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Abstract

Current advances in technologies and treatments provide pet owners and veterinarians with more options for prolonging the life of beloved pets, but can simultaneously lead to ethical dilemmas relating to what is best for both animal and owner. Key tools for improving end-of-life outcomes include (1) sufficient training to understand the valid ethical approaches to determining when euthanasia is appropriate, (2) regular training in client communication skills, and (3) a standard end-of-life protocol that includes the use of quality of life assessment tools, euthanasia consent forms, and pet owner resources for coping with the loss of a pet. Using these tools will improve outcomes for animals and their owners and reduce the heavy burden of stress and burnout currently being experienced by the veterinary profession.
April 2017 | Volume 4 | Article 451
PERSPECTIVE
published: 19 April 2017
doi: 10.3389/fvets.2017.00045
Frontiers in Veterinary Science | www.frontiersin.org
Edited by:
Paul Koene,
Wageningen University and
Research Centre, Netherlands
Reviewed by:
James Serpell,
University of Pennsylvania, USA
Manuela Zebunke,
Leibniz Institute for Farm Animal
Biology (LG), Germany
*Correspondence:
Emily Patterson-Kane
ekane@avma.org
Specialty section:
This article was submitted to
Animal Behavior and Welfare,
a section of the journal
Frontiers in Veterinary Science
Received: 23November2016
Accepted: 14March2017
Published: 19April2017
Citation:
KneslO, HartBL, FineAH, CooperL,
Patterson-KaneE, HoulihanKE and
AnthonyR (2017) Veterinarians and
Humane Endings: When Is It the
Right Time to Euthanize a
Companion Animal?
Front. Vet. Sci. 4:45.
doi: 10.3389/fvets.2017.00045
Veterinarians and Humane Endings:
When Is It the Right Time to
Euthanize a Companion Animal?
Oliver Knesl1, Benjamin L. Hart2, Aubrey H. Fine3, Leslie Cooper4, Emily Patterson-Kane5*,
Kendall Elizabeth Houlihan5 and Raymond Anthony6
1 Zoetis Inc., Parsippany, NJ, USA, 2 Department of Anatomy, Physiology and Cell Biology, School of Veterinary Medicine,
University of California Davis, Davis, CA, USA, 3 College of Education and Integrative Studies, California State Polytechnic
University, Pomona, CA, USA, 4 Davis, CA, USA, 5 Animal Welfare Division, American Veterinary Medical Association,
Schaumburg, IL, USA, 6 Department of Philosophy, University of Alaska Anchorage, Anchorage, AK, USA
Current advances in technologies and treatments provide pet owners and veterinarians
with more options for prolonging the life of beloved pets, but can simultaneously lead
to ethical dilemmas relating to what is best for both animal and owner. Key tools for
improving end-of-life outcomes include (1) sufficient training to understand the valid
ethical approaches to determining when euthanasia is appropriate, (2) regular training in
client communication skills, and (3) a standard end-of-life protocol that includes the use
of quality of life assessment tools, euthanasia consent forms, and pet owner resources
for coping with the loss of a pet. Using these tools will improve outcomes for animals
and their owners and reduce the heavy burden of stress and burnout currently being
experienced by the veterinary profession.
Keywords: companion animal, euthanasia, human–animal bond, humane endings, veterinary medicine, wellness
INTRODUCTION
e changing nature of the bond between humans and animals has made pets an increasingly integral
part of many peoples lives. is in turn has changed the landscape for the veterinary profession such
that the human–animal bond must be integrated into daily veterinary care (e.g., “bond-centered”
practice) (1, 2). At the same time, veterinary medicine has developed a wide range of technologies
and treatment options, with the result that veterinarians and pet owners are increasingly confronted
with ethical dilemmas concerning whether a procedure that is medically available is truly appropriate
for the animal or the owner. Recognizing that there is a diversity of cultures and beliefs inuencing
the veterinarian and the owner, the veterinarian’s core duty remains to navigate these in order to
serve the best interests of the animal and owner.
e following commentary looks specically at the decision-making process in relation to the
euthanasia of a companion animal and asserts that this needs to be supported by specic tools
that assist the veterinarian in serving the interests of the animal and the wellness of the client and
veterinarian.
2
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Frontiers in Veterinary Science | www.frontiersin.org April 2017 | Volume 4 | Article 45
EUTHANASIA DECISIONS ARE
STRESSFUL FOR VETERINARIANS
It has been clearly established that euthanizing animals is broadly
stressful for veterinarians (3). is includes the euthanasia of
companion animals that are unwanted in shelters or at owner
request a.k.a. “convenience” euthanasia (4). is article, however,
focuses on serving clients bonded to animals with terminal
conditions that cause suering, where euthanasia should be
considered. Discussions of this type are a regular feature of many
veterinarians’ days and the stress they cause may be exacerbated
by veterinarians not easily accepting death as an outcome. at
is: “Veterinarians are trained to heal, but they are routinely con-
fronted with ending life rather than saving it”. 1 As “gatekeepers”
for the animal’s end of life, veterinarians nd themselves acting
on behalf of the animal’s silent voice (5), and needing to somehow
also accommodate the needs and desires of their human clients,
and a plethora of idiosyncratic circumstances that limit their
therapeutic and emotional resources in that moment.
In one study of 21 veterinary students, several pointed out
numerous distressful situations that they had already experienced
(6). Even at this stage in their training, the highest level of stress
related to end-of-life decisions. One student described that his
major sense of stress occurred when he believed an animal’s suf-
fering was prolonged because the owner did not want to accept
that its condition was not likely to improve and that death was
inevitable. e student went on to state that: “Sometimes we take
cases too far and subject dogs to radiation or chemotherapy to
satisfy the client.A lot of times the animal is in intensive care
and it’s just for the people.” is scenario was also reported as a
common and stressful dilemma for practicing veterinarians (7).
Although euthanasia serves as a method to end suering in
animals, the decision, inevitably, is dicult, and highly bonded
owners require more support from their veterinarian at this time
(8). Most committed pet owners have probably experienced, or
know someone who has experienced, a situation where they were
le with a feeling that euthanasia was provided for an animal too
soon or delayed too long. Both owner and veterinarian have some
ability to refuse euthanasia which may cause it to be withheld
when it would serve its role in ending unnecessary suering, and
both client and veterinarian may feel guilt for being responsible
for an animal’s death (810).
e ethical and emotional strains associated with euthanasia
decisions are oen not openly acknowledged or a subject of
structured assessment and improvement eorts, despite their
importance to the veterinary profession and pet owners (9). Few
veterinarians could name specic tools they use to dene and
address these problems, and their prior education may not have
included any instruction on these tools (7, 9, 11). e rst addi-
tions to this tool kit, if not already acquired, should be an ethical
decision-making framework, a good communication system, and
quality of life assessment and consent tools.
1 Verdon DR. Euthanasia’s Moral Stress: A High Psychological Price. DVM 360.
(2003). Available from: http://veterinarynews.dvm360.com/euthanasias-moral-
stress-high-psychological-price.
Ethical Decision-Making Frameworks
Engaging in a quality process, e.g., training in ethical delibera-
tion, can have the eect of minimizing distress experienced by
veterinarians as a result of routinely performing euthanasia,
one of the major reasons for burnout and moral distress (12).
By adopting conscientious ethical decision frameworks that
focus on the animal and its interest, less emphasis is placed on
the question: “When is the right time?” with which veterinarians
are routinely confronted and which can oen exacerbate moral
distress. Ethical decision-making frameworks that encourage
deliberation, dialogue, and agreement between owners and vet-
erinarians on important characteristics of quality of life for the
animal patient in question engenders trust between veterinarians
and their clients. By promoting trust and eective communication
as essential skills to ensure healthy veterinarian–client partner-
ships, the veterinarian can devote their attention to making sure
that the interests of a dying animal are prioritized.
By emphasizing the quality of the deliberative process (includ-
ing acknowledging the role of animal-based measures in guiding
the decision to euthanize and when), and not merely focusing on
the nal outcome, veterinarians can have condence that they
are living up to their commitment to provide quality care to their
animal patients at the margins of life and that they have provided
conscientious counseling to their clients, integrating their clients
needs and interests into the deliberative process (5, 13).
In Sandoe etal. (14), veterinarians can nd a robust analysis
of the ethical principles that typically factor into the deliberations
that deal with companion animal palliative care and euthanasia.
Here, the authors conclude by stressing that while the interests
of the pet owner, veterinarian, and animal may not always be
fully compatible, it is the quality rather than the quantity of the
animals’ life that is of greatest ethical signicance. For some pet
owners and veterinarians, the decision to euthanize an animal
can be made rationally on the basis of nancial, convenience,
or compassionate considerations. For others, attachment to
an animal can signicantly complicate the decision as can the
inherent inability of animals to communicate their preference.
e later situation resembles that seen with very young, mentally
impaired, or comatose human patients, where the principle of
“best interests” can be applied to the decision-making process.
is implies that the decision should always consider what is best
for the animal, irrespective of the owner’s wishes. An opposing
viewpoint is one that focuses on the best interest of the owner
(a contractarian perspective) and can lead to situations where a
suering animal is kept alive to minimize the emotional distress
of the owner. Veterinarians frequently have to search for a middle
ground between the extremes of keeping an animal alive because
modern veterinary medicine provides the means to do so (over-
treatment) or situations where the owner insists that everything
humanly possible must be done (contractarian) and considering
what is in the best interests of the animal (14).
Rights and Care Considerations
Although there are numerous ethical models that represent a
spectrum of ethical problem solving alternatives (e.g., utilitar-
ian, virtue, and fairness approaches), the authors will focus on
a couple of principles from two alternatives. Veterinarians may
3
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wish to begin their ethical deliberations by considering two basic
principles. Firstly, according to the ethics-of-rights approach
(15), an ethical action is an alternative that protects and respects
the rights of all parties involved (5). is principle suggests that
veterinarians have a primary obligation of respecting the ethical
rights of individuals, both the animal and the client, and where
necessary striving to resolve conicts between the two (i.e., to
be “fair”). is principle assists in considering what constitutes a
valid right and how the rights of stakeholders should be balanced.
e ethics-of-care approach (16) places greater emphasis on
the relationships and bonds that individuals have with each other.
According to this approach, decision making should be guided by
a motivation to care for dependent and vulnerable beings. is
includes the veterinarian’s primary duty to the patient, and how
the patient’s health impairments impact quality of life (5, 13).
Tools based on this principle can assist veterinarians in nding
ways to help clients be guided by their own duty of care as an
animal owner and caregiver.
Veterinarians tend to innately understand both principles.
For example, one study found veterinary students approached
hypothetical ethical dilemmas trying to achieve a fair outcome
for all which and a care-centered approach, being empathetic to
the companion animal and human caregiver (17).
Deliberate Frameworks
In terms of a deliberate framework to guide veterinary medical
interventions, two valuable models are provided by Morgan (18)
and van Herten (19). ese frameworks focus on case-by-case
care; they begin with the interests of the animal patient as their
starting point and are set within the framework of deliberation.
is deliberation is a structured process that is investigative by
nature and which invites partnership between the veterinarian
and the owner or client to reach a shared treatment outcome
for the animal patient. e frameworks give veterinarians the
opportunity to discover their own values with respect to vet-
erinary medicine and quality of life issues (value articulation)
and to employ this knowledge in determining the best course
of treatment for their animals, in conversation (and hence with
some measure of transparency) with the client (moral delibera-
tion) (20). e process of identifying central issues (e.g., medical
indications) and the underlying ethical values or principles at
work [e.g., respect for clients autonomy, benecence, non-
malecence, and justice (11, 17, 21)] is coupled with careful
dialog about reasonable treatment alternatives (informed by
ethical detective work and backed by empirical evidence), limits
of technology, the capacity of both veterinary medicine and client
husbandry to maintain the quality of life for the animal patient,
and what responsible companion animal ownership entails at the
end of life for this animal. ese deliberative frameworks help the
veterinarian nd common ground with the client, and acknowl-
edge the roles of the veterinarian as information and service
provider and as animal and client advocate (22). As van Herten
notes “Whether killing is in the interest of the animal itself and
its future well-being and whether there are human interests that
outweigh the interest of the concerned animal to stay alivethe
veterinarian and owner must nd morally acceptable justication
for euthanasia.”
ese frameworks have the additional eect of helping clients
prepare for their companion’s passing while honoring the human–
animal bond. Empathy central in the process of deliberation.
However, if excessive, it can also increase the stress experienced
by the veterinarian without improving the outcome (23).
By going through the assessment and deliberative framework
highlighted here, veterinarians have the opportunity to com-
municate with their clients in a way that helps expose and gently
resolve conicts whenever possible, for example, where the medi-
cal evidence shows that an animal’s condition is terminal, but the
client is still seeking therapeutic treatment; or when clients need
to keep the animal in their life but the animal’s quality of life has
reached the point where it does not have a life worth living. It
may also occur that the animal’s life could potentially be extended
from a medical point of view, but this option is not truly available
because the owner has an unresolvable obstacle to supporting
that option (24).
When veterinarians are able to explicate their own ethical
roadmap condently, they will also be able to reliably guide
a client toward a sound decision and leave them feeling they
made that decision in a morally sound way. e two frameworks
highlighted here reect the deliberative and assessment guide-
lines regarding the morality of euthanasia that can be found in
the introductory section of the American Veterinary Medical
Association’s (AVMA) Guidelines for the Euthanasia of Animals
which also includes some ethic decision aids for euthanasia (25).
ese frameworks build public condence in the profession that
“the delicate task of weighing the request to perform euthanasia
and to give owner advice in the end of life decisions” (19) are
made judiciously and that the ethical process is shaped around
the goal of providing a good death for companion animals.
Furthermore, one of the virtues of the process’ quality is that it
is done in a transparent manner, highlighting how veterinarians
are fullling their obligations to their clients, animal patients, and
the public (25).
One example of a specic tool consistent with these principles
is available from the Markkula Center for Applied Ethics, Santa
Clara University. e tool provides a simple framework for
ethical decision making that can be accessed via their website or
downloaded as an app.2 e app helps users ask questions about
ethical choices and can serve as a good starting point for explor-
ing ethical decision-making.
Once clients develop a high level of understanding of the
ethically acceptable options, veterinarians may be prompted to
expand which options they can make available through con-
tinuing education, the use of consultants, or referrals. Veterinary
options have increased not only in the area of treatments and
techniques but also the manner in which these can be made
available to clients (e.g., client training, mobile practice, and
veterinary hospice). ese caregivers should be folded into
the communication system discussed below. Sandoe et al. (14)
highlight “overtreatment” as an ethical concern that also needs to
be considered given the increasing availability of advanced treat-
ment options and pet insurance. e potential for overtreatment
2 http://www.scu.edu/ethics/practicing/decision/framework.html.
4
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is a particular concern in certain veterinary specialties (geriatric
medicine, oncology, emergency and critical care) where seriously
ill animals may be “saved” but where the negative experiences of
continuing to live outweigh the positive.
Explicit ethical discussion may also expose less-than-optimal
client–veterinarian pairings; for example, clients from religions
that do not permit euthanasia may not t well with a veterinarian
unable to accept and work with this perspective. As with physi-
cians or other professional caregivers, while every eort should
be made to meet client needs, clients should also be supported in
selecting a practitioner that best meets all of their needs rather
than choosing them purely on an arbitrary basis of proximity,
habit, fear of causing oense, or the desire to retain a customer
client.
A Communication System
Given the intricacies of caring for pets and their families during
humane endings, robust relationships between the veterinary
team, client, and patient can reinforce and maintain the vet-
erinarians role as a trusted guide even when unexpected adverse
events occur. Conversely, when a companion animal end-of-life
experience is poorly handled and this trust is not present, ongo-
ing personal guilt and recrimination can reverberate for the pet
owner and grief may become more debilitating (8). is may
lead to a client going to another veterinarian, avoiding further
veterinary care, or ceasing to be a pet owner. ese relationships
are built over time through empathic communication.
In many busy veterinary practices, clients only consult a vet-
erinarian when their pets need medical attention and frequently
they see whichever veterinarian happens to be available at the
time. is approach of treating veterinarians as interchangeable
may be implicitly supported when the practice does not clearly
record and seek to reconnect clients with their regular veterinar-
ian, and thus undermines the veterinarian–client relationship
(10, 26).
However, regular contact is not sucient to ensure that a good
relationship will develop. Borden etal. (27) analyzed euthanasia
discussions in companion animal practice and found that some
veterinarians were not fully exploring client feelings, ideas, and
expectations. Additionally, they also found that many veterinar-
ians did not always solicit client involvement in dening the
problem and in developing goals for treatment and management
of the pet, particularly with less assertive clients. Explicit train-
ing in communication will assist veterinarians in providing the
support required to make ethical decisions and help ameliorate
feelings of guilt or grief.
Communication skills are eminently teachable (28, 29) and
specic communication skills can be learned and implemented in
a veterinary practice with great success (30, 31). Appropriate train-
ing programs and workshops, such as the frank Communication
Series (see text footnote 1) can improve the communication
skills of all veterinary practice sta. Training in more than one
method will assist veterinarians in developing formalized systems
most suitable for their practice and provide options for adapting
their approach to the needs of the client. Eective veterinary
practitioners continue perfecting their communication skills
in non-verbal communication, reective listening, open-ended
inquiry, and empathic statements throughout their careers, and
mentoring others in these skills (28).
Development and discussion of communication tools and skill
sets by the veterinary team as a whole can also help in acknowl-
edging the stress associated with euthanasia decisions for both
the owner and sta involved in the patient’s care. One appropri-
ate approach is considering client relationships and emotions
as topics for continuing education and team communication
during regular sta meetings. is can improve sta interactions
with clients and encourage the development of healthy coping
mechanisms as part of an overall sta health and wellness plan.
Deciding how to manage a pet near the end of its life can be
a very dicult process, and a pre-established habit of honest,
respectful, and caring communication reduces stress and the
chances of misunderstandings. Engaging established clients in
conversations about quality of life and gradually introducing the
idea of end-of-life goals for their pets prior to the time when those
decisions are needed helps them establish appropriate goals and
expectations prior to a time when the pet is already in crisis and
the owner’s grief process has been triggered by the realization that
their pet has a terminal condition.
Without eective client communication, clients may not be
given the time or discussion they need to transition away from
therapeutic treatment and toward palliative care, or they may
not even realize this has occurred. Clients may inadvertently feel
pressured into end-of-life decisions or miss the chance to make
decisions about the euthanasia that may dier from the practices
more commonly selected, i.e., “default” opinions. For example,
it used to be assumed clients should not observe the euthanasia,
whereas when clients make this decision for themselves, the
majority opted to be present and this was oen helpful to them
in the grief process (32). Practices that are the norm today may be
similarly misguided, and we rely on clients to let us know when
they are not comfortable with what is happening.
Quality of Life Assessment Tools
One specic example of a tool to use during discussions with
clients is a quality-of-life assessment. ese assessments are like
other health and welfare questionnaires or checklist tools for
healthy animals (33) but are focused particularly on the needs of
animals during the end-of-life period. ey help clients appreciate
the severity of the health problems their animals are experienc-
ing and how this is aecting their ability to enjoy life. Ideally, the
owner and veterinary team can use these to track the progression
of the animal’s condition and agree on a point where euthanasia
should occur. ese tools direct clients to focus on their animal’s
quality of life as being the key determinant for when euthanasia
becomes ethically appropriate. Veterinarians and their sta play
a pivotal role in communicating the medical realities of a pet’s
disease to pet owners, while simultaneously respecting the strong
emotional bond between a client and their pet (34).
Quality-of-life tools vary in the circumstances they address,
and veterinarians should be familiar with or seek out examples
suitable for each patient and client. ere are general checklists
that might help illuminate whether any animal has “a life worth
living” (35); there are species-specic tools that address the eect
of a particular disorder or symptoms (3638). Villalobos and
5
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Kaplan (39) have proposed specic parameters for caregivers
of cancer patients. ese include the degree of pain the pet is
experiencing, changes in mobility, presence of appetite, hydra-
tion, and an estimation of the proportion of “good” versus “bad”
days. is can help a client to more objectively monitor a pet’s
quality of life. If individual scores reach only 30–50% of normal
for a pet, this could be set in advance as the point at which a
decision to euthanize is taken. Bijsmans etal. (40) have validated
a psychometric tool for assessment of owner-perceived quality of
life in cats and used it to compare quality of life between healthy
cats and those with chronic kidney disease.
Veterinary hospice and palliative care are currently hindered
by an inadequate amount of scholarly research to guide clinicians.
e increasing use of palliative care and hospice in veterinary
medicine necessitates further development of quality-of-life
assessment tools for decision making when caring for termi-
nally ill pets (41). e 2016 AAHA/IAAHPC End-of-Life Care
Guidelines for Dogs and Cats review the latest information to
help sta address central issues and perform essential tasks to
improve the quality of life of a pet that has entered the nal life
stage.3 e guidelines include resources to assist in client com-
munication and patient care.
For vets beginning to use these tools for the rst time, a
practical example of a simple pet owner quality of life assessment
tool is provided by e Honoring the Bond service at the Ohio
State College of Veterinary Medicine.4 is service also provides
a Pet Loss Library containing various resources for pet owners
on how to make end-of-life decisions and cope with the loss of
a pet. e quality-of-life assessment tool is a printable brochure
titled “How Do I Know When it’s Time? Assessing Quality of Life for
Your Companion Animal and Making End-of-Life Decisions5 that
provides pet owners with a suite of parameters to help assess their
pet’s quality of life in conjunction with a veterinarian. Another
important resource oered through the Honoring the Bond
service is access to a veterinary social worker who can act as a
liaison between the animal owner and veterinary medical team.
When a decision to perform euthanasia is reached, it should
be expressed clearly both verbally and in writing, such as the
Model Euthanasia Authorization6 developed by the AVMA. e
use of euphemism and verbal-only communication is subject to
misinterpretation. e client should then be educated about the
process and options and given as much control over the process
as is practicable and consistent with ethical practice.
THE PROBLEM OF VETERINARY
BURNOUT
As we have discussed, everyone associated with an animals death
can be strongly impacted, including veterinarians (42). e impact
3 https://www.aaha.org/graphics/original/professional/resources/guidelines/2016_
aaha_iaahpc_eolc_guidelines.pdf.
4 http://vet.osu.edu/vmc/companion/our-services/honoring-bond-support-
animal-owners.
5 http://vet.osu.edu/vmc/sites/default/les/import/assets/pdf/hospital/companio-
nAnimals/HonoringtheBond/HowDoIKnowWhen.pdf.
6 https://www.avma.org/KB/Policies/Documents/model-euth-auth-form.pdf.
for veterinarians dealing with sick and dying patients on a daily
basis can eventually take its toll, resulting in tremendous emo-
tional stress and the well-recognized “burnout” syndrome. e
topic of burnout is a great concern in human medicine, and there
is evidence that veterinarians in practice are aected the same way
(43). Aside from the adverse impact on the mental health of prac-
titioners, burnout could be considered the “elephant in the room
with regard to eectiveness in communication with clients (1).
A full 50% of medical clinicians—and most likely veterinary
clinicians as well—suer burnout, characterized by emotional
exhaustion, cynicism, and negative self-evaluation7 (44). Hartnack
etal. (11) found younger female veterinarians and those working
in small or mixed animal practice to be at a higher risk of work-
related stress and suicidal thoughts. Burnout may lead to a loss of
empathy with clients and attentiveness to their needs, resulting in
clients being less compliant with treatment instructions (45, 46).
Additionally, veterinarians experiencing burnout may appear
withdrawn or uncaring to their clients.
Strategies for preventing or dealing with burnout range from
insisting on meaningful breaks from practice, such as vacations
with no email or phone access to the hospital, a regular exercise
program, colleague support group meetings, and opportunities
for mindfulness and meditation (47, 48). Aside from the mental
health benets to the clinician, one study in human medicine
reported that clinicians rated as more mindful and engaged in
more patient-centered communication had a higher percentage
of satised patients (49). One expects that the ndings on human
patient communication apply equally to client communication
in the veterinary realm—and this includes the reality of clinician
burnout.
As well as seeking to cope with stress, eorts should also
be made to reduce stress to its lowest necessary levels. ere is
evidence that veterinarians cope better with stress resulting from
adverse surgical events when they can learn something from the
experience that can benet their future patients (50). is same
approach of open discussion and constructive learning should
be taken to both euthanasia decision making and the euthanasia
process, from the decision point to the disposition of the remains.
It has been shown that veterinarians benet from having col-
leagues at work who discuss cases and provide mutual support
during and aer euthanasia (11). Veterinarians who lack this
support within their workplace can look for safe and supportive
veterinary groups outside the workplace or online (e.g., “Not One
More Vet” on Facebook).
If veterinarians ultimately nd their employment does not or
will not support them with an ethical decision-making frame-
work or workplace wellness eorts, they should consider seeking
out a dierent employment opportunity that will make it easier
for them to nd meaning and satisfaction in their work—as
this is the greatest single factor for reducing workplace stress.
Employers nding that they struggle to retain veterinarians and/
or clients should include ethical and wellness considerations in
their analysis of the problem.
e high rate of suicide among veterinarians (as well as
human health professionals) is a matter of extreme concern
7 http://www.scu.edu/ethics/practicing/decision/framework.html.
6
Knesl et al. Veterinarians and Humane Endings
Frontiers in Veterinary Science | www.frontiersin.org April 2017 | Volume 4 | Article 45
(51), and a wide range of professional groups is attempting to
address it. Pioneering work by Bartram and Baldwin (52, 53) led
to the creation of the supportive Vetlife website8 in the United
Kingdom. In the United States, assisted by the AVMA, concerned
veterinary students have recorded brief videos expressing sup-
port to distressed fellow students, entitled “It’s OK” (54). e
AVMA Future Leaders Program has developed tools that have
been integrated in the AVMAs Wellness and Peer Assistance
resources.9 Volunteer positions are available for veterinarians
motivated to help tackle this wellness crisis in the profession at
a leadership level.
CONCLUSIONS
Promoting healthy decision making during the euthanasia process
of a companion animal is important for veterinarians’ wellness, for
ensuring a humane and respectful outcome for animal patients,
for strengthening the human–animal bond, and for maintaining
the reputation of the profession. Veterinarians need to develop
and maintain empathic, professional relationships with their
clients if they are to serve as a partner in dialog when euthanasia
is an alternative to continued suering. Understanding the nature
of the bond between the pet and caregiver plays the most impor-
tant role in determining the outcome for each animal, owner, and
veterinarian. Ideally, the occasion includes a shared and compas-
sionate appreciation of the situation, the options, and the likely
outcomes of the choices that are to be made. Veterinarians who
are not comfortable with addressing the full range of a clients
needs should explore the options for training and collaboration
with professionals trained in grief support.
e continued strengthening of the human–animal bond
has greatly complicated the ethical conundrum surrounding
euthanasia. Euthanasia is an emotional, psychological, and eco-
nomic issue that every veterinarian must wrestle with. Many in
the profession experience extensive stress as they grapple with
the conundrum of ending an animals life too soon, or waiting
too long, in addition to managing the client’s expectations and
8 www.vetlife.org.uk.
9 https://www.avma.org/professionaldevelopment/personal/peerandwellness/
pages/default.aspx.
accommodating their emotional needs. A number of approaches
are available to help veterinarians develop strategies for putting
end-of-life decisions and experiences into perspective and to
help prevent or deal with “burnout” syndrome. Having a work-
ing knowledge of ethical values, principles and decision-making
frameworks can help veterinarians make decisions with con-
dence and in turn help their clients problem-solve and confront
ethical dilemmas together.
For veterinarians wrestling with the conundrum of euthana-
sia, this article has outlined a number of ethical decision-making
tools and deliberative frameworks that can to help them better
manage end-of-life discussions with their clients to produce
optimal outcomes. Actively encouraging clients to carry out
regular, routine preventive care visits with the same veterinarian
will foster the development of meaningful, long-term veterinar-
ian–client–patient relationships. ese relationships can be fur-
ther enhanced when the veterinarian and all of the veterinary
hospital sta undergo regular continuing education on client
communication focusing on non-verbal communication, reec-
tive listening, open-ended inquiry, and empathic statements. e
ethical decision-making frameworks highlighted here facilitate
conscientious, humane, end-of-life decisions between veterinar-
ians and their clients in order to promote the best quality of life
for animal patients. Finally, it is important for veterinarians to
have a standard end-of-life protocol that includes the use of
quality-of-life assessment tools, euthanasia consent forms, and
pet owner resources for coping with the loss of a pet and that is
reviewed at least annually with all of the practice sta.
AUTHOR CONTRIBUTIONS
All the authors contributed signicantly to the concept and text.
ACKNOWLEDGMENTS
is manuscript represents work the authors completed in
their role as the members of, or sta support to, the AVMA
Steering Committee on Human-Animal Interactions (SCHAI).
e authors thank Dr. Lynette Hart, Lindsay Rojas, and
Lindsey McKinney for assistance in draing and reviewing the
manuscript.
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Conict of Interest Statement: e authors declare that the research was con-
ducted in the absence of any commercial or nancial relationships that could be
construed as a potential conict of interest.
Copyright © 2017 Knesl, Hart, Fine, Cooper, Patterson-Kane, Houlihan and Anthony.
is is an open-access article distributed under the terms of the Creative Commons
Attribution License (CC BY). e use, distribution or reproduction in other forums
is permitted, provided the original author(s) or licensor are credited and that the
original publication in this journal is cited, in accordance with accepted academic
practice. No use, distribution or reproduction is permitted which does not comply
with these terms.
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... Some publications intended their model to cover the entire decision-making process from the initial discussion up to body aftercare and emotional support, whereas others focused on a specific aspect of the EOL decision. The model presented by Arora et al. 17 30 Brandt and Grabill (2007) 46 Cornell and Kopcha (2007) 2 Shaw and Lagoni (2007) 6 Gray and Moffett (2010) 48 Parker and Yeates (2011) 14 Hewson (2015) 50 Bishop et al. (2016) 19 Knesl et al. (2017) 52 Pierce and Shanan (2017) 53 Van Eps et al. (2017) 15 Bley (2018) 21 Goldberg (2019) 23 Smith (2019) Language n=10 Could Not Obtain Full Text n=11 F I G U R E 1 Flow diagram outlining the process used for a scoping review of the current literature on serious illness and end-of-life decision-making models in dogs, cats and equids the fewest components. The most frequently identified component was "presentation of treatment and/or EOL options" (n = 20), followed by "knowledge exchange between veterinary team and owner" (n = 18), "consider impact of options on animal patient QOL" (n = 17), and "make a treatment and/or EOL care plan" (n = 17). ...
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... Euthanasia was recognized as a traumatic experience by some producers and for this reason they were not prepared to delegate this task to other employees. One previous study has identified the practice of euthanasia generating emotional strain in dairy producers (37) and chronic stress associated with euthanasia of animals in other animal professions such as the veterinary industry, has been shown to be related to increased rates of burn out (38). These finding suggests that the human impact of euthanasia of non-replacement dairy calves should also be considered as a key imperative for the generation of viable production pathways for these animals. ...
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Male non-replacement calves in dairy systems represent an underutilized economic resource for dairy producers worldwide. Despite this, increasing the practice of rearing non-replacement male calves has significant barriers both in on-farm adoption and practice. Poor neonatal rearing practices, higher levels of morbidity and mortality, and disaggregated production pathways with multiple points of handling, have all been described as barriers to adoption of surplus calf production. To identify the critical decision-determining challenges associated with broader adoption of raising non-replacement stock, and to investigate the whole-of-value chain issues faced by dairy producers to rear non-replacement male calves, we undertook a series of semi-structured interviews with Australian dairy producers to interrogate their key challenges. To achieve this, a constructivist grounded theory approach was used to inform the process of analysis of in-depth interviews with Australian dairy producers regarding their current practices and perceptions. Five major themes emerged from these conversations that were key barriers to on-farm non-replacement calf rearing in the producer group participants. These were: impacts of drought on cost and availability of feed for these calves and the whole herd; the management requirements of non-replacement male calves as an additional workload to that of their current operation; their attitudes and current practices to and surrounding euthanasia; perceived ease of supply-chain access for these calves, and their perceptions of the economic value of dairy-beef product as a return on investment. Understanding the barriers to adoption of non-replacement calf rearing, and addressing the value proposition for dairy beef, can assist increased uptake of non-replacement calf rearing. These findings will allow development of strategies to address these barriers, and extension of viable management strategies to increase adoption of profitable business practices surrounding non-replacement male calf production.
... Wanneer niet de kwaliteit van leven, maar de duur van het leven voorop gesteld wordt, en daarmee euthanasie keer op keer wordt uitgesteld, is er sprake van aantasting van het dierenwelzijn. Deze discussie doet zich meer en meer voor bij de dierenartsenpraktijken voor gezelschapsdieren waarbij eigenaren ongeacht de kosten niet over willen gaan tot euthanasie om het lijden van terminaal zieke gezelschapsdieren te stoppen (Knesl et al., 2017). Terwijl dit deels een gevolg is van de veterinaire medische vooruitgang en de toenemende beschikbaarheid van voorheen ontoegankelijke behandelingsopties, weerspiegelt het ook het dilemma van huisdiereigenaren om 'the end of life' beslissing te blijven bezien vanuit menselijk èn dierlijk perspectief. ...
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Een belangrijk deel van onze interesse in de wereld om onsheen is gericht op dieren. Niet alleen voor de voedselproductieof het transport, maar ook vanwege onze empathie voor henen onze fascinatie voor wat ze voor ons in veel andere rollen(kunnen) betekenen. Paarden, honden, katten en anderegezelschapsdieren maar ook veel landbouwhuisdieren wordenals metgezel behandeld en met genegenheid verzorgd.Deze belangstelling voor de band tussen mens en dier is sindseind vorige eeuw enorm toegenomen door onder anderede berichtgeving in de populaire pers over de positieve impactvan dieren op het leven van mensen. Hierdoor is de nieuwsgierigheidvan professionals en de samenleving gewekt om dezeunieke relatie tussen mens en dier tot meerwaarde te brengen.Met de toenemende inzet van dieren in ons leven, rijst vanzelfsprekendde vraag of die mens-dier interactie wederzijdspositief uitpakt.In 2019 is de zienswijze Dierbare Hulpverleners: welzijn voormens en dier? van De Raad voor Dierenaangelegenheden(RDA) (Raad voor Dierenaangelegenheden, 2019) verschenenwaarbij de vraag gesteld werd of, en op welke wijze, dieren bijinterventies op verantwoorde wijze kunnen worden ingezet.Zowel in de dagelijkse omgang met, als de inzet van dieren,maar zeker ook in de wetenschappelijke literatuur, is veel vakeraandacht voor hoe dieren de kwaliteit van leven van de menskunnen bevorderen in vergelijking met hoe de mens de kwaliteitvan leven van dieren zouden kunnen verbeteren.Alhoewel deze thematiek het meest herkenbaar is bij sectorenwaar dieren ingezet worden bij dierondersteunde interventies(zoals therapie) of hulp (blindengeleidehonden), moet heteffect van de mens-dier interactie op het dier veel bredergezien worden. Ook bij de inzet van dieren in opsporing,beveiliging, sport, recreatie en vermaak is er sprake van eenintensieve interactie tussen mens en dier. In sommige gevallenis de mens in het partnerschap met het dier zelfs geheel ofgedeeltelijk afhankelijk van het dier. De mens-dier interactieis ook (indirect) zichtbaar in het management, en dan metname in de houderij en fokkerij van dieren. Daar waar mensenbeslissen over huisvesting, voeding en fokdoelen van dieren,kan de kwaliteit van leven van dieren in gevaar komen wanneeronvoldoende rekening wordt gehouden met de behoeftenen aanpassingsmogelijkheden van het dier.Gek genoeg is onderzoek naar het effect van de mens-dierinteractie pas aan het einde van de vorige eeuw als eenonderzoeksgebied opgekomen. Sindsdien is het onderzoekexplosief gegroeid met multidisciplinaire onderzoeksgroepenover de hele wereld. Ook in Nederland wordt voornamelijkop universiteiten onderzoek gedaan naar de interactie tussendieren, mensen en maatschappij. De thematiek wordt vanuitverschillende disciplines benaderd, waaronder ook vanuit hetdiergedrag en dierenwelzijn. Op het hbo wordt onderzoekgedaan naar diergedrag, dierenwelzijn en diermanagement;het effect van de mens-dier interactie op het dier heeft daarechter nog een ondergeschikte rol.Het lectoraat Human-Animal Interactions draagt bij aanhet verder ontrafelen van wat zich af speelt in de mens-dierinteractie en vooral ook wat het voor het dier betekent.De focus ligt bij twee diersoorten: paarden en honden.In de publicatie wordt verder ingegaan op hoede mens-dier interactie tot stand komt, hoe dierenwelzijneen rol speelt in de mens-dier interactie en in welke sectorenmensen met paarden en honden samenwerken.
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In this chapter, the authors discuss the future of veterinary ethics. In doing so, they follow the model of veterinary practice in which veterinarians first document the medical history of a patient, come to a diagnosis, and finally make a prognosis on that basis. The authors provide a brief overview of the development and establishment of the field of veterinary ethics, and examine the prevailing context‐specific responsibilities of veterinary professionals. They look into the future of the evolving research field by discussing challenges in the context of advanced veterinary medicine and introduce ethical tools as well as ethics support services as possible formats to provide support for veterinarians in their clinical decision‐making. Finally, the authors also discuss promising approaches for teaching ethics to future generations of veterinarians. An important pillar of veterinary ethics lies in educational programs for veterinary students, the future veterinarians.
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Death is an inevitable part of veterinary practice. Vets may cause death, deliberately or unintentionally support practices that cause it, or allow it to occur. Death can involve or prevent suffering, avoids animals enjoying (or suffering) ongoing life, and can be in accordance or against owners' wishes. It occurs in a variety of morally‐relevant contextual settings. This chapter considers different types of death, why death might be morally important directly and indirectly, the veterinary professionals' role in relation to death, how veterinary professionals might improve end of life decisions, and some specific scenarios and a case study. While death relates primarily to the animals who die, it also affects other stakeholders. Killing animals may detract from veterinary professionals' image as healers or make us seem uncaring. Veterinarians in practice have a variety of roles and face various ethical dilemmas related to end‐of‐life decisions.
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Background: End-of-life decision making for animals happens daily in veterinary practice. However, access to such discussions as they happen is difficult, in view of the highly emotional circumstances of end-of-life consultations. Despite the expanding literature on euthanasia, few studies have explored the circumstances of euthanasia disagreement or delay. Methods: To explore euthanasia discussions in veterinary practice, consultations recorded in electronic health records in a UK veterinary surveillance database (SAVSNET) were examined. From a sample of 2000 identified consultations, 69 canine and 76 feline consultations were purposively sampled for detailed thematic analysis. Specifically, consultations were selected if they involved a decision to delay euthanasia, including disagreement about the timing of euthanasia. Results: Reasons identified for euthanasia refusal or delay included client-related factors (e.g., allowing other family members to say goodbye, differing opinions on the quality of life) and veterinary surgeon-related factors (eg, the wish to carry out further investigations or to try a new treatment). In the instance of refusal or delay, palliative treatment was commonly provided to preserve animal welfare. Conclusion: This study illustrates some of the processes used to negotiate end-of-life decision making in dogs and cats. Its findings shed light on the importance of palliative care in providing owners with time to decide.
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As veterinarians, we support not only our patients but also the millions of humans who share their lives with animals. Veterinarians and their colleagues are accustomed to being reminded that the veterinary profession is built on human connections with animals, and we recognize that the human-animal bond is important in all settings. In terms of academic theory and practical application, however, the human-animal bond approach is most advanced in the area of companion animals. The benefits of promoting the human-animal bond in companion animal practice are, by now, quite clear. It has, for example, been shown that the bond between owners and their pets has an important influence on the care those pets receive, that owners who have the strongest bonds with their pets are more likely to accept health-care recommendations from their veterinarian, and that highly bonded owners visit their veterinarian more often and are more likely to seek preventive care. For veterinarians in companion animal practice, however, it can sometimes be unclear how the human-animal bond can be incorporated into everyday practice activities. For those veterinarians, focusing on client communication and animal handling provides practical methods for emphasizing the human-animal bond.
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The death of a pet is a universal experience for those who share their lives with animals. In parallel with a rising interest in palliative medicine, hospice care and advance-care planning within human medicine, increasing attention is currently being given to serious illness and death within veterinary medicine. Our ability to prolong life has created the need for thoughtful end of life discourse. Interest in hospice and palliative care for companion animals is on the rise, yet there has been limited scholarly research in these areas to date. This review concludes that veterinary hospice and palliative care is currently hindered by an inadequate amount of scholarly research to guide clinicians. Given a lack of prospective studies in veterinary hospice and palliative care to date, a significant opportunity exists for veterinary teaching institutions to contribute to the literature in an important and growing field.
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Euthanasia of pets has been described by veterinarians as “the best and the worst” of the profession. The most commonly mentioned ethical dilemmas veterinarians face in small animal practice are: limited treatment options due to financial constraints, euthanizing of healthy animals and owners wishing to continue treatment of terminally ill animals. The aim of the study was to gain insight into the attitudes of Austrian veterinarians towards euthanasia of small animals. This included assessing their agreement with euthanasia in exemplified case scenarios, potentially predicted by demographic variables (e.g. gender, age, working in small animal practice, employment, working in a team, numbers of performed euthanasia). Further describing the veterinarians’ agreement with a number of different normative and descriptive statements, including coping strategies. A questionnaire with nine euthanasia scenarios, 26 normative and descriptive statements, and demographic data were sent to all members of the Austrian Chamber of Veterinary Surgeons (n = 2478). In total, 486 veterinarians answered sufficiently completely to enable analyses. Responses were first explored descriptively before being formally analysed using linear regression and additive Bayesian networks – a multivariate regression methodology – in order to identify joint relationships between the demographic variables, the statements and each of the nine euthanasia scenarios. Mutual dependencies between the demographic variables were found, i.e. female compared to male veterinarians worked mostly in small animal practice, and working mostly in small animal practice was linked to performing more euthanasia per month. Gender and age were found to be associated with views on euthanasia: female veterinarians and veterinarians having worked for less years were more likely to disagree with euthanasia in at least some of the convenience euthanasia scenarios. The number of veterinarians working together was found to be the variable with the highest number of links to other variables, demographic as well as ethical statements. This highlights the role of a team potentially providing support in stressful situations. The results are useful for a better understanding of coping strategies for veterinarians with moral stress due to euthanasia of small animals.
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Background: Numerous validated psychometric tools are available to assess impact of disease on a human's quality of life (QoL). To date, no psychometrically validated general health-related QoL tool exists for cats. Hypothesis/objectives: To develop and validate a tool for assessment of owner-perceived QoL in cats (CatQoL) and to use this tool to compare QoL between healthy cats and those with chronic kidney disease (CKD). Animals/subjects: Total of 204 owners of young healthy cats (YH, n = 99; <9 years), older healthy cats (OH, n = 35), and cats diagnosed with CKD (CKD, n = 70) completed the CatQoL. Methods: Discussions with a focus group and 2 pilot surveys informed design of 16 QoL questions grouped into 4 domains. Each item scored according to frequency and importance, and item-weighted-impact-scores were calculated. The validity of the tool was assessed using principal components analysis and Cronbach's α. The average item-weighted-impact-score (AWIS) was compared among groups and domains. Results: Sixteen-item CatQoL showed good internal consistency reliability (Cronbach's α, 0.77) and unidimensionality with significant loadings (0.2-0.7) and communalities (>0.3). Young healthy cats had significantly higher AWIS (median [IQR], 1.25 [0.63, 1.88]) than OH (0.56 [-0.06, 1.00]) and CKD cats (-0.06 [-0.81, 0.88]), P < .001). CKD cats had significantly lower AWIS for eating domain (YH: 2.00 [1.00, 3.00]; OH: 2.00 [0.67, 3.00]; CKD : 1.00 [0.00, 2.67]) when compared with the YH group and OH group, and all groups differed significantly in their management domain (YH: -0.50 [-1.00, 0.00]; OH: -1.00 [-1.88, -0.50]; CKD : -1.50 [-2.50, -1.00], P < .001). Conclusions and clinical importance: The CatQoL was validated for use in cats, and can be used as additional assessment parameter in clinical and research settings.
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Veterinarians are believed to be at increased risk for suicide compared with the general population. Few data on the occurrence of suicidal behavior and suicide risk factors among U.S. veterinarians are available. Veterinarians participating in two wellness summits held during September 2013 concluded that more research is needed on veterinarians and their mental health.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711171/
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Purpose: Mindfulness (ie, purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care. Methods: We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care. Results: In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58-10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46-1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17-1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15-1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues. Conclusions: Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.
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Looking into end of life decisions concerning companion animals roughly two kinds of issues can be identified. On the one hand we sometimes kill companion animals too late causing unnecessary suffering and on the other hand there are situations in which might we kill them too fast, depriving them a natural lifespan and possible future wellbeing. These situations raise moral questions about role and responsibilities of pet owners and veterinarians and about justification of end of life decisions regarding companion animals. We can address these questions by looking at the implications of moral standing of companion animals in modern Western societies. The so-called human-companion animal bond implies a moral obligation to take the interests of our companion animals seriously into account. I will argue that when making decisions about end of life of our companion animals, the interests of the concerned animal will normally outweigh the interests of the owner. An animal’s future quality of life is the most important parameter. We therefore have a moral obligation to euthanize animals in case of unbearable and hopeless suffering. Killing healthy companion animals however can only be justified in special circumstances. To help veterinarians in making difficult end of life decisions, we have developed an assessment model. By using this model veterinarians are guided to carefully weigh all the different interests in play and make justified decisions about killing companion animals.
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The BVA's Ethics and Welfare Group recently considered the issue of euthanasia to review what advice could be given both to recent graduates and older veterinary surgeons on the euthanasia of owned animals (BVA 2009). Expanding on those deliberations, and using the approach to ethical dilemmas suggested in a previous article by Siobhan Mullan and David Main (In Practice, July 2001, volume 23, pages 394–401), James Yeates discusses the ethical aspects associated with a decision to euthanase an animal from both the vet's and owner's perspective.