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End-of-life decisions for companion animals can be stressful for veterinarians and owners, and when delayed result in poor animal welfare. Delayed euthanasia has been identified as a particularly prominent issue for horses. This scoping review aimed to identify the available literature on veterinary decision-making models, which can support end-of-life planning.
A protocol was preregistered, and a structured literature search was performed on six electronic databases. Publications were reviewed against specifically developed eligibility criteria. Data from original studies and narrative-type reviews were extracted separately, and the components of each model were charted.
A total of 2211 publications were identified, 23 met the inclusion criteria and were included in the final review. Eight were original research studies and 15 were narrative reviews or similar. Publications were not indexed uniformly, increasing the difficulty of discovering relevant sources. The end-of-life decision-making process comprised three stages: (1) making the decision, (2) enacting the decision and (3) aftercare. Twenty key components of decision-making models were identified, although no publication reflected all of these.
A lack of original research studies and equine-specific publications was identified. Shared decision-making models for euthanasia in veterinary practice should include all three stages and consider species-specific issues.
Pet owners caring for a pet during the end of its life are faced with aftercare choices and decisions. This study, through the use of an online anonymous survey, explored the perceptions and expectations of United States (US) pet owners regarding end-of-life issues, with a focus on after-death body care. Participants living in the US who were the current owners of at least one cat or dog, had a regular veterinarian, and had made end-of-life decisions for at least one pet were recruited for the study. Survey respondents included 2043 dog and/or cat owners (41.4% male, 57.9% female) of which 68% had made cremation decisions and 32% had made burial decisions for at least one pet in the past. The majority of these owners indicated they preferred to work with a specific crematory (43%) or cemetery (70%) and over 95% of these owners reported feeling it important to work with their preferred after-death body care service. In terms of guidance, most owners indicated they rely on their veterinary team to help them with end-of-life decisions and orchestrating arrangements on their behalf with tertiary pet aftercare services/companies. Participants indicated being more likely to use veterinary staff for pet death and dying as well as after-death body care and memorialization than any other source. When asked about these after-death body care conversations, 73% indicated they need 20 minutes or less. Participants expressed significant concern over several aspects of after-death body care (e.g., body mislabeling, type of container used for short term and long-term storage). Results of this study create the foundation for practical, ethical after-death body care recommendations to help guide veterinary teams acting on their clients’ behalf.
Through a collaborative partnership, Seneca College and VCA
Canada are pleased to share this set of best practice
guidelines. Funded by Seneca Innovation, the project involved
the completion of a literature review, data collection from 310
pet owners who shared their experiences interacting with
veterinary teams, and a consultation with leading industry
experts. The culmination of this work has resulted in the Pet
Loss Best Practice Guidelines for Veterinary Teams.
Equine welfare issues are receiving increasing attention in the UK, but welfare problems can arise from a wide range of causes. In order to identify the most important welfare concerns for horses, we used a Delphi method with 19 equine welfare experts. An initial list of 84 equine welfare issues was generated using an online discussion board and NVivo thematic analysis. Subsequently, experts ranked these welfare issues for perceived prevalence, severity and duration of suffering associated with each issue on a 6-point Likert scale. All issues with a mean score of 3 or above (n = 37) were included in subsequent rounds. Finally, a subset of experts attended a two-day workshop to determine the final priority list of welfare issues. The welfare issues perceived to be most prevalent were lack of biosecurity, delayed euthanasia, lack of owner knowledge of equine welfare needs, fear and stress from use, and obesity. The issues considered to cause greatest suffering for individual horses were delayed euthanasia, lack of recognition by owners of pain behaviour, large worm burdens, obesity and being fed unsuitable diets for equine feeding behaviour. These outcomes can help to focus research and education interventions on the most pressing welfare issues for horses.
To (1) provide an up-to-date overview of shared decision making (SDM)-models, (2) give insight in the prominence of components present in SDM-models, (3) describe who is identified as responsible within the components (patient, healthcare professional, both, none), (4) show the occurrence of SDM-components over time, and (5) present an SDM-map to identify SDM-components seen as key, per healthcare setting.
Peer-reviewed articles in English presenting a new or adapted model of SDM.
Academic Search Premier, Cochrane, Embase, Emcare, PsycINFO, PubMed, and Web of Science were systematically searched for articles published up to and including September 2, 2019.
Forty articles were included, each describing a unique SDM-model. Twelve models were generic, the others were specific to a healthcare setting. Fourteen were based on empirical data, 26 primarily on analytical thinking. Fifty-three different elements were identified and clustered into 24 components. Overall , Describe treatment options was the most prominent component across models. Components present in >50% of models were: Make the decision (75% ), Patient preferences (65% ), Tailor information (65% ), Deliberate (58%), Create choice awareness (55% ), and Learn about the patient (53%). In the majority of the models (27/40), both healthcare professional and patient were identified as actors. Over time, Describe treatment options and Make the decision are the two components which are present in most models in any time period. Create choice awareness stood out for being present in a markedly larger proportion of models over time.
This review provides an up-to-date overview of SDM-models, showing that SDM-models quite consistently share some components but that a unified view on what SDM is, is still lacking. Clarity about what SDM constitutes is essential though for implementation, assessment, and research purposes. A map is offered to identify SDM-components seen as key.
PROSPERO registration CRD42015019740
Euthanasia of companion animals is a challenging responsibility in the veterinary profession since veterinarians have to consider not only medical, but also legal, economic, emotional, social, and ethical factors in decision-making. To this end; an anonymous questionnaire-based survey of Austrian equine veterinarians examines the attitudes to the euthanasia of equine patients in a range of scenarios; to identify factors which may influence decisions on the ending of a horse’s life. This paper describes the distributions of demographic and attitude variables. Mann-Whitney U tests were used to test the associations of gender, work experience, and equine workload with attitudes in relation to euthanasia statements and case scenarios. In total, 64 respondents (response rate = 23.4%) completed the questionnaire. The study showed that veterinarians consider contextual and relational factors in their decision-making. They are aware of owners’ emotional bonds with their horses and financial background, however, requests for convenience euthanasia are typically rejected. Although some significant differences between the tested variables emerged, the attitudes of the veterinarians were shown to be largely shared. In conclusion, veterinarians are aware of the multiple factors that influence their decision-making and gave indications as to the weight of animal- and owner-related factors in the handling of euthanasia.
Scoping reviews, a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. Although more scoping reviews are being done, their methodological and reporting quality need improvement. This document presents the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist and explanation. The checklist was developed by a 24-member expert panel and 2 research leads following published guidance from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. The final checklist contains 20 essential reporting items and 2 optional items. The authors provide a rationale and an example of good reporting for each item. The intent of the PRISMA-ScR is to help readers (including researchers, publishers, commissioners, policymakers, health care providers, guideline developers, and patients or consumers) develop a greater understanding of relevant terminology, core concepts, and key items to report for scoping reviews.
Modern veterinary medicine offers numerous options for treatment and clinicians must decide on the best one to use. Interventions causing short-term harm but ultimately benefitting the animal are often justified as being in the animal’s best interest. Highly invasive clinical veterinary procedures with high morbidity and low success rates may not be in the animal’s best interest. A working party was set up by the European College of Veterinary Anaesthesia and Analgesia to discuss the ethics of clinical veterinary practice and improve the approach to ethically challenging clinical cases. Relevant literature was reviewed. The ‘best interest principle’ was translated into norms immanent to the clinic by means of the ‘open question argument’. Clinical interventions with potential to cause harm need ethical justification, and suggest a comparable structure of ethical reflection to that used in the context of in vivo research should be applied to the clinical setting. To structure the ethical debate, pertinent questions for ethical decision-making were identified. These were incorporated into a prototype ethical tool developed to facilitate clinical ethical decision-making. The ethical question ‘Where should the line on treatment be drawn’ should be replaced by ‘How should the line be drawn?’
Many owners of companion animals with cancer are overwhelmed by having to choose the “right course of action.” With the aim of reducing the burden on owners who are forced to act as surrogates for their animals, this work discusses principles that apply to ethical treatment decision-making for animal patients with cancer. Four principles frequently used for ethical decision-making in human medicine will be considered for their potential applicability in veterinary medicine. As a result of these considerations, preliminary guidelines are presented, along which a decision-making discussion can be held. The deliberate integration of the non-maleficence and beneficence principles into the purely empirical facts of what is medically possible helps to maintain a moral perspective in specialized veterinary medicine. At the same time, such guidelines may contribute to individual decision-making in a way that animal patients neither have to endure unnecessarily severe side effects, nor that they are euthanized prematurely.
The patient–provider relationship in the context of veterinary medicine represents a unique opportunity for studying how bad news is communicated to pet owners by conducting structured interviews with veterinarians. A sample of 44 veterinarians’ responses was recorded and content-analyzed in an effort to identify themes among providers in their clinical experience of breaking bad news (BBN). Two coders revealed several themes in the data that were organized by three overarching areas: (1) breaking bad news in general, (2) euthanasia, and (3) social support. The findings from interviews indicated the COMFORT model (Villagran, Goldsmith, Wittenberg-Lyles, & Baldwin, 2010) in medical education provided a useful framework to organize the communication of BBN in veterinary medicine. Results were discussed in relation to future research in patient–provider communication and COMFORT’s potential value for training students in veterinarian education.
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.
End-of-life (EOL) care and decisionmaking embody the critical final stage in a pet's life and are as important and meaningful as the sum of the clinical care provided for all prior life stages. EOL care should focus on maximizing patient comfort and minimizing suffering while providing a collaborative and supportive partnership with the caregiver client. Timely, empathetic, and nonjudgmental communication is the hallmark of effective client support. Veterinarians should not allow an EOL patient to succumb to a natural death without considering the option of euthanasia and ensuring that other measures to alleviate discomfort and distress are in place. Animal hospice care addresses the patient's unique emotional and social needs as well as the physical needs traditionally treated in clinical practice. An EOL treatment plan should consist of client education; evaluating the caregiver's needs and goals for the pet; and a collaborative, personalized, written treatment plan involving the clinical staff and client. Primary care practices should have a dedicated team to implement palliative and hospice care for EOL patients. How the healthcare team responds to a client's grief after the loss of a pet is a key factor in the client's continued loyalty to the practice. Referral to professional grief-support counseling can be a helpful option in this regard.
An understanding of patients' care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress. However, conversations about care goals are often conducted by physicians who do not know the patient, do not routinely address patients' nonmedical goals, and often fail to provide patients with sufficient information about prognosis to allow appropriate decisions; in addition, they tend to occur so late in the patient's illness that their impact on care processes is reduced. This article (1) reviews the evidence and describes best practices in conversations about serious illness care goals and (2) offers practical advice for clinicians and health care systems about developing a systematic approach to quality and timing of such communication to assure that each patient has a personalized serious illness care plan. Best practices in discussing goals of care include the following: sharing prognostic information, eliciting decision-making preferences, understanding fears and goals, exploring views on trade-offs and impaired function, and wishes for family involvement. Several interventions hold promise in systematizing conversations with patients about serious illness care goals: better education of physicians; systems to identify and trigger early discussions for appropriate patients; patient and family education; structured formats to guide discussions; dedicated, structured sections in the electronic health record for recording information; and continuous measurement. We conclude that communication about serious illness care goals is an intervention that should be systematically integrated into our clinical care structures and processes.
To describe the process aspects (communication) of the information expectations of clients accessing oncology care services at a tertiary referral center for dogs with life-limiting cancer.
Qualitative analysis of data acquired during in-person single and dyadic interviews.
43 dog owners participating in 30 interviews.
Independent in-person interviews were conducted with standardized open- and closed-ended questions from April to October 2009. Thematic analysis was performed on transcripts of the interview discussions.
The participants expected information to be communicated in a forthright manner; in multiple formats; with understandable language; in an unrushed environment wherein staff took the time to listen, answer all questions, and repeat information when necessary; on a continuous basis, with 24-hour access to address questions or concerns; in a timely manner; with positivity; with compassion and empathy; with a nonjudgmental attitude; and through staff with whom they had established relationships.
Conclusions and clinical relevance:
Results indicated that the manner in which information is communicated is vitally important to clients of dogs with life-limiting cancer in that it not only facilitates comprehension but also creates a humanistic environment from which clients derive the psychosocial support needed to successfully cope with their pet's condition.
To evaluate the content aspects of the information expectations of clients accessing oncology care services at a tertiary referral center for dogs with life-limiting cancer.
Qualitative analysis of data acquired during in-person single and dyadic interviews. Sample-43 dog owners participating in 30 interviews.
Independent in-person interviews were conducted with standardized open- and closed-ended questions from April to October 2009. Thematic analysis was performed on transcripts of the interview discussions.
For the clients, the central qualification was that the information given had to be the truth. Information was expected about all aspects of their dog's cancer and its treatment, varying in relation to clients' basic understanding of cancer, their previous experience with cancer, and their information preferences. Provision of information generated the trust and confidence necessary to engage in treatment, the ability to make informed decisions, and the ability to be prepared for the future. Provision of information also engendered a sense of control and capability and fostered hope.
Conclusions and clinical relevance:
When dealing with owners of dogs with life-limiting cancer, results indicated that in addition to abiding by the principle of truth-telling, it is important for health-care service providers to ascertain clients' understanding of and experiences with cancer as well as their information preferences and thereby adopt a tailored approach to information giving. Provision of information enabled client action and patient intervention but also enhanced clients' psychosocial well-being. Veterinary healthcare service providers can purposely provide information to build and sustain clients' ability to successfully cope with their pet's condition.
The study of human-animal interactions (HAI), and the resulting human-animal relationships (HARs) and bonds (HABs) which are set up as a consequence, is currently a topical issue in comparative psychology. Here we review the HAI/HAR/HAB literature to detect the main publication trends, and to identify the predominant research themes in this area. Research in HAI/HAR/HAB only really started in the 1980s, but since then there has been a growth in studies which is still continuing. Most of these studies have been in the contexts of companion animal or agricultural animal research, but there is now a growing literature on laboratory, zoo and wild animals too. In the companion animal HAI/HAB literature the greatest emphasis has been on Animal-assisted Interventions (AAI), and the benefits to people of pet ownership and interaction with pets. Agricultural HAI/HAR research, on the contrary, has been more concerned with the welfare consequences of HAI/HARs to the animals. This disjunction is reflected in the preference of companion animal researchers to use the term ‘bond’, but agricultural researchers to use ‘relationship’. Other themes prominent in the literature include methodological issues, the characteristics of caretakers, the role of veterinarians, sociological approaches, and theoreticalaspects. It is concluded that currently HAI/HAR/HAB research does not constitute a unified field, and there is a need to: i) agree and define a standard terminology; ii) undertake more research on the effects of HAI on companion animals; iii) undertake more research on the form and frequency of interactions; and iv) increase research on HAI/HAR/HABs in laboratory, zoo and wild-living animals. This research is important to understand whether HAI has positive, neutral or negative consequences, both for humans and for animals.
Pair and social bonding has been documented in various taxa, where pair formations are often described as being driven by kinship or sexual motivation. However, pair-bonding between unrelated individuals where sexual motivation is not a factor is not well documented. Many social relationships and pair-bonds between members of a dyad are facilitated by each individual's ability to recognise their partner using cues which are characteristic of that particular individual. The aims of this study were i) to investigate the existence of pair-bonding in domestic donkeys and ii) to determine whether members of a dyad could recognise their companion during a Y-maze recognition test. Subjects were 55 unrelated donkeys (38 gelded males, 15 females) in seven groups of mixed or same sex, comprising 4–14 individuals. Spatial proximity (nearest-neighbour) was observed three times a day over a 22-day period. Using a simulation approach based on observed data to generate randomised nearest-neighbour matrices, the statistical significance of social relationships was estimated. Of these, 42 (79.2%) were involved in significantly (p < 0.05) non-random nearest-neighbour relationships, most of which were reciprocal pair relationships. Based on the spatial data, 24 of the donkeys which had shown significant reciprocal nearest-neighbour preferences for one individual (companion) were then used in a Y-maze recognition test in which they were presented with a choice of their companion and either a familiar donkey from the same group or an unfamiliar donkey from a different group. Donkeys’ spatial location in the Y-maze demonstrated a preference for their companion versus familiar (one sample Wilcoxon signed rank test, W = 239, p = 0.002) or unfamiliar donkeys (W = 222, p = 0.041). These results verify anecdotal evidence from donkey handlers that donkeys often form pair-bonds, and show that reciprocal social preference and recognition are the basis of these. Pair-bond formation and companionship among donkeys have potential implications for their management, husbandry and welfare.
Physician competence in end-of-life care requires skill in communication,
decision making, and building relationships, yet these skills were not taught
to the majority of physicians during their training. This article presents
a 7-step approach for physicians for structuring communication regarding care
at the end of life. Physicians should prepare for discussions by confirming
medical facts and establishing an appropriate environment; establish what
the patient (and family) knows by using open-ended questions; determine how
information is to be handled at the beginning of the patient-physician relationship;
deliver the information in a sensitive but straightforward manner; respond
to emotions of the patients, parents, and families; establish goals for care
and treatment priorities when possible; and establish an overall plan. These
7 steps can be used in situations such as breaking bad news, setting treatment
goals, advance care planning, withholding or withdrawing therapy, making decisions
in sudden life-threatening illness, resolving conflict around medical futility,
responding to a request for physician-assisted suicide, and guiding patients
and families through the last hours of living and early stages after death.
Effective application as part of core end-of-life care competencies is likely
to improve patients' and families' experiences of care. It may also enhance
physicians' professional fulfillment from satisfactory relationships with
their patients and patients' families.
Owners' satisfaction with, and expectations from, their veterinarians around euthanasia, including questions on disposal of pet remains subject to animal species, clients' gender, age, family conditions, area of living and type of veterinary clinic visited were evaluated by questionnaire. Questionnaires were to be filled out by clients consecutively visiting the individual practices and hospitals for any kind of consultations. Of 2350 questionnaires distributed, 2008 were returned and available for analysis. Owner satisfaction concerning the procedure of euthanasia was high (92 per cent, 1173/1272). After the event of euthanasia, 14 per cent (170/1250) had changed their veterinarian, even though 75 per cent of these 170 had been satisfied with the procedure. Most owners (88 per cent) expected veterinarians to talk about their pet's final destination, and 38 per cent expected this to happen early in the pet's life. For 81 per cent clients, the veterinarian was the primary informant about the possibilities concerning the disposal of pet remains, and 33 per cent indicated their veterinarian as the contact person to talk about pet loss. Area of living, or veterinary specialisation, only marginally influenced the answers. Veterinarians play an important role to inform their clients concerning questions around euthanasia and the care of pet remains, and to support them during the process of mourning.
Information that drastically alters the life world of the patient is termed as bad news. Conveying bad news is a skilled communication, and not at all easy. The amount of truth to be disclosed is subjective. A properly structured and well-orchestrated communication has a positive therapeutic effect. This is a process of negotiation between patient and physician, but physicians often find it difficult due to many reasons. They feel incompetent and are afraid of unleashing a negative reaction from the patient or their relatives. The physician is reminded of his or her own vulnerability to terminal illness, and find themselves powerless over emotional distress. Lack of sufficient training in breaking bad news is a handicap to most physicians and health care workers. Adherence to the principles of client-centered counseling is helpful in attaining this skill. Fundamental insight of the patient is exploited and the bad news is delivered in a structured manner, because the patient is the one who knows what is hurting him most and he is the one who knows how to move forward. Six-step SPIKES protocol is widely used for breaking bad news. In this paper, we put forward another six-step protocol, the BREAKS protocol as a systematic and easy communication strategy for breaking bad news. Development of competence in dealing with difficult situations has positive therapeutic outcome and is a professionally satisfying one.
Euthanasia is a double-edged sword in veterinary medicine. It is a powerful and ultimately the most powerful tool for ending the pain and suffering. Demand for its use for client convenience is morally reprehensible and creates major moral stress for ethically conscious practitioners. But equally reprehensible and stressful to veterinarians is the failure to use it when an animal faces only misery, pain, distress, and suffering. Finding the correct path through this minefield may well be the most important ethical task facing the conscientious veterinarian.
Although shared decision-making (SDM) has knowledge and satisfaction benefits for patients and is promising, we lack data demonstrating that SDM is associated with better patient-reported functional outcomes. Such data would support the integration and prioritization of SDM into all aspects of orthopaedic care.
(1) Is a measure of SDM before total joint arthroplasty associated with better patient-reported outcome measures (PROMs) 1 year postoperatively? (2) What is the relationship between the measure of SDM and two measures of patient experience (patient rating of the provider and patient likelihood of recommending the provider) at 1 year postoperatively?
In this observational longitudinal survey-based study, patients receiving an initial THA or TKA from a large, multispecialty medical group in the Midwestern United States were surveyed after they were scheduled for surgery and again at 12 months after their procedure. The three-item collaboRATE measure of SDM was added to existing patient surveys of PROMs. However, the surgeons and their department had no organized approach to SDM during this time. The surveys also included the Oxford knee or hip score and two validated measures of patient experience (patient rating of the provider and whether a patient would recommend the provider). Of the 2779 eligible primary joint arthroplasties that occurred from April 23, 2018 to May 1, 2019, 48% (1334 procedures; 859 TKAs and 485 THAs) of the patients responded to both the preoperative and 12-month postoperative surveys. Most of the patients who were included in the analytic sample were white (93%; 1255 of 1344), with only 3% (37) using Medicaid benefits at the time of surgery. Differences between responders and nonresponders were present and explored in an analysis. Patient responses were analyzed in regression models to estimate the association between preoperative collaboRATE scores and the Oxford knee or hip scores, and patient experience measures 12 months postoperatively.
There was a moderate, positive association between preoperative collaboRATE scores and the Oxford scores at 12 months, after adjustment for potential confounders such as patient age and preoperative functional score (β = 0.58; 95% CI 0.14-1.02; p = 0.01). Similarly, patients with preoperative collaboRATE scores had marginally higher patient experience scores at 12 months postoperatively (β = 0.14; 95% CI 0.05-0.24; p = 0.003) and were more likely to recommend their surgeon (OR 1.43; 95% CI 1.11-1.84; p = 0.005). The patient experience measures were also modestly correlated with collaboRATE scores in cross-sectional associations, both preoperatively and at 12 months postoperatively (0.29 ≤ r ≤ 0.54; p < 0.01).
The association between preoperative collaboRATE scores and Oxford hip or knee scores suggests that SDM could be one tool to encourage better outcomes. Although previous studies have shown that SDM can improve patient experience, the lack of a strong correlation in our study suggests that PROMs and experience measures are separate domains, at least partly. Improving preoperative SDM between the surgeon and patient might help improve surgical outcomes for patients undergoing TKA and THA.
Level of evidence:
Level II, therapeutic study.
There is a lack of research exploring how the horse-human relationship influences horse owners' decision-making. The aim of this study was to investigate how an owner's relationship with their horse affects decisions around key events during their horse's lifetime.
An online survey and semi-structured telephone interviews were conducted with horse-owners. The online survey asked horse owners about their experiences of decision-making and their relationship with their horse and identified interview participants. Two semi-structured interviews were conducted with 11 horse owners on their experience of purchasing and euthanasia of horses. Interviews were recorded and transcribed, and thematic analysis was performed.
There were 938 responses to the online survey. The majority of owners considered their horse to be a member of the family (92.9%, 808/870). The mean amount spent annually on their horse was £9215 (range £324-14,240). Seven themes were identified in the interviews including mismatching of horse and rider; financial, time, welfare and personal obligations involved in horse ownership; shared-decision making; the horse's quality of life; guilt and responsibility grief surrounding euthanasia decisions.
This study highlighted the strong owner-horse relationship, the significant obligations involved in horse ownership and the emotional impact of euthanasia decisions.
To illustrate the use of shared decision-making (SDM) and SDM tools and aids as the essential components in the care of asthma.
We reviewed individual randomized controlled studies conducted between 1998 and 2020 to compare SDM interventions and the use of SDM tools and aids for the care of asthma. All studies were published or translated in English.
We excluded studies of interventions that involved multiple components other than the SDM intervention unless the control group also received these interventions. We evaluated the existing literature on both SDM tools and aids and the process of SDM to summarize in this review.
Shared decision-making tools and aids most commonly clarify the diagnostics and options for a treatment. The 6 elements of SDM were clearly supported. We found no considerable association between the presence of these elements of SDM and asthma outcomes.
We found that SDM for asthma and SDM tools and aids were often made to transfer information about asthma treatment options and their harms and benefits. The correlation between their support of SDM key elements and their impact on asthma outcomes is often difficult to ascertain but when present, there was positive correlation to improving risk communication, adherence, patient satisfaction, and possibly decreasing liability.
While euthanasia is a common feature of veterinary practice, research has yet to adequately explore the experiences, perception and wishes of pet owners, including their satisfaction and grief following companion animal euthanasia.
An online questionnaire was conducted with pet owners who had experienced euthanasia within the last 10 years to explore the relationship between pet owners’ experiences and their resulting satisfaction and grief following companion animal euthanasia. Data were analysed using descriptive statistics and multivariable linear regression.
Overall, participants (N=2354) reported high levels of satisfaction with their euthanasia experience. Their experience with the administration practices (i.e., payment and paperwork), emotional support, follow-up care and care for their pet’s remains was found to be associated with overall satisfaction. Participants’ grief was associated with the number of euthanasia previously experienced, the type of human–animal bond, if the euthanasia was emergent and the emotional support they received.
Findings contribute to existing research and shed light on some of the most important practices associated with companion animal euthanasia. Several practical recommendations are made, including developing standard operating procedures for companion animal euthanasia; exploring owners’ previous experiences, expectations and emotions; the importance of reassurance; and access to grief resources and services.
This article demonstrates how good communication sets the foundation to provide superior comprehensive care during the stressful time surrounding end of life. Communication addressing end-of-life care in veterinary medicine has significant impact on all involved: the patient, the client, the health care team, and the practice. These conversations require training and practice to achieve mutually satisfying outcomes. Suggested guides for facilitating these conversations and several typical scenarios are presented to provide methods for future evidenced-based evaluation in effective communication. The Critical Incident Stress Management is presented as a model for mitigation of adverse consequences related to traumatic events in veterinary practice.
A qualitative study using group and individual interviews involving 10 veterinary hospitals in Wellington County, Ontario, explored how the practices involved in euthanasia-related care impacts the wellbeing of veterinary professionals. Thematic analysis indicated two major outcomes: the goal and desire of veterinary professionals was to facilitate a ‘good death’ for the companion animal and navigating the euthanasia decision process was more challenging than the actual event of performing euthanasia. When successful in achieving a ‘good death’ and navigating euthanasia decisions, participants reported feeling that their own sense of wellbeing and the veterinary client’s sense of wellbeing were improved. When unsuccessful, participants reported experiencing a reduced sense of wellbeing, reduced job satisfaction, increased emotional strain and feeling that the client was also detrimentally impacted. For many participants, navigating euthanasia decision-making consultations was seen as a greater challenge and a greater contributor to a reduced sense of wellbeing than the act of euthanasia itself. These findings suggest that there is a need for greater attention and support for veterinary professionals, particularly when navigating euthanasia decision-making consultations. Additional training and resources on navigating euthanasia consultations may assist in improving the wellbeing for veterinary professionals and the companion animals and owners under their care.
Goals of care (GOC) conversations and resulting goal-concordant treatment are the heart of palliative medicine. Despite repeated evidence that GOC conversations offer significant benefit and minimal harm, barriers to widespread and high-quality implementation persist in human medicine. One strategy to overcoming these barriers has been utilization of a structured checklist format for serious illness conversations. The Serious Illness Conversation Guide was developed for human patients and has been modified for use in the veterinary profession. The guide promotes individualized, goal-concordant care planning even when conflict and emotional demands are high.
Many palliative care patients have reduced oral intake during their illness. Managing inadequate intake through appetite stimulation and/or artificial hydration and nutrition poses many clinical, ethical, and logistical dilemmas. This article aids the health care team in making appropriate recommendations regarding assisted nutrition and hydration for palliative care and terminal patients. It provides a decision-making framework, including an ethical approach to determining appropriate use of assisted feeding and hydration methods in pets at the end of life. It also summarizes various clinical and logistical approaches to treating decreased food/water consumption, including potential benefits and burdens, should intervention be deemed appropriate.
Medical progress has greatly advanced our ability to manage animals with critical and terminal diseases. We now have the ability to sustain life even in the most dire of circumstances. However, the preservation of life may not be synonymous with providing ‘quality of life’, and worse, could cause unnecessary suffering. Using the results of an electronic survey, we aim to outline and give examples of ethical dilemmas faced by veterinary anaesthetists dealing with critically ill animals, how the impact of these dilemmas could be mitigated, and what thought processes underlie decision-making in such situations.
End-of-life care is one of the most ethically complex and challenging areas of veterinary practice and animal caregiving. Caregivers and animals are both particularly vulnerable during the final stages of an animal's life, when illness, suffering, and mortality push their way onto center stage. This chapter focuses on how clinicians and clients can navigate through treatment decisions with moral and emotional integrity. It explores how professional standards and practices can influence clinical decision making in both subtle and overt ways, often out of the direct control of either clinicians or clients. The chapter looks at how cultural and social attitudes can influence moral decision making in the hospice and palliative care setting. Clinical plans that involve hospice and palliative care must be included in the range of options presented and are best described as “comfort care”.
This chapter is a compilation of the views of the authors regarding the judgment of changes in management, including medical therapies, approaches to foot care, the decision for euthanasia of the laminitis case and, importantly, the communication of these changes in management with the owner of the horse. Medications for the predisposing disease processes are primarily a concern for sepsis-related laminitis and endocrinopathic laminitis, although they play an important role in supporting limb laminitis if due to a septic condition in the originally affected limb. Foot care in the laminitis case requires a great deal of teamwork between the veterinarian and farrier, with constant communication with the owner and/or trainer. Since laminitis cannot be effectively cured, but will not lead directly to the death of the horse, euthanasia becomes an important consideration for horses that have progressive or persistent lameness or dysfunction.
When companion animals become seriously ill clients may have doubts about treatment choices, if any, and turn to veterinarians for help. But how should veterinarians reply? Influence on clients’ decision-making may or may not be acceptable—depending on one’s attitude to principles such as ‘paternalism’, ‘respect for autonomy’ and ‘shared decision-making’. This study takes as a starting point a situation where the animal is chronically ill, or aged, with potentially reduced animal welfare and client quality of life, and thus where clients need to consider treatment options or euthanasia. It is assumed throughout that both veterinarians and clients have the animals’ best interest at heart. The purpose of the study was to explore the challenges these situations hold and to investigate how clients experience veterinary influence. A second aim was to reflect on the ethical implications of the role of veterinarians in these situations. Qualitative interviews were conducted with 12 dog owners considering treatment or euthanasia of their chronically ill or aged dogs.
Challenges relating to the dog and to the client were identified. Some situations left the interviewees hesitant, e.g. if lacking a clear cut-off point, the dog appeared normal, the interviewee felt uncertain about treatments or animal welfare, or experienced conflicting concerns. Some interviewees found that veterinarians could influence their decisions. Such influence was received in different ways by the interviewees. Some interviewees wanted active involvement of the veterinarian in the decision-making process, and this may challenge a veterinarian’s wish to respect client autonomy.
Different preferences are likely to exist amongst both veterinarians and clients about veterinary involvement in clients’ decision-making, and such preferences may vary according to the situation. It is suggested, that one way to handle this challenge is to include respect for client preference on veterinary involvement under a wider understanding of respect for autonomy, and to apply models of shared decision-making to veterinary practice. In any case there is a need to further explore the challenges these situations raise, and for the veterinary profession to engage in more formal and structured deliberation over the role of veterinarians in relation to clients’ decision-making.
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Cancer is a common diagnosis in companion animals and, increasingly, clients choose to pursue treatment for their pets. Veterinary oncology is a rapidly growing field and diagnostic and treatment options for animals with cancer are constantly improving and becoming more widely available. Treatment outcomes can be good, but in many cases definitive treatment is not an option and palliative treatment is necessary. This article explores the palliative care of dogs and cats that have been diagnosed with cancer and summarises the various treatment options, with a particular focus on quality of life and the role of communication in the decision-making process.
Making palliative care decisions for a patient who lacks decision-making capacity presents several challenges. Other people, such as family and caregivers, must choose for the patient. The goals and values of these decision makers may conflict with those of each other and with those of the patient, who now lacks the capacity to participate in the decision. This paper presents a case study of a patient with severe Alzheimer disease who has two common clinical problems: neurogenic dysphagia and aspiration pneumonia. The case study describes a consensus-based decision-making strategy that keeps what is known about the patient's wishes and values in the foreground but also expects guidance from the physician and elicits input from family members and other people who care for and have knowledge about the patient. The steps of this process, including key clinical prompts and potential transition statements, are outlined and described. The overall goal of the case commentary is to demonstrate that physicians can guide a highly emotional and personal process in a structured manner that has meaning for the patient, family, physician, and other caregivers.
Dealing with clients’ distress, especially at euthanasia, is one of the main stressors for veterinary nurses. However, few have had formal training in how the death of an animal companion affects clients, and how to communicate with them. This article introduces some practical approaches and wording that you might use to support clients at the end of their animals’ lives.
We describe a protocol for disclosing unfavorable information—“breaking bad news”—to cancer patients about their illness. Straightforward and practical, the protocol meets the requirements defined by published research on this topic. The protocol (SPIKES) consists of six steps. The goal is to enable the clinician to fulfill the four most important objectives of the interview disclosing bad news: gathering information from the patient, transmitting the medical information, providing support to the patient, and eliciting the patient’s collaboration in developing a strategy or treatment plan for the future. Oncologists, oncology trainees, and medical students who have been taught the protocol have reported increased confidence in their ability to disclose unfavorable medical information to patients. Directions for continuing assessment of the protocol are suggested. The Oncologist 2000;5:302-311
As a unique species of equine, the donkey has certain specific variations from the horse. This review highlights the origins of the donkey and how this impacts on its behavior, physiology, and propensity to disease. The donkey is less of a flight animal and has been used by humans for pack and draught work, in areas where their ability to survive poorer diets, and transboundary disease while masking overt signs of pain and distress has made them indispensable to human livelihoods. When living as a companion animal, however, the donkey easily accumulates adipose tissue, and this may create a metabolically compromised individual prone to diseases of excess such as laminitis and hyperlipemia. They show anatomic variations from the horse especially in the hoof, upper airway, and their conformation. Variations in physiology lead to differences in the metabolism and distribution of many drugs. With over 44 million donkeys worldwide, it is important that veterinarians have the ability to understand and treat this equid effectively.
The human–horse bond is powerful and unique and strengthened with years of ownership. Yet, in aged horses, the decision for euthanasia will be faced at some time by most horse owners. We hypothesized that euthanasia is a difficult and distressing decision for most horse owners,
and that the decision will be influenced by the owners' personality, difficulty of euthanasia decision, and experiences of euthanasia, as well as external factors. Horse owners were recruited by the use of a postal questionnaire distributed to an equestrian group. A subgroup of surveyed owners
was selected based on postcodes for selected regions. One hundred and eleven owners of 350 aged horses in South East Queensland, Australia, completed a personality assessment and were asked to indicate the perceived difficulty in making the decision to euthanize an aged companion horse. Their
experience of euthanasia and the perceived distress over the loss of their aged horse, as well as the acceptability of the procedure, were determined. Personality scores were compared with published reference ranges against perceived difficulty to euthanize and experience of euthanasia. The
importance of factors that influenced the decision to euthanize an aged horse was also determined. Most owners considered euthanasia of a horse to be a difficult decision, which they based on considerations of the horse's current health, anticipated future quality of life, and veterinary advice.
Owners reported the loss of their horse to be a distressing experience rather than providing a sense of relief, although the procedure itself was more acceptable than distressing. Female owners who found it more difficult to make the decision were more likely to have neurotic personalities
and they based their decision more on their relationship with the horse and the horse's quality of life. Veterinarians play a central role in the diagnosis of health factors that influence the decision to euthanize but also need to appreciate the distress perceived by owners, in particular
as a result of the loss of their horse rather than the act of euthanasia itself. The personality of the owner may influence the extent to which they find this distressing, especially in female horse owners who find the decision to euthanize more difficult.
Breaking bad news to patients is one of the most difficult and demanding tasks that oncologists face—and one for which they are often poorly trained and emotionally ill equipped. The S-P-I-K-E-S protocol described in this article provides a simple, easily learned strategy for communicating bad news and suggests ways to assess the situation as it evolves and respond constructively to patients. Showing empathy, exploring the patient's understanding and acceptance of what he or she has just learned, and validating that patient's feelings can provide much-needed support to the patient, an essential psychological intervention for managing distress and helping the patient face the treatment decisions ahead. Although breaking bad news will never be easy, having a plan of action and knowing that you can support your patient through a difficult period should help considerably.
This paper focuses on scoping studies, an approach to reviewing the literature which to date has received little attention in the research methods literature. We distinguish between different types of scoping studies and indicate where these stand in relation to full systematic reviews. We outline a framework for conducting a scoping study based on our recent experiences of reviewing the literature on services for carers for people with mental health problems. Where appropriate, our approach to scoping the field is contrasted with the procedures followed in systematic reviews. We emphasize how including a consultation exercise in this sort of study may enhance the results, making them more useful to policy makers, practitioners and service users. Finally, we consider the advantages and limitations of the approach and suggest that a wider debate is called for about the role of the scoping study in relation to other types of literature reviews.
This study builds upon existing protocols for breaking bad news (BBN), and offers an
interaction-based approach to communicating comfort to patients and their families. The
goal was to analyze medical students’ (N�21) videotaped standardized patient BBN
interactions after completing an instructional unit on a commonly used BBN protocol,
commonly known as SPIKES. Through post hoc interviews with the medical student,
standardized patients, and faculty member for the unit, we revealed discrepancies
between clinicians’ idealized BBN interactions and their actual bad news delivery
enactment. COMFORT, is an acronym for the seven empirically derived, resulting core
communication competencies that seek to overcome some of the communicative
constraints to effective BBN experienced by clinicians and patients. COMFORT is built
around the fundamental principles of interaction adaptation theory (Burgoon, Stern, &
Dillman, 1995), which in this case is applied to communication in medical encounters.
The scale of the ethical challenges faced by veterinary surgeons and their perceived stressful consequences were investigated via a short questionnaire, completed by 58 practising veterinary surgeons. Respondents were asked to report how frequently they faced ethical dilemmas, and to rate on a simple numerical scale (zero to 10) how stressful they found three common scenarios. Fifty seven per cent of respondents reported that they faced one to two dilemmas per week, while 34 per cent stated they typically faced three to five dilemmas per week. The three scenarios provided were all rated as highly stressful with 'client wishing to continue treatment despite poor animal welfare' rated as the most stressful (median 9). The female veterinary surgeons gave two of the scenarios significantly higher stress ratings than the male veterinary surgeons. Stress ratings were not influenced by number of years in practice (which ranged from one to more than 25 years). The results show that veterinary surgeons regularly face ethical dilemmas and that they find these stressful. This has implications for the wellbeing of veterinary surgeons and supports the case for increased provision of training and support, especially for those who entered the profession before undergraduate ethics teaching was widely available.
Assessing patients' quality of life (QOL) is a core part of clinical decision making. Various methodologies for assessing patients' QOL have been developed in human medicine and small animal veterinary disciplines. In contrast, the lack of aids for QOL assessment in equine veterinary practice leaves practitioners reliant on subjective assessments of QOL, which may be prone to avoidable errors.
This paper suggests pragmatic ways in which QOL may be enhanced, while remaining appropriate for the time, financial and owner-based constraints within equine practice.
Through interdisciplinary research, this paper identifies, adapts and applies insights from several areas of research and practical experience in order to develop an overarching approach to making QOL-based decisions in clinical cases.
The paper identifies 6 steps involved in QOL-based decision making and provides examples of how these steps may be practically applied. These include deciding what each clinician feels is important; deciding how to evaluate it, including taking owners' views into consideration; making decisions about each case and achieving the desired clinical outcomes.
Practitioners can draw their own conclusions on how they may improve QOL assessment in practice and may usefully share these with colleagues. Reporting cases and sharing practical examples of QOL tools used on the ground are vital to the development of this field and appropriate methodologies.
Improvements in QOL assessment are relevant to all areas of equine veterinary practice, and several areas of research. Further research may develop QOL assessment in practice, but more important are the personal improvements that each practitioner may achieve.
The E4 model for physician-patient communication is presented with specific techniques for implementing the model. Derived from an extensive review of the literature on physician-patient communication, the model has proved to be a useful tool in workshops for and coaching of physicians regardless of specialty, experience or practice setting. Information on how to obtain descriptive materials about the workshop and an annotated bibliography is included.
Geriatric horses (aged≥15 years) represent a substantial proportion of the equine population, yet very few studies have investigated the prevalence of diseases within the UK equine geriatric population.
To describe the provision of routine preventive health care measures, prevalence of clinical signs of disease and the prevalence of owner reported diseases. Additionally, the effect of increasing age on the provision of preventive health care and the presence or absence of clinical signs and disease was assessed.
A cross-sectional study was conducted, surveying a randomly selected sample of veterinary registered owners with horses aged≥15 years, using a self-administered postal questionnaire.
As geriatric horses increased in age, there was a reduction in the provision of preventive health care measures, such as vaccination, farrier care and routine veterinary checks. Only 68.7% of horses had received a routine veterinary visit within the previous 12 months. Owners frequently observed clinical signs in their animals, with 77% reporting at least one clinical sign of disease. Increasing age was associated with increased reporting of many clinical signs of disease. Over half (58%) of horses had at least one episode of disease within the previous 12 months, yet only 31% of owners reported that their animal currently suffered from a known disease or disorder.
Although owners frequently observed clinical signs in their aged horse, there may be incorrect or under recognition of many diseases and health problems. Reduced frequency of routine preventive health care measures, along with suboptimal owner recognition of health and welfare problems may lead to compromised welfare in the geriatric population.