This week I enjoyed the first of three ‘Winter Webinars’ run by the Sir James Dunn Animal Welfare Centre at The Atlantic Veterinary College (AVC). For those of you who are not familiar with these, they are web-based seminars (aka ‘webinars’) available to veterinarians and veterinary technicians. Enrolment is free to students – including postgraduates. Last year’s webinars were very good, so I have enrolled again this year. The webinars are hosted at a set time and you login via a link that is emailed to you. There are opportunities to ask the speaker questions during the webinar, and a copy of the recording is emailed to you later. This last point is a real bonus for those of us in different time zones. Last year I could attend the webinar ‘live’, but as it is being run at a different time this year, I watch the recording later instead.
The theme for this year is ‘New Approaches to Old Diseases’ with the aim of going over some approaches for discussing end-of-life (EoL) with clients. The webinars are given by Dr Caroline Hewson and Dr Christine Savidge. Caroline has published widely on EoL care [1-3] and is The Pet Loss Vet. Christine is an assistant professor at the AVC and a small animal internal medicine specialist (Dip.ACVIM).
The first webinar (last week) was titled ‘The Toolbox’. Caroline went over some tools to deliver terminal diagnoses and to identify when to start taking about euthanasia with clients. I am going to briefly review the webinars.
Caroline started by going over why The Toolbox is important; why it is needed in the first place. She said the tools could help us (veterinary professionals) to prevent animals from suffering, to support our clients in talking about EoL and their concerns, and to help our clients be ready for clinical uncertainty. She mentioned a study by Fernandez-Mehler, Gloor  where roughly a third of clients would have preferred the EoL issue was raised sooner.
Caroline has FOUR tools in her toolbox. They are: (1) disease trajectory graphs; (2) a key question; (3) communication tools; and (4) a euthanasia decision-making tool.
1 Disease trajectory graphs
These ask, ‘what is the change in physical functioning over time?’ Caroline showed us some examples of disease trajectory graphs from a human paper . These types of graphs provide a visual aide to owners, showing them what the disease progression may look like and what they should expect with their pet. Caroline indicated that we don’t need to have one for every disease, but a few generic ones instead. For example, we could have one for diseases/illness that have long-term limitations with intermittent serious episodes – this could be used for cases of renal insufficiency or heart disease. I like this idea. We can overwhelm our clients with lots of statistics and quote numbers at them from textbooks or the latest research, but a simple diagram invariably shows more than all those numbers ever could.
2 A key question
This is a trigger question for veterinarians to ask ourselves (in our head) when we diagnose a condition and at every check-up with a diseased animal. It is meant to help us decide if it is appropriate to discuss EoL with our client(s). The question is: ‘Would I be surprised if this dog/cat died in the next 6 months?’ The idea being that if you answer ‘no’ (you would not be surprised) then Caroline suggests you must raise EoL with the owner. This is quite a good way of thinking about it. If you, as the veterinarian, think the animal may die soon (i.e. in the next 6 months) then shouldn’t you bring this up with the owner? Wouldn’t it be better to have that discussion sooner rather than later (later potentially being in 8 months’ time, when the owner suddenly realises the animal is suffering terribly and wishes they had contacted you sooner OR wished you had brought it up with them sooner )?
3 Communication tools
If you have decided you need to have this EoL discussion, or the owner has come to you wanting to discuss euthanasia, then good communication is key. Caroline has three areas that she thinks are important: empathy, honesty, and finding out information preferences.
Empathy can be learned and involves recognising emotion in others and reflecting this understanding of their emotion back to them. Caroline said that instead of empathising, veterinary professionals can sometimes be guilty of lecturing (i.e. giving lots of information) or distracting (ignoring feelings by offering tea/water/platitudes) clients. Honesty is also important; ‘protecting’ clients from reality isn’t helpful. Asking clients outright how much information they would like to know (i.e. finding out their information preferences) may help with this.
4 Euthanasia decision-making tool
Designed to answer whether the animal has a ‘life worth living’  or to assist the client who asks “How do I know when it’s time?”, Caroline uses her own ‘A-B-C Yardstick for euthanasia decisions’. Much like the ABC’s of CPR, this initialism mneumonic stands for three steps in the decision-making process. In this case, they are:
- A for ‘Agony’: Is the animal in unmanageable pain or distress OR at imminent risk of these?
- B for ‘Burden’: Is treatment a burden to the animal?
- C for ‘Continue to enjoy positives of being alive’: Does the animal have what s/he wants and enjoys?
This is a great little way to get our clients to think about their animal and their treatment, but, like some of the EoL scales already in use [7, 8], it does limit the areas (or domains)  considered.
Overall, I enjoyed the first webinar and look forward to hearing Dr Savidge speak to us this week about the use of disease trajectories in renal disease.
- Hewson, C., Grief for pets – Part 1: Overview and some false assumptions. Veterinary Nursing Journal, 2014. 29(9): p. 302-305.
- Hewson, C., Grief for pets Part 2: Realistic client care so that you ‘do no harm’. Veterinary Ireland Journal, 2014. 4(8): p. 431-436.
- Hewson, C., End-of-life care: the why and how of animal hospice. Veterinary Nursing Journal, 2015. 30(10): p. 287-289.
- Fernandez-Mehler, P., et al., Veterinarians’ role for pet owners facing pet loss. Veterinary Record, 2013. 172(21).
- Lynn, J. and D.M. Adamson, Living well at the end of life: Adapting health care to serious chronic illness in old age. RAND white paper, 2003.
- Yeates, J.W., Is ‘a life worth living’ a concept worth having? Animal Welfare, 2011. 20(3): p. 397-406.
- Villalobos, A. and L. Kaplan, Canine and feline geriatric oncology: honoring the human-animal bond, ed. L. Kaplan. 2007, Ames, Iowa: Blackwell Publishing.
- Hilst, K., J.O.U.R.N.E.Y.S.: A quality of life scale for pets. 2013.
- Mellor, D.J. and N.J. Beausoleil, Extending the ‘Five Domains’ model for animal welfare assessment to incorporate positive welfare states. Animal Welfare, 2015. 24(3): p. 241-253.