Monthly Archives: July 2012

When it’s time….making the decision to euthanize

Companion animals are such a blessing in our lives.  They provide us with unconditional love.  We laugh at their antics, and enjoy their company.  Many of us post pictures of them on Facebook, celebrate their birthdays, and buy them presents on the holidays.  They give us friendship when we are lonely, and comfort us in our darkest hours.  In turn we adore them, feed them, clean their messes and allow them into our hearts.

It would be a wonderful world  if dogs and cats died peacefully in their sleep.  Unfortunately, very few of them do.  Instead, we are left to make the difficult, heartbreaking decision to euthanize them.  We give them the gift of a painless, peaceful death, but we still have to decide the time.

This is often an agonizing choice for owners to make.  Many of them are worried about making the decision too soon.  They will make up their minds and steel their resolve only to wake up the next day and find that their pet is having a “good” day.  They desperately wish that their pet would pass peacefully in their sleep.  They contemplate what life will be without their friend.  For some, they look ahead to coming home to an empty house, with no wagging or tails or happy meows.

Owners often ask their veterinarian when and if they should put their pet to sleep.  Most of us won’t answer this question.  We know the power that our knowledge and experience wields, and we don’t ever want to have owners feel pressured into making such a crucial choice.  We don’t want them to look back on it and feel that the vet made them do it.  I know what a heavy burden this choice is, and although I will not make the decision for them, I often will counsel owners to help them know when the time has arrived.  Here is what I usually tell them:

Trust yourself.  You will know when it is time.

The main reason I will not make the choice for owners, is because I will never know their pet like they do.  They have spent years with their dog/cat, and know their personality.  They know when they are happy, upset, angry, jealous, afraid and sad.  I also honestly believe that dogs and cats will “tell” their owners when it is time.  It is a look they have in their eyes, or a certain energy that they give off.  Through the years I have had many people tell me that they woke up one day and their pet looked at them and told them that it was time.  I tell owners to trust themselves because their instincts are almost always right.

Make a list of what defines a good quality of life for your companion animal

Decide what makes your dog or cat who they are.  What is it that they enjoy most in life?  Contemplate this, and write it all down.  Do they absolutely LOVE to eat?  Write that down.  Chase a ball?  Put that on the list.  Sleep in the sun…go to the lake…jump on your bed at night…put them all on the list.  For example, if I was making this list for my cat, Tommy, I would write the following:

 Eat.  Have his chin scratched.  Sleep in the sun.  Torment the other cats.  Chase fuzzy mice. Ruin toilet paper rolls.  Demand his food LOUDLY at 530 every morning.

Once you have your list, use it to keep track of your animal’s quality of life.  When you see things on the list disappearing, cross them off.  This can help you in the decision making process.  If you need guidance with this, ask your veterinarian.  We will always help you evaluate your animal’s quality of life.

There will be good days, there will be bad days

Aging animals, and animals suffering from terminal illness will have waxing and waning health.  There will be days where they act like the puppy or kitten they once were, and days that it is obvious they are in pain.  It is very common that when you have decided to euthanize that your animal will have a “good” day.  When this happens, ask yourself if one good day outnumbers the bad days.  Consult  your quality of life list.  If your pet has one good day after a week of bad days, ask yourself how you really feel your pet is doing.  Remember that dogs and cats live utterly in the moment.  Unlike us, they don’t contemplate having another day, week or month of life.  They know what is happening right now.  If they are in pain, and their now moments are bad, the kindest gift you can give them is to relieve their suffering.

Remember that animals don’t always show us when they are in pain

A few months ago I saw an 18 year old cat.  She had not been eating or really drinking, or moving for about a week.  I diagnosed her with end stage kidney failure, and discussed the options with the owner.  At that point it was to hospitilize her, knowing the prognosis was grave, or to put her to sleep.  The owner was shocked I brought up the option of euthanasia.  “But she’s not in pain,” she said “She is not crying or meowing.”

Animals usually don’t cry, whimper or vocalize, even if they are in immense pain.  It is in their nature to hide signs of illness and discomfort to the very end.  It is a protective mechanism…in the wild it is the animals that are obviously suffering that are easily spotted by predators.  Animals that are in pain will do other things, like stop eating, become lethargic, vomit, drool, stop drinking, and stop doing other things on their quality of life list.

Remember that we veterinarians are solemn and serious about euthanizing animals.  We never treat this lightly.  If your veterinarian tells you that your animal is in a great deal of pain, trust them.  This is as close as we often will come to telling you directly that the time has come to euthanize.  We would never exaggerate or be dishonest about this.

Involve the entire family in the decision making process

Some of the most stressful euthanasias I have participated in where those where there were family members that disagreed with the timing or were left out of the loop entirely.  Come together as a family, and discuss your pet’s quality of life.  Unless your children are very young, I would recommend involving them as well.  If you have a family member in complete denial, schedule an appointment with your vet to discuss quality of life.  I do not recommend simply euthanizing the animal behind their back.  Everyone needs their chance to say goodbye and you don’t want anger and resentment to be present during the grieving process.

It is rare that you will make the decision too soon

In my eight years of being a veterinarian, I have had one owner tell me she felt she euthanized her cat too soon.  She really didn’t…the cat was comatose and non responsive.  Her feelings came from the immense grief she went through after losing her companion.  Other than that, I have never had an owner tell me that they made the decision too early.  On the other hand, I have had several owners tell me they waited too long to euthanize.  Once their animal dies a painless, peaceful death and their suffering is ended, the owner will look back on it and feel that they let it go on too long.

Even in these cases, I try to ease the owner’s guilt.  This is a really, really hard decision.  You are making a conscious choice to end the life of a companion you love.  It shouldn’t come too easily.

I hope some of those suggestions help.  There are numerous other resources that your veterinarian can provide to help you through this process.  Don’t be afraid to ask for guidance.  We will answer any questions you have about the euthanasia process.  Bear in mind that by choosing to euthanize your pet, you are granting them one last loving gift of a dignified, peaceful death.  It is heartbreaking and gut wrenching, and one last way to thank them for their years of companionship.

 

 

 

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Communicating with the crazies

Good communication skills are essential for a veterinarian. If you cannot communicate with owners about their animals, it doesn’t matter if you are a kick-ass surgeon or an internal medicine whiz…they won’t like you. In fact, they may even label you as a “bad” veterinarian. The reverse is also true…you may be the world’s worst surgeon, and may treat every ailment with a shot of Depo, but if you are a good talker, many clients will label you as a “good” or even “awesome” veterinarian.

I cringe and generally want to punch something when I hear people say “Oh, I always wanted to be a vet because you don’t have to work with people!” Sometimes I think that I actually deal more with people than certain human doctors do. I mean, if a client calls wanting to talk to me, if I am not busy I will get on the phone and chat with them. I don’t know many human doctors that would do that.

As a vet, I have to be able to extract an accurate history from an owner, explain to them my exam findings, get them on board with necessary diagnostics and explain the treatment plan. This can be extremely challenging at times. The following incident happened to me about six months after vet school, and taught me a very valuable lesson in communicating with a client.

It was a fairly typical day at the clinic. I was seeing appointments and the other vet, Dr. M, who was older and wiser than me, was doing surgeries. All of a sudden an older woman, who I’ll call Mrs. Roberts, came running in with her 14 year old shih tzu, Max. He was collapsed, gasping for breath and quickly turning blue. A quick physical exam revealed a raging heart murmur and fluid in his chest. I ran Max back to the treatment room and started him on oxygen. My technician placed an IV catheter, and we took x-rays of his chest. They showed he was suffering from severe heart failure.

At that point I brought Mrs. Roberts back to the treatment area. I explained what was happening. I showed her the x-rays and pointed out Max’s enlarged heart and the fluid in his chest. I went over the options, which were to admit Max for critical care, or to consider euthanasia. I have to admit I was very proud of myself for so quickly and competently making a diagnosis, and explaining it to her in such an awesomely clear, compassionate manner.

“What is THAT?” Mrs. Roberts asked. She pointed to the oxygen mask the technician was holding on Max’s face.

“It is an oxygen mask.” I said. “He is having a hard time breathing, so we are trying to give him as much oxygen as possible.”

“TAKE IT OFF!!” She screamed. “YOU ARE POISONING HIM!”

I was fairly stunned. “Mrs. Roberts,” I said. “We are not poisoning Max…we are giving him oxygen.”

“YOU ARE POISONING HIM I KNOW HOW THE GOVERNMENT POISONS PEOPLE AND PUTS LEAD IN THE DRINKING WATER. STOP POISONINING HIM RIGHT NOW OR I WILL SUE YOU MY BROTHER IS AN ATTORNEY.”

“Mrs. Roberts, Max will die if we take away oxygen.” I said. I was shaking at this point. “If you do not wish to continue treatment, then we need to consider the option of euthanasia so that Max doesn’t suffer.”

“I am going to take him home!” Mrs. Roberts said.

I shook my head. “If you take him home without treatment he is going to die a painful, stressful death.”

Mrs. Roberts shook her finger at me. “HE NEEDS TO DIE A PAINFUL DEATH TO GET TO HEAVEN!”

I was lost at this point, and getting angry. “What are you talking about?” I asked.

“I AM CATHOLIC. HE NEEDS TO SUFFER BEFORE HE DIES OR ELSE HE WON’T GO TO HEAVEN. GIVE HIM TO ME NOW SO THAT I CAN TAKE HIM HOME!!!”

At this point in the conversation I was very angry. I should have recognized that the client had jumped on board the crazy train. I should have taken deep breaths, given myself a second, and tried a different approach. Instead, I jumped on the crazy train with her.

“Do you know Saint Francis of Assisi?” I asked. I was referring to the patron saint of animals.

“YES.” Mrs. Roberts said.’

“Well, he would say it was BAD for an animal to suffer. He believed strongly in euthanasia.” I said. Of course, I had no idea if that was true, but it sounded good.

“How do you know he said that?” she asked, glaring at me.

“BECAUSE I TALK TO HIM AND HE TELLS ME THOSE THINGS!” I yelled at her. “HE WANTS YOU TO EITHER TREAT MAX OR END HIS SUFFERING!”

“HE DOESN’T TALK TO YOU, HE ONLY TALKS TO GOOD CATHOLICS!” she said.

“I TALK TO ST. FRANCIS ALL THE TIME!” I yelled.

At this point, the technician very wisely left and got Dr. M. I have a feeling she told him that his new, bright young veterinarian was arguing with a crazy woman about who really talked to a dead saint.

Dr. M walked into the room. He was the calm in the midst of Hurricane Insanity. He quietly told Mrs. Roberts that he understood that she was upset. He said he was sorry that Max was ill. He said that we either needed to treat him, or end his pain.

Mrs. Roberts at this point started to cry. She hugged Max and tearfully agreed to euthanize him. Dr. M. quietly walked her through the procedure, and ended Max’s suffering. There was no more mention of St. Francis.

I had definitely failed to communicate with her. I made an accurate diagnosis, and made very appropriate recommendations, but in the end my lack of compassion and sympathy unhinged the whole conversation. I allowed myself to get angry and irrational, instead of asking myself how this poor woman was feeling in the situation. Her dog went from being happy to dying in the course of a day, and here this young cocky vet was demanding that she make a decision NOW. I was more intent on being “right” and getting her to listen then I was on truly helping her make a good decision about Max.

Yes, Mrs. Roberts was crazy and yes she was being a wee bit irrational, but I reacted in a manner that made it much worse. I learned that day how important it is to stay calm no matter how the client is reacting, and to NOT join them in their craziness. I also learned to try to keep compassion and understanding at the forefront of all of my client interactions.

This is certainly not easy. There are certain clients that can be downright hostile, mean, abusive, non-compliant, rude and sometimes psychotic. I have had clients tell me that they don’t “trust lady doctors” or that I “don’t look like I know what I’m doing.” I have acquired a pretty darn good poker face, where I can smile and nod and NOT say the things I really, really wish I could say.

Now, as a side note to the Mrs. Roberts story…as she was checking out she informed me that she became Catholic because God saved her from being stung by 1000 fire ants that came after her, from being assaulted by a gang of Hell’s Angels that went after her, and from being injured even after she fell down a flight of 100 stairs and hit her head on EVERY single one. I nodded and said she was quite the survivor. What I REALLY wanted to tell her was that she needed to talk to St. Francis more.

 

The Unanswerable Question

Clients have asked me a lot of questions through the years. I generally lump the questions into the following three categories:

THE “I’M SO GLAD YOU ASKED THAT” QUESTIONS

These are my favorite types of questions, because they often allow me to discuss important things like behavior or nutrition with clients. Examples would be “What is the best food for my cockerdoodlesnicker puppy?” or “I am a small, frail elderly woman and my grandchildren want to buy me a Lab puppy. What do you think?”

(For what it’s worth, Lab puppies in general are NOT good gifts to give your frail, elderly grandma or grandpa. Same with Border Collies, Australian Shepherds, or Saint Bernards)

THE “BREAK OUT THE TINFOIL HAT” QUESTIONS

The “tinfoil hat questions” are the questions that make me want to put on a tinfoil hat to ward off the crazy beams radiating out from the client in front of me. If you are confused about the reference, watch “Signs” starring Mel Gibson.

A few years ago I was wrapping up an exam I did on an adorable Siamese kitten. When I asked her owner if she had any further questions for me, the owner cocked her head, furrowed her brow, and said “Well, yeah. She like, totally wants to nurse on me like a baby would.   I let her, even though I don’t make milk. Is that weird?”

Ummmm…..yeah. I bit my lip really hard, and mumbled something about orphaned kittens and the suckling reflex. I managed to talk to her about it with a straight face, but what I really wanted to do is open up my skull and pour some bleach on my brain in order to clean up the image I suddenly had in my head.

I would also include in this category the men who have asked if I could do their prostate exam, the women who ask if I believe in alien mutilations, questions about government conspiracies and microchips, and pretty much any question that begins with the phrase “My breeder said…”

(Oh, and by the way, NO I WILL NOT DO YOUR PROSTATE EXAM YOU CREEPY OLD MAN. EWW. )

THE ONE UNANSWERABLE QUESTION

This question is the one I am most commonly asked, and the one that I still don’t have an answer to. It is usually asked by grieving clients who have just euthanized their beloved dog or cat.

“How do you do this?”

By ‘this’ they mean euthanasia. They are asking how I deal with euthanasia….with the loss of an animal, and with the grieving, heartbroken families.

Here’s the thing…euthanasia is part of my job. I personally consider it to be the most important part of my job. I am there to give an animal the gift of a peaceful, painless death, and to help the owners start the grieving process. I want the last memory an owner has to be of their animal passing away quietly in their arms.

We are fortunate as veterinarians that we have euthanasia as an option. I cannot imagine being a human doctor, and having to watch as a patient dies a painful, slow, excruciating death. I have felt the most sorrow and anger in dealing with owners that absolutely refuse to euthanize their pet, and instead watch it slowly and painfully fade away to skin and bones.

That being said, euthanasia can be very hard on veterinarians. We all have had those days, weeks or even months where it feels like all we do is kill our patients. We usually react to times like this by it by making jokes about how our name should be “Dr. Death” or “Dr. Terminal.” We stuff ourselves with chocolate and/or wine. We go home and watch trash TV. We jump at the chance to see a kitten/puppy appointment. We exercise. We read. We somehow push through it and carry on.

Except….sometimes we don’t. Sometimes all of that death and grief can be overwhelming. As a profession, we have one of the highest suicide/addiction rates. Get a group of veterinarians together and ask who among them knows a colleague who has been treated for addiction or committed suicide. Most of them will raise their hands.

Over the past year I have given a few lectures to vet tech students and shelter workers on compassion fatigue. Compassion fatigue is just what it sounds like…it gets so emotionally/physically/spiritually exhausting to care for grieving clients that we get to the point where we cannot care for anything anymore…including ourselves. We withdraw, isolate, self-medicate, become angry, bitter, and zombie-like.

So far, every single time I have lectured on the causes and symptoms of compassion fatigue I have seen most people in the audience nodding their heads or wiping away tears. It is a real problem in this profession.

A few years ago, I went through a nasty bought of compassion fatigue myself. I dreaded going to work. I had once loved my job, but found myself dragging myself to the clinic. I was easily annoyed at my clients and co-workers. I wasn’t sleeping, and kept obsessing about patients that were dead. I was told by some that I was perhaps not meant for this profession…that I needed to toughen up or get out of it.

Fortunately, through the love of my family and friends, and the invaluable help of certain colleagues and other professionals I pulled through that dark period and returned to loving my job. I found healthier ways to cope with the tougher aspects of being a vet. I learned valuable lessons, and now I try to help others when I can.

So, for any vets/technicians/others that are reading this, here is my advice, for what it is worth:

For starters, as simple and new-agey as it sounds, make sure you are taking care of yourself. This means all of those things like eating well, exercising and sleeping. I know that many days we are lucky if we have time to cram down a Del Taco burrito and slurp a Diet Coke, but I personally have found that when I force myself to take care of me, I am in a much better space to handle the tougher parts of my job.

Second, make sure you have a life away from veterinary medicine. As best as you can, when you leave the clinic leave your work behind. I used to go home and read vet journals and watch Animal Planet. Now, I read trash magazines and watch shows like Toddlers and Tiaras (Seriously).

Cultivate hobbies. Play an instrument. Hike. Fish. Read.  Take a vacation, even if you don’t think you should.  These are ways to recharge yourself and keep your brain and spirit strong.

Third, you know those cards and letters that grateful clients send you? Keep them. When you feel like you are doing nothing but killing animals, go back through and read those cards. Remember and recognize the people that you have touched and the good that you have done, even in the face of euthanasia.

Fourth, remember that it takes a strong person to recognize when they can’t heal themselves. There is no shame in seeking out the help of a therapist or family doctor. Many times just having a sympathetic, compassionate ear can be a life saver.

Last, remember that MANY of your colleagues have gone through this. You are not alone, and you are not some weird weakling. There are many resources out there for you…use them, and then pass what you learn onto others. There is always hope, and you can find your way back to loving and enjoying this profession.

So…to answer the unanswerable question. How do I do this? To be honest, I still don’t know. It is something I know I will work on and struggle with every day. I’ll be kind to myself, play with puppies and kittens whenever I have a chance, and ensure that my tin foil hat is nice and shiny.

The thing I hate about being a veterinarian

In my day to day life as a veterinarian, there is something that I dread doing. This particular thing makes me squirm, twitch, drool and retch. I try to avoid it at all costs, and I consider myself to be blessed if I have technicians willing to do it for me. Want to guess what it is?

Expressing anal glands? (Nope. I secretly think it is rewarding to do this)

Doing a dental on a pus filled, rotting mouth? (Fun times!)

Sifting through dog puke to make sure it threw up all the rat poison? (Love it, even though I am a sympathy puker)

Draining a 4 day old, putrid, maggot infested cat bite abscess? (No, although dealing with maggot wounds sometimes makes me reconsider my career choices.)

As gross and vomit inducing as all of the above may be, the thing I hate doing the most as a veterinarian is talking to clients about money.

That may surprise those of you non-veterinarians out there, but if you were to take a poll I have a feeling you would find many vets feel the same way. We came into this career to do the best we possibly can for each patient, and when finances intervene it gets tricky and heart wrenching. We find ourselves having to consider and weigh the best interests of the patient, the finances of the client, and the demands of our business. I love and want to help animals, and yet I have to make a living. These sometimes competing interests can put us in a horrible dilemma, where no matter which way we turn someone gets hurt.

After vet school I practiced for about 3 years in the desert of Southern California. If you are nuts enough to stay with me on this blog you will realize how much I learned out there. Anyways, in that area were a lot of backyard Chihuahua breeders.

Chihuahuas are cute little dogs. Sometimes they can be little bitty land sharks, but regardless of their nature the females often have a teeny pelvis and have to give birth to puppies with larger than normal skulls. As a result, it is a breed in which pregnant females often need to undergo a Caesarian section.

One day, a man I will call Mr. Smith came running into the clinic with his pregnant Chihuahua, “Precious.” Precious weighed all of 5 pounds, and had been in unproductive labor for 2 days. By this point she was cold, weak and in tremendous pain. Her puppies were dead, and lodged in her pelvic canal.

I quickly did an exam on her, and started her on emergency treatments….warming her, giving her IV fluids and a dose of pain medication. I told Mr. Smith that the only hope for saving Precious was to do an emergency C-section. She would need to be on intravenous fluids, pain medication and antibiotics. The total cost for treatment was going to be 600-800 dollars.

Mr. Smith scoffed, and told me that the only money he had was the forty dollars he had in his pocket…not even enough for the initial exam. He didn’t own any credit cards, and insisted there were no relatives he could call, or items he could pawn. I had a sweet, shivering, dying dog whose owner could not possibly afford the treatment needed to save her life.

I went and begged and pleaded with my boss, who kindly but reluctantly allowed me to cut Mr. Smith a break. I would give Precious the treatment she needed, we would spay her so she could no longer have puppies, and we would only charge Mr. Smith $100.00, which would need to be paid within 5 days. Mr. Smith appeared to be grateful, and left Precious in my care.

The surgery went extremely well, and 2 days later Precious was bright, happy, and munching on the daily chicken I would bring her. Mr. Smith thanked us, and took Precious home.

Guess what? He never paid us a cent.

About 2 months later, Mr. Smith returned to the clinic with “Angel,” another pregnant Chihuahua with the exact same problem as Precious. Dead puppies. Unproductive labor, this time for 3 days. Cold. In tremendous pain. Dying.

Now, the veterinarian in me wanted to rush Angel back and get to work saving her. However, this would have meant doing another 600-800 dollar procedure at no cost. I spoke to my boss, who as gently as he could told me we could not afford to extend more charity to this man who had yet to pay us ANYTHING for the first C-section. He told me I could offer to have Mr. Smith sign ownership of Angel to us, or I could offer to put Angel to sleep at no charge, which would at least end her suffering.

I went back into the exam room and explained this all to Mr. Smith. He was very angry. He told me there was no way he was going to let me “steal or murder” his dog. He kept begging me to save her. He cried. He pleaded. He told me that his mother had just recently died and Angel was the only friend he had left in the world. He asked me how I could be so cold and heartless. Didn’t I see she was suffering?

It was an awful situation. In the end, Mr. Smith yelled that I was a cold hearted witch that only cared about money. He took Angel home, where I am sure she died a horrible, painful death. That case still haunts me.

Now I know some of you may be agreeing with Mr. Smith…that I was cold, that I should have just done the surgery and saved Angel. I could have let him make payments, or taken a post-dated check, or just gone ahead and done the surgery at no cost. The kind, compassionate veterinarian in me agrees with you. After all, it wasn’t Angel’s fault that her owner could not afford the surgery, right?

Here’s the thing though….when would it end? What if in another few months Mr. Smith came into the clinic with no money, with another sick dog that needed help? What about the clients that sacrificed and stretched to pay for their animal’s treatment? If I continued to give my services away for free, I would either bankrupt the hospital or find myself without a job and a mountain of student debt, a car payment, insurance payment, rent, etc.

It is expensive to operate a veterinary hospital. For your average clinic, by the time you factor in the daily cost of employee salaries, supplies such as medications, electricity, water, waste disposal, taxes, etc. it costs at least $2800 per day.

This is why I hate discussing money with owners. I feel guilty, because there is a part of me that feels bad for charging people for what I do. In a perfect world, I could give each pet the best care every time. Money would be no object AND I would make enough to pay my bills and save a bit.

However, that dream world doesn’t exist. I used to think human doctors had it so easy because insurance paid for everything. Hmm. It seems like they aren’t even close to figuring that one out. How do you provide good quality health care to everyone when good quality health care is REALLY expensive? Like I said, it is a dilemma.

We veterinarians are not rich. We don’t go into this profession to make a gazillion dollars. Many of us are happy if we have enough left over to put into savings. We want to practice good medicine, and we want to use our knowledge and expertise to save lives. It breaks our heart when this isn’t possible, and it crushes our souls when we get accused of loving money more than the well-being of our patients.

There are, of course, a few dishonest veterinarians out there that try to milk clients for everything that they are worth…who pad the bill with unnecessary tests, or the most expensive medications. Trust me…they are few and far between. Our profession abhors them.

If you own a pet, please consider that veterinary care is often quite expensive. Plan for it, and consider having a savings account, or looking into pet insurance. Take your dog or cat into the vet for annual exams so that potential problems can be addressed early on. Remember that when we present you with a treatment estimate we are not trying to scam you. We care about your pet, and we need to get paid for what we do so we can continue on caring for pets for many years to come.

If you are a vet that has found yourself in the same dilemma, my next blog entry will be for you. (Compassion fatigue). In the meantime, be kind to yourself and remember that you can only do what you can, with what you have, given the situation in front of you. Take care.