08 Aug Accustomed to euthanasia — The everyday life of veterinarians
The 104-year-old Australian scientist, David Goodall decided to travel to Switzerland in order to undergo voluntary euthanasia. Goodall had been ill and claimed that his quality of life had fallen dramatically. He did not want to live that way any longer. In Switzerland, assisted suicide is permitted. This gave Goodall the possibility of a humane ending of life — which is, I believe, a great privilege. In Poland, however, strong emotions arise when it comes to disconnecting terminally-ill people from life-support machines or abortion (in cases guaranteed by the Constitution). People who know little about euthanasia are particularly loud about it.
In this article, I will tell you about euthanasia from a veterinarian’s perspective — someone who takes lives on a daily basis. Our job is highly demanding due to the different aspects euthanasia brings and the mental burden it puts on us. The topic is rarely discussed. Here, I would like to open the conversation about it and warmly invite you to join me. ‘Death is inscribed in this profession’ — as phrased in the title of Magdalena Rigamonti’s interview with me, the first discussion of its kind in Poland.
The recipe of a humane death
It is not a secret that pentobarbital is used for carrying out euthanasia. As described by the media, Dr Goodall unblocked the valve to release the solution himself, complying with Swiss laws. After eating his favorite meal — fish and chips, he was accompanied on his last journey by a friend and his grandchildren. By entering euthanasia agents in Google Search, you can find the list of authorized products in different countries. In Poland, for instance, on the website of the National Veterinary Chamber you will find the article of Maja Taraszkiewicz about veterinary pharmacological euthanasia. Indeed, in our veterinary practice, we use the same substance.
Animal euthanasia ought to be fast, painless and should cause minimal distress. Nevertheless, the administration of pentobarbital is accompanied by pain and stress. Therefore, premedication is often used, which calms the animal and helps it fall asleep. Afterwards, the animal receives the intravenous injection containing pentobarbital. This stops the cardiopulmonary action. As a result of the paralysis of the respiratory muscles and the respiratory center in the brain, hypoxia and death occur.
While studying veterinary medicine, we only come across euthanasia agents during pharmacology classes. We learn about groups of barbiturates, doses and duration of action. And that’s all. We are told nothing about how to carry out the treatment or how to take care of the owner and the animal in the process. We have to learn it later, in practice, often to our superior’s first, possibly surprising request to perform the procedure.
The owner remembers
Euthanasia is an important and often traumatic experience for the owner and the animal, therefore I make sure to carry it out in an atmosphere of support, peace and dignity. Timing is a notable aspect: I usually perform euthanasia at the end of the shift or in the evening when there are no other clients in the clinic, and when there is no bustle of conversations and laughter. I make sure that the owner, crying, with his best friend’s body wrapped in a towel, does not have to pass through the waiting room full of people and animals.
During my internship in the USA, I saw a candle-shaped lamp lit at the reception desk with a note that the last farewell is taking place in Room 4. What a beautiful and humane gesture! It respectfully showed the seriousness of the moment to customers, and left no need to silence anyone. In Sweden, the room has dim lights and a candle in the table. The window and the door are covered so that nobody sees inside. At the end of the process, the owner can leave through the back door.
I perform the procedure in an empty office, with a blanket or a towel on the ground where the animal can be comfortable. It is even better if we can use its favorite bed or comforter, something that smells familiar. For the owner, I prepare tissues and water, knowing how much crying can dehydrate us and lead to a runny nose.
Having inserted the catheter (usually in the vein on the front limb) and given the intramuscular injection with premedication, I invite the owner to spend some more time with their beloved. I describe the process step by step, I explain what happens to the animal: it gradually falls asleep, stops feeling pain and react to stimuli. It reassures the owner and makes them feel that they and their animal are treated with dignity and respect. I ask the owner to call me when he is ready. Meanwhile, I prepare the injection of pentobarbital and a stethoscope.
In a few minutes, I’m asked to come back. In the company of the owner, having a chance to cuddle the pet, I give a second injection and say “The first injection caused Harry to fall asleep deeply. After the next one, his heart will stop, and Harry will start crossing the rainbow bridge. Don’t worry, he doesn’t feel any more pain. You did the best for him, and made a good decision. He lived a wonderful and happy life.”
The heartbeat accelerates for a moment, then slows down and becomes arrhythmic. I keep the stethoscope on my patient’s chest, with my other hand stroking them over the head. In a few moments, heartbeats quiet down, get less and less steady until stopping completely.
Then I nod gently. I hug the crying owner, I caress their hair. I repeat that I am sorry. Because I really am sorry. Always, with no exception. Sometimes, I even have a lump in my throat, especially after a long and bitter fight against disease. I let the owner be with the animal some more. After they leave the clinic, I prepare a protocol about the visit. Depending on whether the owner decided to collect the body or cremate (collectively or individually, with the possibility to collect the urn), I gently arrange the corpse for collection with the help of a nurse or place it in the freezer so that it can be collected by the company specializing in cremation of animals.
I’ve received several thank you notes from owners. “Thank you, Dr. Natalia, for warmly helping us through such difficult moments.” “Dr. Natalia, thank you for the last journey of Rocky.” The owner remembers every little thing: our tone of voice, how they were treated, our calmness, hurry or nervousness — and the jokes in the waiting room.
My first euthanasia
I carried out my first euthanasia during my studies, when volunteering in India at a foundation helping street animals. One day I brought an old, molted, devastated dog to the clinic that was unable to stand up on its own. My colleague said we have to put the animal to sleep due to its grave condition.
I inserted the catheter and prepared the injection. Due to the modest facilities and the poor access to medicines, we used thiopentone for the euthanasia without any premedication. Thiopentone is a short-acting barbiturate, no longer used in Poland. A much bigger amount of it is needed for the same effect compared to pentobarbital. I was sitting there listening to the dog’s heartbeat, which continued after the administration of the high intravenous dose. It was terribly fast, as if it were to jump off its chest. I had tears in my eyes and I wanted it all to be over fast. The dog alternately fell into apnoea, breathed quickly and shallowly, then slowed down: Cheyne-Stokes’ respiration… Only after the second did the animal relax, its heart slowing down, then stopping completely. I was holding my stethoscope to its breast. Silence. One more breath. And one more. I jumped up, my colleague laughed. Then silence again. The experience has accompanied me through my veterinary practice ever since.
Now, a few years later, the situation looks utterly different. “It’s over. Milka fell asleep forever.” And then there are two more chest movements, and the owner goes “But doctor, she’s breathing!” I can see the terror in their eyes. I say ‘Yes, sometimes after death there is a brainstem reflex. I’m sorry it frightened you. She has fallen asleep forever.” In such an overwhelming moment, we mustn’t tell the owner not to worry and that it’s normal, even though we are prepared for the unpleasant symptoms accompanying death, like agonal breathing. Our reaction and our calmness is a key factor in the owner’s experience.
The administration of pentobarbital is also accompanied by slight involuntary muscle spasms, the expected death not happening or taking a longer time. This is very common in the case of perivascular administration that chronically ill, dehydrated or enfeebled animals tend to require, since their veins can burst and hematomas can form around them. In situations like so, we are forced to look for another vessel, or when everything else fails, inject the patient intracardially or intraperitoneally (especially in small mammals). In such circumstances, I tell the owner calmly that this unfortunate event occurs, I calm them, and look for the new place of injection. We also have to be prepared that the animal can discharge feces and urine after passing away and that cats’ eyes stay wide open.
As a veterinarian, their fear, despair and terror is in my hands. Every single time, I wish it had been over at the first try, to save them the unnecessary stress. Only we, veterinarians comprehend the amount of stress we have to face ourselves. Euthanasia causes the so-called “compassion fatigue”, being one of the significant factors of burnout in the industry.
The many reasons
Why do veterinarians perform animal euthanasia? Because we have the right, the luxury, the privilege to see whether an animal’s quality of life is excessively low. It is our role as veterinarians to assess if the patient’s suffering calls for the decision of ending their life. However, the final decision has to be made by the owner. We can only make suggestions.
Most often, euthanasia is chosen in the case of incurable ill animals. In these cases, all forms of treatment have been tried and failed, and the prognosis is bad. This can be the end of a long and cumbersome palliative therapy, e.g. in ontological treatment.
However, it’s common to encounter situations where there is a treatment to cure the animal, but the owner cannot afford it, so they decide on euthanasia. Knowing that the animal’s chance to heal is only hindered by the owner’s means is an important factor leading to the burnout of veterinary surgeons. As a study conducted in the USA shows, veterinarians are much less satisfied with their work when they are unable to provide the highest quality and most efficient services.
Here are some other scenarios of requesting euthanasia. The animal is old and smells or there’s a new puppy already that needs the room. The owner feels like they are wasting money on treatment, which is very common in the case of small mammals: it’s not worth it to treat the pet because a new one costs 20 zlotys (4 euros 50 cents). Sometimes the owner feels like the dog or cat is a burden or become bored with it. There might be a problem with the animal, e.g. peeing on the bed, having bad breath, not getting along with other pets. In such situations, we, veterinarians, have to think humanely but also consider the limits of our job. Only humans are able to think about others with sympathy and tenderness — and those of us who are unable to do so, do not deserve animals. Sadly, in Poland, animals are still likely to be treated like disposable objects.
Sometimes, I do think euthanasia is the best option for the animal: it can set a neglected animal free from a careless owner. I have seen tennis ball-sized tumors, which, according to the owner, only appeared the week before. I’ve also seen cats with kidney failure, so emaciated that they could barely stand. Sometimes the owner comes too late, or only requests a nail-clipping for a severely ill animal. Other owners demand a long-term therapy in cases when it would only prolong the suffering of the animal, not cure it.
After examining the animal, I have a difficult and long conversation with the owner. I present my insights, supported by arguments aimed at protecting the animal from further suffering. The decision is, again, the owner’s.
Many times we could report animal abuse, but we are afraid of the online hate. The disappointed owners are more and more common to arouse such hateful conversations and encourage their friends to join, destroying our reputation. When witnessing dramatic scenes, we must keep our calm and stick to medical confidentiality.
The owner might try to force us to make the decision for them. This often happens in ambiguous situations, e.g. when the cure of the animal cannot be guaranteed, and when the expensive palliative therapy would barely be enough to keep them alive. This is heavy and stressful veterinarians: the owner bears full responsibility in the decision, and we can at most suggest options and give an advice.
Five scenes of life and death
A) “Good morning, I am here to put my dog to sleep. He’s old and smells really bad.”
“Let me invite you into my office. Please tell me more. Is something bothering or hurting your dog? Have you seen him suffer?”
“No. He’s 10 years old now. He smells and doesn’t want to eat lately.”
“10 years for a dog means about 56 years of human age. I bet you would not want to die at such a young age.” Meanwhile I examine the animal. “Your dog has severe plaque and periodontitis. No wonder he doesn’t want to eat. We can remove it easily. As a result, he will feel much better and the smell will disappear.”
“So he will stop smelling? Could you also clip his nails?”
B) A man enters with two dog, a female a male, siblings. The 12-year-old female is euthanized because of liver cancer. After the procedure, I cover her with a blanket. The owner bursts into tears, and I hug him. “Can you also put him to sleep? He cannot go on without his sister,” he says.
C) A lady comes in with a 22-year-old cat, extremely skinny with a thyroid failure and chronic kidney failure. I inform the lady that the insertion of the catheter might be hard because of the sunken veins. She tells me there is no problem. She has had 4 cats and she’s not afraid. She doesn’t want to participate in the procedure, knowing what it looks like. She doesn’t want the body back. She reassures me, so I start the procedure. I give the premedication, and after it fell asleep, the cardiac injection. I am calmer when the owners aren’t present. I know that it’s a dramatic experience for them.
D) A couple with two school-age children arrives. Their old Labrador is scheduled for euthanasia, and they all insist to be present. We sit on the ground, and they hug their friend’s body. All four of them cry. It makes me tear up as well. They order an urn in the shape of a toy-bone. It will stand on the fireplace next to another urn made of beech. That one belongs to their beloved cat who was put to sleep 3 months before. (This story happened in England where children are allowed to be present during euthanasia.)
E) We got an order from our manager to put a 2-year-old, healthy female dog to sleep. According to the owner, the dog bit her child. I didn’t meet the owner, only heard her screams ordering the clinic to “kill her as soon as possible”. I was told that the owner was about 20 years old and had a 2-year-old daughter. I imagined the story happened like so: the toddler, running around the house, wanted to cuddle the dog. She pulled its ear and the dog showed its teeth or delicately bit the child. The owner spends half an hour talking to the staff, trying to convince and encourage her to find a temporary home instead. Our receptionist is calling our friends, trying to do something about the situation.
However, the owner’s decision has been made, and our manager insists on carrying it out. She refers to the UK laws: a dog can be put to sleep in case of biting a human. But we have no physical proof of it. We are devastated but the discussion is over. It has to be done. The owner has paid for the procedure, signed the agreement about euthanasia, and left the clinic. The dog is licking our faces joyfully. Tears are rolling down our cheeks as a friend gives the injection to the dog. We lie on the ground next to the animal that’s still warm.
In 15 minutes, the receptionist enters and informs us that she managed to find a temporary home. Can this get any worse? Sobbing, we place the body in a bag and in the freezer. Half an hour later, the manager comes. “Can I spoil your mood even more?” she asks. She goes on to tell us that the owner has changed her mind. She wants the dog back, and her friend would receive it.
Not to die like an animal
“I want to die with dignity. I do not want to die like an animal,” say several elderly people. I can assure you though: my animal patients do leave with dignity and respect, often surrounded by their loved ones, the owners caring for them all their lives, who made the tough but crucial choice not to let them suffer more.
I will never forget visiting my grandfather in hospital as a child: he was dying of bone cancer with metastases to his brain. He had bedsores, and a catheter distributed morphine into his bruised arm. I can hear his wheezing breath to this day. Now I know it was the symptom of pulmonary oedema. He suffered much, for a long time. Too much, too long. He was not given a dignified death. Dr Goodall however, did not suffer from severe pain or serious illness. He was simply dissatisfied with his quality of life and did not want to live any longer. He consciously chose a peaceful ending.
I have the power to give life, as well as to end it. It is a gift and a curse at the same time. “You become responsible forever for what you’ve tamed,” said the fox to the Little Prince.
Author: DVM Natalia Strokowska
Extracts of the article can be found in an extensive interview with Magdalena Rigamonti, in Dziennik Gazeta Prawna on 8.06.2018. The European Union’s role in the fight against terrorism. Death is written into this profession (Polish).