factors in place, the more comfort can be brought to their experience. To help foster this familiarity, the following guidelines are suggested: Provide clients with the option to include whomever they deem important to their support network in the euthanasia process. i) Consider virtual options for family or friends that are unable to be present but would be supportive of the client (e.g. Skype, Facetime, Hangouts etc.) Any client who has experienced the loss of their pet outside of their regular practice should be contracted within a 24-hour period. Prompt communication is an important factor to ensuring clients feel connected and supported. i) Veterinary teams providing euthanasia to clients of other practices must inform the regular clinic as soon as possible to facilitate this communication. If possible, confirm receipt of the message. There may be a need for designated staff trained in grief counselling in emergency clinics because clients will likely not be as familiar with staff in an emergency care setting, Although this may be helpful in all hospitals, there is an added need in emergency hospitals due to the decreased level of familiarity and the added stress of being in an emergency situation. 15