Religious objections and futile treatments: A primer for handling euthanasia disputes | Veterinary Videos & Podcasts

Good evening and welcome to tonight's platinum webinar. I'm Rich Daley, head of sales for the webinar vet, and I'm pleased to welcome you all this evening to our webinar entitled Euthanasia Disputes, Religious Objections and Futile Treatments. Firstly, the housekeeping.

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So, on to tonight. I'm delighted that we've been joined by Caroline Hewson. We've, Caroline has done a number of webinars for us previously, and they've always been really well received, so I'm really looking forward to tonight's as well.

So for those of you not aware of Caroline, Caroline, after practising for six years in the UK, moved to Canada. There she received a PhD from the University of Guelph, and from 2000 to 2006 was inaugural research chair in animal welfare at the Atlantic Veterinary College. She then returned to the UK where she resumed her clinical work.

So without further ado, I'd like to hand over to Caroline for Tonight's webinar. Oh, before I do, sorry, one last thing, there will be two poll questions tonight, so please do take part in those poll questions at the right time. I will be launching the poll question and please do select your answer, as once again, it'll really help with the discussion.

So sorry about that, Alan, now it's over to you. Thanks, Rich and good evening everyone. It's great to be with you to talk about this subject.

Thank you for taking time out of your long and busy day to all get together this evening. And we're talking about euthanasia disputes in general and then focusing in a little bit on religious objections to euthanasia and on futile treatments. And I call myself these days the pet cloth that.

So having returned to practise, I was especially interested in these end of life issues and how they might intersect with animal welfare concerns and ethics and all that good stuff. And for the last few years, that's really been my work, spending time with practises and training and teaching and that, that sort of thing. What we're doing tonight is I'm simply sharing with you.

The information I've been able to to pull together and, and in response to what colleagues have asked me about. So my starting point is, I'm sure you're already doing a really, really good job, and I'm not here to tell you that I've suddenly found the answer to everything, and you know nothing, far from it. I'm here simply to share some ideas and some particular potential answers to these really difficult areas that sometimes come up for us when we're in the clinic.

And what we'll be covering tonight are 6 things. We look at why disputes happen. We look at a core communication tool, and then we'll go through a simple 6 step road map.

If you are getting in a dispute, what are the steps to follow? And we'll then look more closely at religious objections and requests for futile treatments in light of the other earlier points of communication and the road map and so forth. And we'll also look a bit at palliative sedation and analgesia.

And you'll see at the bottom of this slide, I've highlighted the slide number in red and pointed an arrow to it. And that's just so you know, if there's something on a slide, in particular when it comes to different wordings, I'll give you examples of those, and we won't spend time on them tonight, but they'll be written out on the slide. So if you'd like to come back to the slide later when you're watching the recording, or when you're looking at the PDF of the slides with space for notes afterwards, you'll know which slides to zero in on.

So, Let's start with our first poll and and just so we get a sense of where we all are, if you think back to May 1st, so just over the last 10 days, have you or any vet in your practise had a euthanasia dispute about putting down an animal that's sick, where the vet thinks euthanasia's best, and the client has been reluctant? OK, so I've just launched the polling now. So please do complete your answer, as I say, yes, no or not applicable.

It's really just helped just give Caroline an idea of the sort of levels that we're dealing with here. So I'll just give you 5 more seconds to register your answer. As I said there's no wrong answer, so you can't lose your CPD hour if you get it wrong.

There's no such thing as a wrong answer in this one. OK, I'll just end the poll in there. OK, so, in the, in the last 10 days, 21% of people have had a, euthanasia dispute.

67% have said they haven't, and 13% have said it's not applicable. Great. Chris, thanks, thanks very much, everyone.

So isn't that interesting that now mind you, I'm not sure how many of you are live on the call if there are 6 of you or whatever, but still 1/5 of, no, there can't be 6 because 21% of 6. Doesn't doesn't compute. But anyway, to about 41 at the moment, Caroline.

Oh, great. Great. So, you know, 1/5 of us just in the last 10 days, have had some sort of an awkward consultation or series of consultations where you felt or or a vet in the practise, another vet in the practises felt euthanasia was best, and the client's been reluctant.

So, the, the first thing to say when we look at disputes is how stressful they are. And you don't need me to tell you that we all know that. And if you're really feeling burned out and stressed by disputes and and life generally, I just put this slide together just to, to encourage you and reassure you that, that happens to so many of us from time to time.

And if you're really, really feeling the squeeze, don't forget about the Vet Life helpline and the Vet Life website, or Samaritans, if you don't fancy talking to vets. There are just a couple of examples of all the support that's there because we travel in company in our profession. Your travelling company in good company.

So, Vet Life helplines there to support us as colleagues and vets and vet nurses together. And, you know, in wider society here in the UK and if you're phoning from other countries, from your countries too, and I don't think either of these helplines are restrictive about who would be phoning them from where, but just to, to reassure you that you're not on your own. You're not on your own if you're really struggling with these things.

So why do disputes happen? Why did they happen? And the first reason, and there are many, and I'm just going to cover a few of them, almost certainly it's because most of us weren't trained in how to have euthanasia consultations and what to do if a client disagrees.

We weren't trained about the psychosocial aspects of all of this. And those two references refer to research by Barker, who expressly asked a random sample of about 158 practises and vets within those practises. How they felt about euthanasia and various questions around that, and 65% of that sample said, I didn't feel prepared.

And then, fast forward 8 years, McDermott and colleagues did a massive random sample of vets in the UK, about 3000 of them, and likewise, from America, and 65% of the respondents, the response rate from the UK I think was about 60%. It was lower in America, but of those respondents, 65% said, I didn't feel prepared for, for all my client encounters. So it's no wonder then, when, when we're in a difficult situation with a sick animal, if a client says, no, I, I don't agree with you about euthanasia, we don't know quite what to do, especially when we're new graduates, and then as older graduates, we, we figure out we're a bit older and more mature, and we figure out our way of doing things, but it doesn't make it easier and it doesn't make it work necessarily.

So that's partly why they come up. Another one is denial. Now, you'll hear people say, well, the client's just in denial.

Denial is not a sulky foldy army childish thing. So it isn't as this image shows someone putting their fingers in their ears and saying, I refuse to listen to you, because I'm just a self-absorbed person who isn't interested in what you have to say. Denial is, almost always, the odd time you'll meet a personality who would be, obstructive, we can say.

But denial is a psychological response to what would otherwise be overwhelming. So it's a very adaptive, protective thing. And with denial, reality seems unreal.

So if a client would be in denial, if we told them that the animal was seriously ill and we felt euthanasia was best. That could be overwhelming for some people because they may just have come through other bereavements and maybe a friend or a partner is dying of cancer and people have a lot going on in their lives just as we do. And so to suddenly be told this, sometimes the brain just kicks in and it seems unreal.

And of course, if it seems unreal that it can't be true that the animal is dying and needs euthanasia, then it makes sense to be reluctant. Why would you? Why would you go along with it and why would you agree?

So denial certainly can affect people's decisions about euthanasia, and it's not generally a weakness in the client at all. It's a deeply human thing. So, that's another reason why we get into disputes.

Another one is that people have negative, they've had bad experiences with the euthanasia of an animal in the past, or they have very negative ideas about it. So in a survey that cats protection here in the UK did of cat owners, and I've not been able to get hold of the original data. So this is drawn from their website, and they mentioned a market research company that they used and a sample size just over 1000.

So I'm assuming that that was proper, proper random sampling and so forth, because typically, a sample of about that number is, will give you a fair idea of what the population at large thinks, but I don't know if that's the case. Whatever the case, amongst the respondents, more than 50%, I think it was about 55%, expected that having to decide to to euthanize their animal would make their grief worse. So they had this feeling that euthanasia would make it even harder.

So, of course, if you've got that sense, if your vet says, I think it's time for euthanasia, then, you know, what, why would you consent? You, you don't want to, it's sad enough even hearing that, but why would you necessarily agree with it because you're, it will be bringing on this, this awful grief. Also in relation to that, we hear so much well it's the client's decision, you mustn't interfere, and we especially hear that from American sources because America is a rights-based culture, so autonomy is so important there.

It's not that it's not important over here in the in Europe, but it's especially important in America. And, having said that, this quote is from a Danish dog owner from research that was done over at the, the, veterinary college in Copenhagen. And one of the comments that the owner made was this particular owner said, but you have to make that euthanasia decision yourself.

I think that's horrible. So we say, you know, I think your animals not very well and this and that, and then we make the diagnosis and then we recommend euthanasia and then say, but you have to decide. And of course, understandably clients feel abandoned and horrified that they have to decide to have their animal killed.

So again, it's not surprising that some of them disagree with us and are reluctant. Here's another one that they perceive we lack empathy. So whether it's receptionists, whether it's the vets, veterinary nurses, they perceive we lack empathy and, and often.

I'm afraid they're right. Alison Lambert from On Switch, the business research group here, did a mystery shopping of reception staff among participating practises, and she particularly did one on euthanasia. So the mystery caller phoned up and said that they had a dog that might need euthanizing, and they've never had to ask this before.

And there was quite a range in response, and some of the the receptionist obviously hadn't been trained. And the responses were not empathic. They were very businesslike and factual, and some of them a bit impatient.

If the caller was was tearful. And then, of course, if the caller then comes in anyway, sees the vet, the vet doesn't show empathy, or the caller perceives that the vet isn't empathic, or the client, we can say, or the veterinary nurse, then, of course, that's another reason they don't, people don't feel understood by us. And sure enough, back to this Danish survey, here's an example.

This client said, I tried to bring up that maybe I was considering euthanasia and it was really difficult for me because I think it's wrong. It was as if they didn't really understand what I was trying to say. It was as if they didn't really understand what I was trying to say.

Now that's not to say that the staff weren't in fact really trying. Of course, we weren't there and so forth. But this is how this dog owner experienced her consultation at the vet College there.

She was struggling with euthanasia because Pat's relig religious beliefs or whatever it is that she felt euthanasia was wrong. And she felt the staff didn't really understand what she was about or was trying to say. And that brings us on to something we'll touch on in more detail later, religious beliefs.

I'm mentioned in the, the, outline for the talk, Christianity and, and, Islam, just simply because vets have asked me about those, but not in any way to to single those out, but simply because those are the ones that had come up. You know, why do people, what are the religious beliefs that might lead someone to to be reluctant to agree to euthanasia and what can we do? Here's a big one.

This is my topic of the moment, in my little world here looking at these things, uncertainty. And in human medicine, there's a big developing movement here in the UK and elsewhere to for clinicians in primary care, so that's GPs. To start talking about advanced care planning with patients early on, that we shouldn't wait until people are half dead with cancer before we start to talk about it.

And one of the aspects of this is that it's really uncertain. Sometimes diagnoses are uncertain, life spans are uncertain. When you're gonna start getting really unwell is uncertain.

And of course, that's true in that new medicine as well. And it's really interesting, the research and the thinking going on around this. And I've got my hypothesis is that that can be quite a big thing for us and our, our clients as well.

So there are two kinds of uncertainty. There's informational uncertainty. And there's intrinsic uncertainty.

So informational uncertainty, we try and address by doing tests. So the cat comes in, drinking a lot, losing weight, breath smells, daddy, we do the tests, and she's not actually ketotic, she's got renal insufficiency. So that's fine, but the question is, well, how bad is it?

It looks kind of bad at the moment, we put her on a drip, but then we need to do a test a few days later or ongoing test to see what the blood, urine nitrogen or the phosphorus and everything are doing. So doing tests helps us to whittle away at an informational uncertainty. It helps us to get diagnoses and to, to get a sense of how the animal's progressing.

But even if, despite our best efforts, that the, the BUN and creatinine and so forth are not really coming down the way we'd like, we still can't say for sure when the animal would would die naturally, when is the best moment for euthanasia. And that is intrinsically uncertain. There is no way we can predict to the day, to the hour, to the minute.

Or sometimes we say, well, you know, we could put her on a drip and see how she does, and the owner wants to say, well, how likely is she to do better? And we don't know exactly. And the, the data suggests from human medicine, where it's been studied, that terms like very likely or somewhat likely aren't that helpful.

And the ideal is, well, if we have population-based data, and that we don't say things like, well, it's 50% of cats get better when. Because some people don't always understand that it's easier for people to understand if we say for every 100 cats, 50 of them will be dead within 6 months or whatever. Now, of course, that's a blunt way of putting it.

But again, there's a lot around uncertainty and how we explain it to people and the fact that we might be honest about it. Because uncertainty breeds either fear, because we're terrible, you know, we don't know when it's gonna happen, and it's a natural psychological response to be fearful if you can't predict and can't control what's gonna happen. And it tends either to generate fear or great hope.

We don't know, and maybe it's gonna be OK, and maybe my cat's gonna live for a long time. And if you end up with excessive fear or excessive hope, then you've got expectations which, which can't be met or which aren't met, and, and it doesn't help. And this is the big theme with the development in discussing end of life and dying and all these things early on in human primary care, to actually start being clear about uncertainty.

And I, I live in Melrose, just south of Edinburgh, and there's really exciting work that's been going on in the medical faculty at the University of Edinburgh for some 20 years. Very exciting, very straightforward, and it's spread around the world. And it's done by the, palliative care in or what do they call it?

Palliative medicine in primary care. Group within the faculty of medicine. So these are GPs who have university positions who are really digging into this and doing really practical research, talking to patients, etc.

And coming up with useful tools to help discussions and to put this on the table. And their view is uncertainty is an opportunity. The fact that we know some of these things are uncertain, it's an opportunity to, to talk to people.

And Doctor Kirsty Boyd. It's one of that group, she, she calls it, the umbrella of opportunity, you know, there's inherent uncertainty about the weather. We never quite know if it's going to rain, and I don't know where you're all calling in from.

If you're here in the UK, we all know about rain, and, and so do lots of other countries. So what do you do? You have an umbrella, you know, you have an umbrella in the hallway, in the car, in your bag, so that if it does rain, you're ready.

And not to be glib about it, because obviously end of life is a serious matter. But, there, the view of that group is, you know, uncertainty is an opportunity just to sit down with people and have honest discussions and use that idea of look, we don't quite know what's gonna happen. So it would be great to plan ahead to, you know, would you be open to having a starting to talk about these things?

And so for us in veterinary medicine, it means, you know, pulling up a chair with the client, booking an appointment or putting a special sign on the door so that people in the waiting room know that you're talking about some serious things and you might be a while. And then you're using some wordings to start these conversations. And here are some examples, and they're all, I've adapted them from human, the, the recommendations for human medicine.

And we won't go through them now, but slide 19's the one to come back to for that. It's things like, you know, Maggie's doing well at the moment with the new diet, and I hope she'll stay well, but I'm concerned she could get ill again. Could we talk about what we can do if that happens?

It's very straightforward, but we're planning ahead and just putting it on the table. Another tool that's I'm becoming very popular in human medicine and can really, I think, help us is this idea of the pattern of disease when we diagnose an animal, there are different disease trajectories, and we can use these kinds of things, showing how physical function declines over time. And we can, you know, with the clients, set a line where we think it's, it's time to stop.

It's time to intervene with euthanasia. And it's not to predict it to the moment, because we don't know when that time will come. Could be tomorrow, it could be 2 years' time.

We don't know. But if we start talking about the criteria that we would use, and in particular, this is an app called the grey Muzzle app, which was developed by doctors Danny McVetty and Mary Gardner, who are veterinarians in Florida, who have the lack of love veterinary hospice, and they've developed this thing to help people, work out if a dog's having good days or bad days or their their pet is having good days or bad days. So that's something that may have, have, I've not used it myself, but that's the kind of thing that we can talk to clients about to help them to, to monitor their pet's progress and and recognise when they're approaching a stop point when euthanasia is likely to start becoming in the animal's interest.

This is something that, I've developed as part of a, what I call the ABC yardstick, which we'll come back to, but this is a sheet where people can actually go through what makes life worthwhile for my pet. What makes life worthwhile. And in animal welfare science, as some of you will know, there's much more of a focus now on positive welfare benefits of different things.

It's not enough to identify situations that make animals suffer and to to prevent those negative things, but it's important to actively promote positive things. And so if we help our clients to look systematically through. The areas of the animal's life that are important to the animal and every animal is different, and we don't know we're vets, we're not the owner, the owner knows.

Then, that's a way again for them to start to get a sense of when their animal is really failing if they're not doing the things that they normally enjoy. So these are a couple of books that have come out in the last 12 months, one about hospice care for animals and one about treating the geriatric patient. And there's some interesting ideas there about all of these things by which we can support people in getting to grips with the uncertainty that's inherent in some of these diseases and get clear about setting a stop point in which they will be in the the zone, if you like, when euthanasia is likely to be in the animal's interest.

So, we've galloped through a few things, there's a few reasons why disputes happen, things like the fact we're not trained, things like inherent uncertainty, religious beliefs, and just the natural anxieties that our clients have about euthanasia, which again, discussion, in advance can really help with. But sometimes we don't have a chance to talk in advance because clients come in for the first time and here we are. So before we go into the road map for disputes, let's look next at a core communication tool, and you'll probably find you're using this anyway, but they're just some ins and outs and neat things around it, which you can always grab on to just to take, take it all to the next level if you need to.

And the core communication tool is empathy, empathic communication. Empathic communication. So empathy is not something touchy-feely creepy that some people have and some people don't.

This is a natural capacity of us as a social species and the available data suggests that other social species like dogs and starlings and horses and sheep. Have some capacity to experience and express empathy. And the reductionist biological explanation for it is that if you're a social species, it makes sense to understand what other members of your group might be feeling and to respond accordingly, because if you can't tune into that, or if you don't respond correctly, then it's likely to be damaging either for you as a member of the group or for the group as a whole.

So empathy is inherent to us as human beings, and it develops in us more or less, and we learn to express it more or less depending on our upbringing and other things. But it's not something weird, it's inherent to us. And empathy is not distracting.

Would you like a cup of tea? Let me get you a glass of water, let me get you a tissue. That's a useful thing, but that isn't empathy.

And hugging people isn't empathy. And telling people don't feel guilty. I know how you feel.

Don't apologise. That isn't empathy either. And isn't that interesting because these are all quite carrying things to do, but none of those is empathic communication.

Empathic communication consists of two things, understanding what the person might be feeling, and we do that through observation, and we're doing it all the time anyway, subconsciously and consciously, as a, as a social species, we are reading each other's facial expressions and body language all the time. And as a species where it's our faces that express our emotions. And research in the 70s pretty well nailed down that there are 7 primary facial expressions of the main emotions.

It doesn't matter where you go in the world, this is how we as a species communicate. And when you think about dogs, you know, we don't worry if we go on holiday to Thailand, how we're going to interact with the dogs in Thailand, because dogs, you know, wag their tails, the hackles go up, their ears go down, they lie on their backs and make some mis postures. It doesn't matter where they are or what breed they are, that's what they do as a species, more or less.

And this is what Homo sapiens does as a species. This is how we communicate. Now, of course, people can have mixed emotions and it's more subtle than that, but those are the broad ones.

So happy, surprise, contempt, sadness, fear, disgust and anger. And this brings us to our 2nd pole for a bit of fun. This man, take a look at this guy.

And then choose which of the 5 things that you think best describes him based on his expression. Is he happy, surprised, afraid, sad or angry? So take a look, and then Rich has just popped up the pole there and pick the one that you think describes his expression.

OK. I'm not too sure myself. I think if I had a couple of options I might kick a couple of boxes, to be honest.

Yeah, and there's no, you know, it doesn't matter. I mean it's just very broad. It's our perception of what you see that picture being.

Yeah, no problem. OK, so come on, a few more of you, let's get your voting. So I'll give you another 5 seconds.

Do we think he's happy, surprised, afraid, sad, or angry? Perhaps he's just seen the vet bill and he's shocked. I don't know.

OK, I'll just send the pole in there. OK, so, no one has said happy, which I think's a, a good observation, personally. 65% have said surprised.

-huh. 29% have said afraid. Mhm.

6% have said sad. And no one has said angry. And this was just my mock up, but I'd say he looks most, and again, he may have mixed emotions, but the raised eyebrows, you know, goggly eyes and open mouth.

Fit and her expression is exaggerated as they were in that seven picture thing I showed earlier. But it seems to me he's, I, I would go with as well, surprised or shocked, and maybe he's a bit angry as well, or whatever it would be. And again, you know, the, the, our emotions can be mixed.

But that was just a bit of fun to, to tune us into the vague, the general facial expressions. But the, the truth is that without even realising we're reading each other's expressions and in lie detection, what, what that is done there is looking at the so-called micro emotions. So seemingly, if we have a quick stab of emotion based on what someone's saying or based on thought that we've had, You get very subtle changes in facial expression, which are quite consistent.

So, some of, as I understand it, modern lie detection techniques are based on that. And of course, we can be talking to our clients and telling them all about this and that and the other thing, and they might be thinking, how am I gonna tell my, my dad who's got dementia, that the cat's got to be put down. And so the, the client might have a quick flash of something.

And then they're back to us, and we may or may not pick that up, and I'm not saying we should all be learning how to read the, the slightest change in someone's facial expression, but just empathic communication is about being aware of the other person's emotional state. And facial expression is a big part of that. So we are aware of what they might be feeding, and then we reflect that understanding back to them.

So reflecting the understanding back is not distracting. Have a cup of tea, and it's not saying, don't feel what you're feeling. Don't apologise, don't cry.

I know how you feel. It simply reflects back that the person is, you don't have to feel it yourself, but that you understand that they are having a, a strong emotion. So things like, I can see how much you love pumpkin.

Or we can say, you know, if someone's crying, just say, I wish I had better news to give you, because that's acknowledging this is sad, this is difficult. I realised you weren't expecting this. I wasn't expecting it either.

So some of these empathic things, the idea is that we align ourselves with the client. So we don't tell them to stop feeling what they're feeling, we acknowledge it is so. And if we only turn that on in crises or when, when the animal is very ill and the end is very upset, it can seem maybe a bit false.

And it's a natural thing, you know, to also empathise when, when things are going well. So at a checkup or something or a vaccination. You know, it's great to see Muffy looking so well, I can see how much you care about him.

That's an empathic statement, you know, because the owner's patting the dog and the dog's happy to be leaving or whatever it is. So, again, these aren't scripts, and I should have said, not again, I haven't said it before, but the whole thing about this is just to give you ideas, not to say you have to say this thing at this time. You know, that doesn't work.

It's, it's fake. And in any case, every consultation is different, and you and I and everybody in the call are different people. So the idea behind here is not to give you scripts, but just to illustrate how you can might communicate.

And there are books and so forth that that have better ideas and that in them or more ideas as well. So that's sympathic communication, if you want to dig a bit more into it, if you Google Onco talk, that's a great resource that was created at now. I've had a brainstorm.

One of the medical schools in America, and they're really short vignettes about 2 or 3 minutes, and they show practising oncologists, with, they're actually actors who are saying words that patients do say and asking questions that patients do ask. But they're actors who who are playing the part, and it's really interesting. So these oncologists demonstrate empathic communication amongst other things.

It's a great little website. And this book on the right, I think is great. It's called Mastering Communication with Seriously ill patients.

It's short and to the point. It's got 8 chapters or 10, I think, with case scenarios and examples of empathic and non-emppathic wording and so forth. And I must say I, I really like it.

So that's another resource if you wanted to learn a bit more about that. So moving swiftly on, we've looked at why disputes happen. We've looked at empathic communication.

Let's now look at the road map. What are we going to do if we actually find in a dispute? And there's a six step road map, I would suggest, and I've developed that from the algorithm that the BVA put together, and those of you who are members of the BVA, that's their guide to euthanasia.

And James Yates also wrote that up and in practise, and the following year. So the 6 steps that we would go through are the first one is We need to back up and go through is euthanasia in the animal's interest and why that is. Then we explore objections that the owners might have, and we decide if the objections are reasonable or not.

And if we think they're not reasonable, we get a second opinion. And if the second opinion agrees with us that euthanasia is in the animal's interest and the owner's objections aren't reasonable, then we might exert some influence. And if the owner is still reluctant, and we think the animals at risk of unnecessary suffering, then we would either report them to the RSPCA or police, or we would under the RCVS guidelines and put them down, because at that point, you know, if we didn't, we'd be getting into unnecessary suffering under the Animal Welfare Act here in the UK.

Now, that's extreme and hopefully it wouldn't come to that. But let's back up. I mean, that those are the 6 steps in brief, but let's back up and go through each one.

And ideally, you know, in the best of all possible worlds, we've already built a relationship of trust with the client, and we've had the rainy day conversation, so we'd be less likely to be in a dispute that we've reached the the the stop line, if you like the line in the sand. But, and we've also addressed uncertainty with them prior. But if we haven't, then and we're into the road map, the first thing is to back up and with the client, work out the euthanasias and the animal's interest.

And very briefly, some of you may know this from, because I've, I've covered this in more detail in previous webinars and conferences and things, but I've put together this ABC yardstick, which is a simple way to work through with the client, whether euthanasias in the animal's interest. And the basis for it is that a fully informed opinion and you that euthanasia's best is an opinion, it's not a fact. So the diagnosis is a fact, the osteosarcoma, the congestive heart failure, the skyrocketing blood phosphorus or whatever.

But the euthanasia is the solution is an opinion. And people have come to us for our opinion for sure. But given all the reasons why people would be reluctant to, to lose their pet, it's not surprising that some might be worried about our opinion.

The uncertainty, maybe we're wrong. Maybe if I did put my to my animal somewhere else and put her on a drip or something, the super vet effect, maybe, maybe. So what we do is we back up and go through the ABC yardsticks.

So, A is for agony or awfulness. So if an animal has pain, for example, extreme pain or nausea or breathlessness or anxiety, or is it imminent risk of those, imminent risk. So that's conditions like osteosarcoma, hemangiosarcoma, seizures, congestive heart failure that's very advanced.

Then we can say the animal is either in agony or awfulness or is it imminent risk of those. So that means euthanasia is probably gained likely to be in their interest. But then we move on to be, and this is something that the owner can help us with.

B is for burden, treatment burden to the animal, because maybe there's treatment available, or maybe we can buy some time. We can bandage and pad the osarcoma leg, we can pile on the analgesia. We can help the owner to get set up at home with no slippery floors, and we can, buy some time so the owner can get used to the fact that the osteosarcoma's got really bad.

And that euthanasia is gonna be, we do need to think about that in the next few days, but it doesn't have to be now today this minute. So, but if we can't do that, if treatment would be a burden to the animal, . For example, to hospitalise a 21 year old cat with deteriorating renal function for the umpteenth time.

And the cat hates being hospitalised and hates coming to the vet and so forth and so on, then probably euthanasia would be in the animal's interest. But we need to talk to you about that. And if agony or awfulness are there, but treatment wouldn't necessarily be a burden, the question is, can this risk give the animal some continued benefit from existence, not simply to keep them alive, but can they continue to enjoy things?

So that's the sea, and that's the owner's domain, because we don't know what the gives the animal pleasure. We don't know what makes life meaningful for the animal. And perhaps part of the reason why people wonder if they've made the right decision about euthanasia or not is that They haven't explicitly gone through these things with our vet.

Perhaps the vet has spoken of it to them, but it's hard to take in everything that that our vet, you know, the vets tell their clients or that our doctors tell us as patients. So, with the ABC yardstick, C is the owner's bit, and they can work through this thing and actually work out, well, what makes life worthwhile for my animal? Will this treatment that the vet says I can give actually restore some of that for him.

And if not, then again, the decision sort of makes itself. So that's shared decision making. No one has to weigh it all up and say, right, I've decided.

But if we work through those things with our clients, we're less likely to be in dispute with them, although it's still possible. Because these factors explain without the client having to name them and decide them, why euthanasia is in the animal's interest. So we worked through the ABC yardstick and the owner says, well, I can see it's best for the animal, but I can't bring myself to do it.

So then we explore that with with empathy. And don't forget one thing that that's come up quite a bit on the human medical side is, you know, not everybody's got the same level of education. And about 20% of the UK adult population is functionally illiterate.

So we may have been talking too much and explaining things in too complicated way and giving people stuff in writing that they can't really understand. And so, even though we thought we'd gone through it all in the umbrella conversation and so forth, perhaps people haven't really grasped all the ins and outs. So, we'll come back into some wording that, they suggest in human medicine for opening up these conversations when, to, to make sure that you and the client both understand the, the severity of the condition in the same way.

So we explore with empathy people's reasons. And then we decide if the reasons are reasonable. If their objections to euthanasia are reasonable.

What does reasonable mean? Well, they're unreasonable. If what they want to do is absolutely deleterious to welfare, for example, there isn't a treatment and the animals in mortal agony, and there's no other analgesia we can possibly use that's workable.

So that it will be unreasonable then to keep the animal alive. It can also be unreasonable if there's no real precedent, and it's relatively extreme. Now, if there's no precedent and it's relatively extreme, but it's not going to be absolutely deleterious to welfare, then it doesn't necessarily follow that euthanasia today, right here, right now is, is called for.

Maybe there's a zone and looking at this area where parents having to decide about end of life for their children, there are different points of view, but a bioethicist at one of the big hospitals in Melbourne, Lyn Gillam, she talks about the zone of parental discretion. And there's a zone, which, although it may not be the clinician's first choice, it still protects the child's interest well enough and avoids quote serious setback to interests. So that's an interesting idea, and I think perhaps some of the time with with our clients, that's what we're doing anyway.

We're sort of compromising and negotiating. And that's valuable, so long as we've got clear lines in the sand, and if we've built trust and we're working together step by step with our clients, rather than in dispute with them, then all being well, and we can keep animals within the safe zone, and once they start to slip out of it, then the client is ready to to go ahead with euthanasia, and as we've discussed it with them. So step 4, so we work out if it's reasonable or not, and if we think it's unreasonable, then we offer or request a second opinion.

And perhaps ideally, we'll be a vet from in a neighbouring practise, but that's not always possible. But whatever the case, the best thing is not to try and buy us our colleague and say, look, I'm really concerned about Caroline because she just won't consent to euthanasia, and I really think she should. And will you have a look at the the cat?

Because that's biassing our colleague. It's better if we just say, look, Caroline and I are in dispute about her cat. Would you ever go in and, and some have a chat with her on and see what you think?

And if you were the vet coming in, I would probably, my suggestion would be to use the ABC yardstick and still proceed on a systematic point and, you know, have the empathic discussion and then see if you think that what the client wants to do is relatively extreme. And if you both think that the clients reluctance and objections are unreasonable, then we can use some excessive influence. So that would be things like, you know, I have to say, if Muffin was my dog, based on everything you've told me, I would, you know, I would want to have him put to sleep, and I would not want to take him home and wait and see how he did, and I certainly wouldn't want him to have a natural death.

Now, that's quite a lot of pressure, and it probably isn't ethical to use it at the start, but if you tried everything else and the client is still really reluctant, then, that, that, slightly coercive influence is, has a place. Or the carrot thing, which is, You know, I think the, the biggest regret that my clients tell me they have is that they didn't allow their animal to die peacefully soon enough. And I would hate for you to look back at this time with regret.

Because people tell me the guilt that they feel then is far worse than the guilt that they would feel if they had, you know, had let their animal die peacefully in the first place, or the grief or whatever. So that's more of a carrot, you know, you'll feel much better if you, if you let muffin die peacefully with euthanasia now than if you wait. So that's a carrot approach and the stick approach, it can also just be social pressure.

You know, I have to tell you that with other clients who have a cat in the state have agreed at this point to euthanize them. And they've been really pleased with the decision or something. So that's social pressure, you're outside the norm.

You're not doing what other reasonable people do. So these are all excessive client infants, we can say, or increased client influence, and at this point, they have a place. And if, despite all of that, the client still isn't able to to consent and the animal is at risk of unnecessary suffering, then we are into having to take them and saying, you know, I wish I didn't have to tell you this, but I'm afraid I've got some difficult news to give you, which is that I'm professionally obliged to put muffin down because he's suffering, da di da.

And spikes at the bottom, that's a six-step framework for breaking bad news. So again, it's important all the time that we try and keep the client's confusion and reluctance in a humane perspective, and we don't just bully them and think they're bad people and selfish people, and that we start judging them as far as possible. We still try and use empathy and so on.

And the criteria for unnecessary suffering under the Animal Welfare Act was spelled out very neatly by Mike Radford, whom some of you will know, he's a professor of law at the University of Aberdeen who specialises in animal law. And in a letter to the veterinary record in, I think it was November 2016. There was a lot of correspondence around unnecessary suffering and how vets define suffering, and he clarified the five criteria for unnecessary suffering under the Animal Welfare Act.

So, that's very quickly that road map, that six step road map, which is work with the owner to work out why euthanasia in the animal's interest. If we just pluck it out of the air as an opinion, I think it's time to euthanize him. Of course, it doesn't make sense to people.

If we work it through together and we acknowledge that we don't know all about the animals, so we can tell them about agony. That together we can work out about treatment burden, and the client has the important piece about whether or not treatment could restore the animal to to what he likes to do. So they say he likes to do this, and we can say, look, you know, treatment will or won't help that, or I've got a treatment that would help that.

So, that will probably help to minimise risk of disputes. But if, if you're still not in agreement, then explore the reasons with empathy. So, you know, I'm so sorry we're having to have this conversation.

Tell me about muffin. Tell me more about that. .

I can see how much he means to you, da di da. So, so we have an empathic discussion. Hopefully the client tells us all their reasons, and sometimes they, it's serious stuff.

My child's being bullied at school, and he's seeing a counsellor, and I'm afraid that he's getting into the mental space where he's suicidal, and I don't know how to tell him. Oh, OK, OK. So that's a totally different matter from just I refuse to let my cat be put down.

Now it's got real meat and those bones, and that might be a situation where we try and move into a kind of hospice, really intensive thing of trying to support the animal with a morphine drip or something for a couple of days or whatever it would be. Signpost clients to to Blue Cross for information about talking to children about these things, whatever it would be. So we explore with empathy, we see if their reasons are reasonable, if the reluctance is reasonable, if we think it isn't, then we get a second opinion.

If both of you think it's unreasonable, then we use influence and if influence doesn't work, if you will, then we might and the animals at risk of unnecessary suffering, then with regret, we have to wade in and of course, called the Royal College, called the Veterinary defence Society, and then euthanize the animal and document it in every last detail. So that's that. Let's look now at religious objections and future treatments and I actually, I think, I put them together because they're, they're all within the dispute area.

Religious beliefs Christian, vets tell me that some people of various Christian, traditions or or churches, and some, individual Muslims are very reluctant to consent to euthanasia. Now, why would that be? We're not theologians, and we don't have a lot of time tonight to talk about all the ins and outs of that, but broadly, as I understand it, and when we look at similar difficulties that doctors face when they have terminally ill children, or, or people who are in a coma or whatever it would be, and they feel it's in the person's interest, for example, to have treatment withdrawn from them.

And the the family members are very strong religious beliefs against that. There's quite a lot written in the human medical literature digging into this, the ins and outs, and how do we respect people's religious beliefs and do what's best for the patient and so forth. And extrapolating from that to the the veterinary situation, it seems to me that the issues are around rules or teaching about the role of animals in in human society, and also about right action for the person.

And if we look very briefly at at Islam, there's very positive teaching about the care of animals in the Koran and also in the teaching derived from the prophet Muhammad's own life. And what he's meant to have said and his interactions with people and so on. And as you will know, within the Islamic tradition, there are 2 main, there are 3 actually, but the two main ones are Sunni and Shia.

And the way the that tradition is structured is that there are jurists or scholars who interpret the Quran and the teachings of Mohammed, so that people then can apply that in their everyday life and different jurists and scholars will have different interpretations. Moreover, there will be differences between Shia, some differences between Shia interpretations and Sunni ones. So it's quite complicated by the time you get down to an individual in a, in a local area who's facing this question.

And it seems to me it may depend to some extent on the particular angle, if you will, that their imam, and the role of the imam depends on the community. They may, they may be a more of a spiritual leader for services and a community support person, or they may have a more elevated status, if you will, where their teachings may even be infallible. So even on the role of the imam, as I understand it can be different depending on the particular community.

However, in general, in veterinary schools, they're in Islamic countries, euthanasia is, as I understand it, very much taught, so it isn't something that's in generally a problem. However, for some individuals, Paternalism is what is expected and what people are comfortable with in their relationships with their physicians and potentially with their vets. So on the one hand, they're minded to to do as their their clinical advisers tell them, but on the other hand, then it's difficult if the clinical adviser is telling them something that doesn't follow what they've been told elsewhere, or what they've learned elsewhere in their tradition.

So I would not be in a position, I wouldn't recommend that we get into theological debates with our clients, . But that, and I'll come in a second to how we might, as practises within our communities, perhaps get advice from the spiritual leaders from different traditions to to come up with a with a assured position, if you will, that would reassure clients or we can signpost our clients to go back and speak with their leaders. So when we look at the different Christian traditions, of course, there are many, those Catholic is is the main Catholic Protestant has been the main divide Catholic, Protestant Orthodox, but within the Protestant traditions, there are many different, different ones, and there's some difference within the Orthodox traditions too.

But in general, for most Christians, euthanasia of animals is not a moral problem. But for some, it may be because it's the idea of taking life and life is any gods to take. And for both Christians and Muslims, the concern is your afterlife.

So you want to do right by by God and other people in this life, so that you are well received in the afterlife. And so if you kill an animal needlessly, or not in accordance with what's been laid down in your religious books, then of course, that may go hard on you in the in the next life, potentially. Or it may be perhaps a slippery slope or if you're agreeing to euthanasia of an animal, then perhaps does that mean you're that that's just one step away from the euthanasia of a person.

So these may not be your beliefs, but these are very important to people and it's important that we are respectful of that and don't trivialise it and perhaps find middle, middle, and middle ground. So, how are we to address this? Well, empathic communication again that we show understanding that this is a struggle for people, that they don't want to give up on their animals and that they might be hoping for a miracle in the Christian tradition.

Or they might be surrendering to God's will in the Islamic tradition or some Christian traditions that you surrender. And that animals, must surrender as well because humans do and animals must. And when it comes to futile treatment, that's, of course, another part of, of the disputes that we may have.

And the thing here is that the animal, of course, is not futile. The animal is not futile ever. But the concern is probably proportionality.

So futile treatment would be one that would have an unacceptably low likelihood of achieving an effect that the animal can appreciate as a benefit. And probably along with that, an unacceptably high likelihood, the treatment will be a burden. So it's the likelihood.

So again, we're into the land of uncertainty. What's the likelihood of achieving an effect the animal can appreciate as a benefit? And what is the likelihood that the treatment will be a burden?

And we don't know exactly. We don't know. We don't know.

And of course, uncertainty again, if we don't know, and then we get into fear and hope and and exaggerated expectations there, how burdensome, how likely is it to to not to work? How burdensome is it? And these are all very individual, so we need again to be hopefully still in a, Maintaining trust with our clients so we can talk about these things and take seriously their requests rather than beating them over the head and say, well, you know, he's too old and it's not fair, and rah blah blah, but just to work it through together.

You know, I'm struggling with what you're asking me to do because I'm concerned it will be a, you know, really a burden for, for, little treacle or whatever it is. The, you know, the only way we could help her already will be to put her into an oxygen, tent and have her in the clinic and this and that and the other thing. So, to, to, to talk that through with, with the client.

And then if we're trying to talk about heroic treatment again in veterinary medicine, we haven't properly ironed all of this out. And some of you may have been at the BVA Congress in 2010 when there was a panel discussion about that, about heroic treatment. Should we be doing any kind of heroic treatment, never mind at end of life.

And of course, different, there are different criteria. What came out of that was, it's what the animal wants, we should think about what would the animal want. That's what they call substituted judgement.

And in human patients, if someone suddenly goes into a coma and their family member is asking the doctor to do what the person would want, in 33% of cases, roughly. The substitute judgement is wrong. So what the family say, the doctor say to the doctor, this is what mom would want, they're wrong.

And it's natural that it's subjective and it's influenced by the fact you don't want mom to die or you, whatever it is. So, you know, how on earth, we, we, it's very hard for us to know what animals want in particular. Only we can, the owners can tell us about their general preferences for taking treatment and not liking to take tablets or not liking dogs or whatever it is.

We can certainly say animals don't want to be in pain. I mean, that's sort of a bottom line. But it's not particularly helpful, I don't think.

Then the RCVS and and others say, you know, the vet must push for the animal's best interests, best interests, best interest. And of course, that's what the owner wants. However, when we look at the human data at end of life, the ethicists say, well, it's not reasonable to to push for a patient's best interests, because they're a member of a family, and no family prioritises one member's best interests.

Normally, it's a compromise. So for us to push and say you have to do what's best for the animal isn't always quite fair or realistic because nobody puts a parent in prison because they don't know what's best for their child or an animal owner. You know, what's best for a lot of cats is not to be indoors, perhaps.

What's best is if their owner jacks in their job, moves to the country, gets rid of all the other cats, and lets the cat live an outdoor life. But no one says, you know, you're breaching our welfare Act if you don't do that. So there's always compromise.

So perhaps best interest, interest by all means, but best interest is perhaps not realistic at end of life. And then, as it turns out, the Animal Welfare Act, they don't talk about best interest. The owner has to avoid harm and prevent harm.

And quite a lot of, it's debated in human end of life ethics that perhaps harm avoidance is a more useful criterion cause it's even easier to get a handle on than what's best. Who knows? But this is where this zone of parental discretion came in.

So this bioethicist Gillam over in Melbourne, she's saying, look, there's a zone of parental discretion. So rather than people having to, to bull's-eye and pinpoint the best. You know, let's just be open to the fact that there are, there are different bests.

And that American book about talking to and talking to seriously ill patients, they talk about that in some of their examples of conversations and those authors are are real live practising oncologists. These are not theoretical people. They're having these conversations.

Admittedly, it's in America, it's a different culture from the UK, but they, they talk about, well, you know, there are different kinds of best. Now you would say, well, there's no such thing as different kinds of best, you know, let's not get pedantic about that. But what they're doing is they're opening the door to the possibility, you know, there are different, different ways of looking at this.

Let's talk about this together and see, see what, step by step what we can work out together. So that's, you know, the safe zone, good enough treatment that avoids serious setback to interest, and that often might be a way for us to buy humane time for the owner to get more used to the sadness that they now have to say goodbye to their pet, buy them a couple of extra days, and then, you know, have the euthanasia at home or whatever it is. So, we're talking about disputes with clients, chapter 8 of this book, and they call it from who's right to what's our shared interest, and that's a great little chapter in there.

And wordings, the different wordings for how do we open up these things, these dispute conversations, how do we have these conferences, different, different wordings, some examples there, slide 62. Ideas for addressing religious objections, refer the person to the pastor or or spiritual leader, invite another pastor to advise, and the UK Board of Healthcare chaplaincy has different members. So that might be a resource potentially that your practise might use to talk to different people from different religious traditions or that group might be able to signpost you to to different spiritual leaders.

And it might even be as a practise, talk to your other practises and have an evening with the various spiritual leaders or the chaplains from the local hospital and say, look, would you ever come in? Let's all sit down together, because we need your guidance about where, where you might stand on euthanasia for animals. And then maybe there might be a letter or something.

I know that sounds like work, but that's what it's come to, because when it's 2 in the morning and you're stuck with your client. You're stuck. Whereas if it's a practise, you, you're, you're ready for this and, and prepare for it, then that might be helpful perhaps.

Another possibility might be to hand over ownership of the animal to the practise. Because it's ultimately the disease that's killing the animal, not you. And of course, you're, you're bringing death on, but it's the disease is the underlying problem.

So I don't have any quick fixes, and I'm sorry if you're expecting that there's some secret sauce there isn't that I know of, but these are just some ideas for you to work with, with your practises as well for the longer term. So here we are. If anyone's still awake and not asleep on the laptop like this guy, is that you, Rich?

I'm not sure. Maybe that's you there. I don't know.

But anyway, we've gone through why disputes happen and the communication to a roadmap and our objections of futile treatments, palliative sedation and analgesia. I got a bit ahead of myself putting that on the thing, because we, we're out of time. But B, because I wasn't in the end able to nail down certainly anything that I've used cause I'm not doing this anymore.

I need to speak about honesty and all that good stuff and disclosure. I'm afraid I'm not doing this in practise anymore. I'm sharing with you guys what you might do.

And I don't have any hands on really good palliative sedation protocols and analgesia. However, these two books talk a lot about it, and these are both hospice type books. So, they're a really good grounding resource for us as this side of practise develops to get a sense of what these pioneering vets use and see if we agree with it or not.

Is it too complicated? Is it this? Is it that?

They don't have a handy dandy table of, you know, these are the different protocols we use. But they do go through all the drugs, which we know anyway, and they say, look, we know this stuff. You know, we know what analgesics are, we know what sedatives are.

It's a question of deciding to use those more near animals end of life, so owners have more time to get used to the idea. So it's just really expanding what we do anyway. Sue To sum up, why disputes happen, keep an open mind.

It's often to do with us, how we've communicated and very genuine and understandable things on our client's part. And uncertainty is a big one, the elephant in the room that, we shouldn't talk up, the probabilities of success or failure, and we need to be honest, there's some inherent uncertainty about when is the day, when is the hour. So let's talk about that and to try and do it early on.

Empathic communication, it's so important to reflect back our understanding of what our clients appear to be feeling. Our road map, we've gone through that, the six step road map, if we are in a dispute. And I think rather than again, the big thing is, well, I've told you euthanasia is in your animal's interest, what's your problem, but instead to back right up and say, let's work through this together.

And you know let the owner be part of that. So it makes sense why we're suddenly recommending this. Religious objections of our treatments again, don't bully our owners and keep talking at them, blah, blah, blah blah.

But to negotiate around to maybe a safe zone, and again, our palliative sedationalalgesia, . And also anxiety relieving drugs, that can really despise the time that we need. There are a couple of things I, I shared earlier, if you're wondering what they are, they're all in this core practise toolbox that I've produced for practises.

So you've got done for you stuff that you can use and that's on the website. And the other thing, I, is I'm writing a couple of books, because I haven't been able to find any that cover this kind of stuff. So, all being well in September this year, there's a pocket guide to veterinary end of life discussions, which is on our side of the stuff.

So all about these kinds of things and disputes and, you know, what's guilt and all that good stuff and how do we address these various questions that are put to us by clients. And also knowing when it's time, a guide for your pet's end of life. So that's covering more of the stuff for clients.

So, with that, enough of me. Thank you for your time and what questions do you have? Oh yeah, no, I, I, I, I promise you I wasn't that gentleman asleep on his laptop.

I'm still wide awaken with you. Don't worry, I'm, but no, that was a fantastic. Thank you very much, Caroline, great, sort of tour, covering the main points there of having the discussion.

I think the one that came across quite clearly for me was the, the real significance of having that clear communication. Not letting there be any sort of, grey areas and making sure that the client is aware of what you're saying and not misinterpreted what you're saying. Because I think obviously, you know, being a pet owner myself, you're always looking for the positives, aren't you?

And you always hang on to that one little ray of hope, when actually, and it's so it's about being that really clear and, and starting that conversation early, saying, you know, look, we are doing this treatment, however, you know, you need to be aware that. You, it may, the animal may get worse, etc. And it's starting to plan that out at an early stage.

So for me those are the sort of the some of the key messages that came across really clearly there. So I'll just say to, obviously please do, we've got time for a couple of questions, so please do, you know, post a couple of questions. That you may have or any, you know, share any, experiences you've got, little tips, that because, you know, there's, there are quite a few of you on the webinar tonight, so I'm sure, you know, it's always good to learn from each other.

So if you haven't got any tips about having those conversations or anything that you do that you've found that helps with the majority of clients, please do share them. One thing I'd just like to mention is, for you, those of you who are diamond member, you get access to this as part of your membership. But for those of you who are platinum members, something that may be of interest to you.

And also Diamond, if you haven't accessed it yet, we have actually got a short three-part course that Caroline has done previously called Client Care at Animals End of Life course. Anna is gonna post the link, to it on our website in the chat box now for you to see. But as I say, it's a three-part course.

And it's really for . Process of, you know, it doesn't matter when the animal died for the owner, this is beginning of a stage of loss and grief. So, it's important, it helps you to know how to treat owners in an ethical and professional manner.

And I'm sorry to interrupt reception. Exactly. So it's really good for any of your team members, you know, to give them access to this.

You can buy it individually or there is also a practise ticket, but you know, for any of those that are reception. Or any front of house, staff, as Caroline says, would be really good for you to give that to, give that, give them access to that, and help them deal with that and help them upskill them in dealing with some of these difficult situations, you know, whether it's handle the phone inquiries about euthanasia, requesting payments, obviously, at a very difficult time for people. So all these really useful hints and tips will be included in there.

So please do have a look at that. And as I say, I know was put in a link to that in the, chat box now. OK, so time for a couple of questions.

I've got one from Carmen here, Caroline, he says, what about the euthanasia of animals which the owner can't afford treatment for or are healthy but not wanted anymore for whatever reason. Many clients get angry if you give them other options. I find them really hard to do any tips.

Mm, gosh, now that tie, Carmen, those are so difficult to, . I think one thing that really struck me about the, first of all, the cost thing, and if so I'm, as I understand you, it's a sick animal who, in fact, could be treated, but it would be more money than the owner could afford to pay. And, that's something I think again, maybe we need to broaden our horizons, if, if we can say that a bit, or, or just accept that reality that being unable to pay is not the same as being unwilling to pay.

And that's something that was pointed out by the veterinary ethicist, Bernard Rollin, who's, was at the perhaps he still is, I think he's emeritus at the vet school over in Colorado, I believe. And he's quite clear about that, and I think it's a fair point that, Being unable to pay does not mean that they're not willing, and sometimes that is a circumstance in which it's not possible to keep an animal alive. If there's no no other solution, then it's something with regret that we have to do.

And in that case, rather than suffering or being untreated with the illness, then we can say euthanasia is then in the animal's interest because unfortunately they are, they do in the end always come second to us, and I know that's, that's cold comfort, but I think ethically and at a human level that Respecting that person's financial reality. And we could say, well, why did you get one if you can't afford to pay for him and so forth, but, sometimes things do happen out of the blue and it's just more money than people have. So and accepting that is hard.

So I don't, I mean to to share that as a wealth pull yourself together, of course, that's reality. I don't mean that at all. I really understand that the grief it is for us as clinicians, but I think in a purely sort of ethical weighing up, certainly in that case, to have a gentle peaceful death has to be better than not being treated.

And the fact that the client has brought the animal to us is, is a very positive thing, and it's absolutely the right thing that they've done within, you know, the Animal Welfare Act and their obligations to their companion. The, and do type back in common if you're, you know, seeing, seeing red as I, as I say this, I'm sorry, I don't have a have a simpler answer. I'm sure this is something that would have crossed your mind anyway, about, the euthanasia of healthy animals, that's a tricky one.

Certainly, because it's we're not morally obliged to euthanize healthy animals. And then there is always the problem. Well, what's the owner going to do instead?

Now, James Yates, who, whom some of you will know or know of, who's a vet who specialised in veterinary ethics, and he writes quite quite often on these subjects, and he has a paper from 2011 about the fact that It's an ethical dissection, but it's how we're not responsible if the animal then gets injured or the owner, God help us, leaves the animal by the side of the motorway. And that's great, ethically and theoretically, but of course it doesn't help us emotionally because it's such a worry, such a worry if the owner says that. I would suggest that I mean, part of the reason the person is angry is because perhaps they're troubled by they have an expectation, and they don't like the fact that we're not going along with it, which is understandable.

So part of our task is to be resilient and more skilled at coping with these responses and being able to show empathy. It doesn't mean empathy doesn't mean you agree with someone. It doesn't mean you're gonna do what they want you to do, but it does show respect for the fact that they're frustrated or angry or sad or whatever it is.

So, Another thing that helps us is if a practise has a policy, and a lot of practises don't. And I think really in the 21st century we use practises and and even perhaps at Royal College level, we still need more detailed guidance about these things, but practises really probably need to have a policy, maybe on the website, certainly internally, about these things and the handout, which clarifies why. You don't normally put down healthy animals.

And I've got a, something that I put together for practises as a starting point for writing their own. I mean, it's quite long and it's, it'll work. I mean, I hope it's written up.

So it's something you can, if you're too busy and your press manager says, look up, I don't care, just give me any old thing, as it were. I've done something that's good to go if you don't want to put it in your own words. But it really just goes through the reasons why we don't normally put down healthy animals, and there are all sorts of reasons.

I mean, the things like just the whole wider ethical thing, which is that we don't want to be part of a community where people don't take the responsibilities seriously, is what it boils down to. So there are things like that, and Carmen, if you wanted to email me, my email address is CH@caroline Hewson.com.

I'd be happy to send that along to you. No, that'd be great. As said, I'm just gonna type that into the webinar, into the chat box now for you, and then it's the email address.

So it's CH at Caroline Hewson.com. And the other thing I think would be part of policy would be that you use the six step approach.

And you actually work through logically. And again, the ABC yardstick sort of makes the decision for you because it's kind of obvious. It's not anyone, no one's, no one person is saying you mustn't or you must euthanize your animal.

It sort of pops out. Because, you know, it's obvious that these things are important, you know, whether or not the animals in agony, whether or not treatment would be a burden. And, the fact that they continue, I mean, obviously, if they're healthy, they can perfectly well have a have a, benefit from life.

But you're not telling the owner that the thing is there and they work, you work through it together and it's sort of, you know, it's just there. So it's perhaps harder for someone than to, to, to go along with that. No problem.

So, yeah, so obviously, Carvin, there's no easy answer, but as I say, it's just working through it and just trying to come to the. Best outcome. One of the someone who's put in a, an obs sort of put their take on things in terms of one of the tips they've done.

Carmen just said that thank you very much, she'll send you an email. Thanks Carmen. One of the things that Sue said she found the works is she never takes off the dog's collar before euthanizing it.

Most dogs always wear the collar and start to their owner or vet takes it off. I promise the client we'll take it off later and they'll be able to take it home, a little thing, but I hope it avoid some stress for the patients. Mm.

Oh, what a lovely thing. Yeah, because we haven't talked about the actual euthanasia thing itself, and I hadn't, hadn't thought about that, that detail, but I agree with you. I think that makes sense, because otherwise it's, .

Yeah, it's sort of writing the dog off before while they're still alive, as it were, or treating them just like any, any creature rather than their own unique one. That's such a nice thing. Thank you.

One Greg, who's a regular attendee, good to see you on again, Greg. He asked the question, when you euthanize a pet, do you routinely sedate or an anaesthetize it, the pet first, to relax it, etc. Is that something that is common practise?

Greg, you know, when I, because I was in practise from '86 to 92, then I was an academic, and then I returned to the UK in 2006 or 7 or whatever it was, and resumed practise in 2008. And I'd really changed my view in that time, because it turns out it's only most countries always sedate. We're quite unusual in this country that we don't.

In Scandinavia, you always sedate. And I'm really totally into that now. And my fear was always perhaps like goes, oh, what about blood pressure and oh dear, and this and that, and what about the expense.

But it seems to me there's almost an overwhelming reason to do it and, and it would only be why wouldn't you? And I don't say that critically because I, I use them to, but I think probably the thing would be some owners may not expect it, and, some people say, look, I want it to be quick. The rationale in Scandinavia, as I understand it, is, if you want it to be like the animal falling asleep, then it's a gradual thing, and sedation would be part of that.

But, certainly the, the vets who specialise in at home euthanasia and animal hospice, they always sedate and they use things like Xylazine, and these will be American Xylazine, buttrophrenol and ACP or ketamine, Valium in cats. And, and they say they don't have a problem with low blood pressure. They can always get a vein, apparently.

So my recommendation would be, absolutely, I think we should always sedate, but it would be something to talk through with the clients still just to get, because we still need to get consent for that. And if we tell them what euthanasia is about and that normally we like to sedate, because sedation, of course, makes animals, they're still aware, but they're just, they're still conscious, but they're less aware of things. And, and the other thing would be just on that subject, you know, should we take the animal through to prep, to put in a catheter?

And what about the owners who don't want to wait with the animal? Something that has become apparent through recent research on dogs and cats, as some of you will probably know, is for dogs in particular. They're social animals, and they are attached to their people.

So attachment is a natural bond that we form with others in our social groups, that's us included, and it's why we grieve on our animals or or family members die, because at some automatic subconscious level, they represent comfort and security, and suddenly they're gone, and grief is a natural reaction to that, and it helps us to adjust in the end. So for dogs, they're social animals, and it's quite clear that they, like us, see, particular members of the social group is providing, quote, a secure base. And I've got a a concern that, it's difficult and again, if we can talk it through with people before the day, and especially if we can euthanize animals at home, it doesn't come up so much.

But when people say I'm too upset to stay, now, if they really are sobbing and crying, of course that can upset the dog too, because there's a degree of empathy or at least understanding between dogs of our feelings. But I'm concerned that if people don't stay, that the dog would have lost his or her secure base. And that that may not be a good experience for him or her.

And I think in that case, sedation is of the essence if people aren't going to wait. I think we must always state the dogs because I suspect it may go hard on them, otherwise, to set for the owner suddenly not to be there. Again, it's it's a case by case thing, and for cats to their home bodies, so if they're being euthanized at the vet clinic, I think sedation is important there because cats, you know, they don't like not being on home territory.

Yeah. And the owner is part of home territory, so if the owner leaves and leaves them in the clinic, again, it's it may go hard on them. So I think there are many reasons why sedation really, probably needs to be our norm.

So, that's a long winded answer, Greg. I hope that helps a bit. Yeah, no, it's Greg says here that he's been doing it for the past 10 years, and to be honest, we had our cat put down last, August time.

And, you know, the vet, in Chester did it as part of the course, sedated, and then, you know, and, and to be honest, it was, you know, the cat was relaxed, you know, it gave my wife my wife time who had the cat, you know, before she met me, so she had more attachment to the cat than she did to myself. And, you know, gave her time to sort of just say goodbye to her, go goodbye to nothing else. So I just thought it was standard practise, to be honest, didn't rise it very so much that was really interesting.

Rob Elliott, er, just on the bit about Sue and the collar, he said also close the collar back to a circle as it then represents a circle of life. So that's a nice little touch there as well, yes, Terry's Rob Elliott, Rob, so then Terry's also saying, yeah, he sedates heavily, gives the client the option of leaving with the animal being unaware. And then we've got Mina.

Hi Mina in San Diego. Hope you're well. Hi Mina.

Mino's always one of our writers and joins us all the time. Hope your ankle's on improvement and, Minka's a keen tennis player as well. You get to know your, members well.

What about the young vet female who killed the neighbour's cat with arrow in Texas and then wrote, I think, on Facebook or Twitter, how easy it was to do that with the first blow. I don't know this, I don't know what you said. Sorry, I've just started doing that.

What about the young female who killed Neighbour's cat with the, with arrow, A R O W in Texas and then wrote, I think on Facebook or Twitter, how easy it was to do that with the first blow. This was a national revolution for the owners and vets to stop her practising it. It's still pending.

Any thoughts about that one? I think that. Somewhere I think that's probably one for another night, Miner.

Wow, yeah. Well, I mean, it's interesting because euthanasia is painless death. So, you know, if, if you are a good shot and whatever, because of course we kill other species like that.

So if we're going to be really detached and clinical about the argument, you can see, yep, it could work, but I, I think there are all sorts of reasons. Why, it's not satisfactory in other ways as I'm as I would imagine most people here would, but, golly me, no, I've not heard of it, so that's that's quite a cool celeb, isn't it? Yeah, no, definitely.

So, so I think that, on that note, oh, Rob says hello back to you, Caroline. so no thank all leaves me to do is say, thank you very much, Caroline. For that very interesting presentation.

Hopefully it's given, you all attending some food for thought. Thank you to my colleague Anna for being on hand, with the technical side of things tonight. We couldn't do it without you.

Thank you to yourselves for attending. Just to let you know, this webinar will be edited, by Anna herself and, will be up on our website within the next 48 hours. Before you do switch off your computers tonight.

Please do take time to complete the feedback survey, which will have appeared in your browser, delivered by SurveyMonkey because your feedback really does help us, to continue to develop our programme of webinars over the year to ensure that we're meeting the needs of yourselves. So, you know, thank you very much for all attending. I wish you all the pleasant evening and I look forward to welcoming you on the webinar in the future.

Thank you very much. Good night. Thank you.

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