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Client considerations

Loss and grief are universal human experiences. A pet owner’s emotional response to the loss of their pet is often as intense as the grief experienced following the loss of a family member or friend. Studies have shown that 30% of pet owners will experience significant grief following the loss of a pet and 50% will question their decision following euthanasia.14,15 Given the intense and sometimes conflicting emotions that attend client bereavement, responding to anticipated and actual pet loss with sensitivity and compassion is vital to the mission of animal hospice.

Although the grief response ranges from emotional to stoic depending on the individual, it is generally helpful for the bereaved pet owner to express their emotions to an empathetic listener. The attending veterinarian or other staff members can fill this role. Regular, empathetic communication is the hallmark of effective client support during EOL treatment and after a patient’s death. The veterinary healthcare team has a responsibility to see the EOL case experience through the client’s eyes and to provide nonjudgmental support.

How clients view the veterinary team’s response following the loss of a pet is a critical factor in their continued advocacy for and loyalty to the practice. Studies in human medicine have demonstrated a correlation between empathetic physician-patient communication and an improvement in patient emotional health, compliance with physician recommendations, and satisfaction with their healthcare.16

Client support during EOL care

Grief is the natural response to loss and is a dynamic process that changes over time. There are many ways to feel and express normal and healthy grief during the continuum of caring for a dying loved one. Grief can be manifested by emotional, spiritual, cognitive, or physical distress. It is useful for veterinarians to view the normal grief response that their clients experience in terms of the five stages described by Elizabeth Kubler-Ross in her seminal work on bereavement: (1) denial, (2) bargaining, (3) anger, (4) depression, and (5) acceptance.17 It is appropriate to inquire if the pet owner has experience with human EOL or hospice care when discussing their pet’s EOL care plan.

Genuine and empathetic interaction with a bereaved client is a skill that can be learned and improved. Asking open-ended questions is an excellent technique for assessing how a client is handling EOL caregiving responsibilities or bereavement over the loss of their pet. Examples include queries such as “How are you managing?” and “What concerns do you have?” The hospice team members can then validate the extent of the difficulty or grief the individual is experiencing. Reflective listening techniques, such as acknowledging that you heard what the client said and then summarizing the individual’s comments, are helpful for facilitating what is always a difficult topic of discussion.

Conversations about EOL, death, and grief with a bereaved client are never easy. Descriptions of various verbal and non-verbal communication techniques appropriate for veterinarians involved in EOL discussions with clients are available from a variety of sources.18-20 For example, client communication programs for healthcare professionals are available from the Institute for Healthcare Communication in New Haven, Connecticut, and from the International Veterinary Communication Institute in Ontario, Canada. Among the many available resources are the Colorado State University College of Veterinary Medicine Frank clinical communication workshops designed to improve veterinarians’ communication skills. Other training opportunities are available at many veterinary conferences.

It is appropriate for veterinary team members to suggest to a bereaved client that professional grief-support counseling may be helpful. This recommendation should be accompanied by reassuring the client that most people whose pets have undergone EOL care experience grief and an often-profound sense of loss.14

Experts recommend that veterinary professionals focus on four specific roles in dealing with clients who have experienced the death of a pet: (1) educator, (2) supporter, (3) facilitator, and (4) a resource and referral guide. Specific actions related to each role are listed in Figure 2.18 Several universal principles that apply to each of the four client support roles are also shown in the figure. Healthcare team members often use one or more phrases intended to be consoling that can be perceived by the client as insincere or out of bounds (Figure 2).21Team members should be careful to avoid these expressions, termed “the clichés of grief.”

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Client support roles

Educator: Observe; ask questions; offer grief counseling information when appropriate.

Supporter: Listen to client's nonmedical concerns; favor listening over dispensing advice; allow expression of thoughts and emotions; acknowledge client's loss; express support in nonverbal and verbal ways.

Facilitator: Ask questions; make suggestions; provide relevant client education; assume partnership role in decision-making; remain neutral, nonjudgmental, and respectful of client's wishes.

Resource and referral guide: Inform client about available resources; encourage client to self-educate and find own solutions to establish control over the situation.

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Client support principles

Observe boundaries: Offer support by mutual agreement; do not overstep boundaries or offer unwanted assistance; do not exceed teh confines of a client-support role.

Have realistic expectations: Understand that client's response to loss is beyone your control; you control only your own response.

Respect the client's feelings: Never express denial of client's feelings; do not assume you completely know how the client is feeling.

Practice open and honest communication: Convey information honestly; avoid withholding or censoring information to spare the client's feelings.

Maintain confidentiality: Respect client's privacy; do not discuss the case outside the practice without the pet owner's permission.

Offer professional support: Seek outside resources when needed.

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Phrases to avoid

"If there is anything I can do, just call me."

"I know just how you feel."

"Time will heal your loss."

"(Your pet) had a long life; think of all the good memories."

"There will be other pets"

"You need to be strong for the rest of the family."

"Children will bounce back."

"Count your blessings."

"God never gives more than we can handle."

 

Client support roles18 | Client support principles18 | Phrases to avoid21

 

FIGURE 2 The figure illustrates an integrated approach to supporting a client who is experiencing bereavement over the loss of their pet. The four client support roles (left box) can be assumed by the attending veterinarian or delegated among members of the veterinary healthcare team.18 All staff members should observe the client support principles (right box) when assuming any of the support roles.18 Certain phrases should be avoided (bottom box) because they may not be true, the client may not agree, or they represent a commitment the veterinarian may not be able to keep.21 Illustration Design: Mark Dana, Kanara Consulting Group, LLC

Within the first week after the initial EOL plan is agreed upon, the client will begin to come to terms with his or her caregiving role. At this stage, the client may have questions for the veterinary healthcare team, and may reconsider whether or not the agreed upon treatment plan was the right thing to do. Unanticipated roadblocks to the patient’s at-home care may also have emerged. Successfully responding to these challenges will help determine whether the client can maintain an appropriate level of care or if a different approach is needed. In fact, unexpected demands of athome care can undermine or change the client’s relationship with their pet. Periodic follow-up appointments or phone consultations initiated by the veterinary team are vital to addressing and responding to these potential problems. Setting up a timeline of regular communication contacts with the client will avoid situations where the patient’s EOL needs are inadvertently overlooked.

Following the death of a pet, a significant number of owners will experience profound grief. In some cases, the client’s sense of bereavement may be accompanied by anger that is directed at the veterinary team. The power of appropriate follow-up by the team to offset the depth and duration of the client’s grief response cannot be overestimated. This type of outreach can take the form of a condolence card, phone call, sponsorship of a pet-loss support group facilitated by a professional counselor, or referral to counseling services or online resources.


Take-away points

  • Grief is a natural response to loss and it changes over time.
  • Timely, empathetic, and non-judgmental communicationis the hallmark of effective client support.
  • Bereaved caregivers may benefit from professional grief-support counseling.

Pet body care

Owners of pets that die while under a veterinarian’s care are usually concerned about the postmortem disposition of their pet’s body.14The veterinarian should initiate a candid discussion of how the pet’s body will be handled and ask if the client has any questions or concerns. For example, the veterinarian should disclose whether the body would be refrigerated or frozen and discuss cremation and burial options. A necropsy should be offered and the findings entered into the patient’s medical record. Veterinary staff members are encouraged to visit local pet crematories and cemeteries to learn about options for body care.

Memorializing a pet

Memorializing a pet is frequently helpful in the grieving process because it acknowledges and honors the human-animal bond. Ways of remembering a pet may include writing a letter to the pet or a poem about him or her, creating a photo album or journal about the pet, planting a memorial tree, or obtaining a professional portrait of the pet. Helping the caregiver memorialize their pet is one of the best ways of expressing support and empathy for bereaved clients. A donation on behalf of the practice, for example, to an animal welfare organization or a charity of the client’s choice, giving the client a memorial item, conducting an annual memorial service for all deceased patients, or sending a personalized condolence card are some of the actions taken by veterinarians to demonstrate empathy and to offer their clients support.