Key facets of end-of-life decision-making identified in review

Some parts of the process have received little research attention, the researchers found.
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Shared decision-making when euthanising companion animals involves three important stages, a review has found, but two of them have received little research attention.

The review team also found that euthanasia decision-making involving horses had received considerably less research attention than cats and dogs.

End-of-life decisions for companion animals can be stressful for veterinarians and owners, and when delayed can result in poor animal welfare. Delayed euthanasia has been identified as a particularly prominent issue for horses.

Amelia Cameron and her fellow researchers at the University of Nottingham in England undertook a scoping review to identify the available scientific literature on veterinary decision-making models that can support end-of-life planning.

Searches were performed on six electronic databases for original studies and narrative-type reviews. In all, 2211 publications were identified, but only 23 met the inclusion criteria. Eight were original research studies and 15 were narrative reviews or similar.

“A lack of original research studies and equine-specific publications was identified,” the review team wrote in the journal VetRecord. Indeed, only two publications expressly related to horses, neither of which were original research studies, while none focused specifically on donkeys or donkey–horse hybrids.

“This,” they said, “is consistent with other areas of companion animal welfare and veterinary practice, where horses have fallen behind dogs and cats in terms of both research and what is offered.”

The end-of-life decision-making process for companion animals was found to comprise three stages:

  • Making the decision;
  • Enacting the decision; and
  • Aftercare.

“The full decision-making process extends from initial conversations between veterinarian and owner about end-of-life up to where the decision is made, all of which is encompassed within the first stage of making the decision, and then onto the second stage of enacting this decision, and then the final stage of aftercare.”

Included within aftercare are decisions about body care and memorialisation, and help in getting emotional support.

“All but one of the included publications addressed the first stage of the end-of-life decision-making process, while the other two stages were addressed much less commonly.”

Twenty key components in decision-making models were identified, although no publication reflected all of these, they noted.

They included starting end-of-life conversations early; protocols for breaking bad news; the knowledge exchange between the veterinary team and owner; learning owner expectations and checking their understanding; presenting treatment or end-of-life options; finding out the level of involvement the owner wants in the decision; considering the impact of options on the animal’s quality of life and the effects on the owner; provision of information in different formats; the matter of costs; owner consent; making a treatment or end-of-life care plan; setting treatment goals and end points; minimising owner guilt; explaining euthanasia procedures and options; planning for the procedure, explaining body aftercare options; pointing owners to, or providing, emotional support; and following up with them.

The review team said the 20 key components varied in how frequently they appeared across the models identified in the review.

“These components offer a basis from which end-of-life decision-making models specific to companion animals can be proposed,” they said. Some components are likely to promote shared decision-making, while others may not need joint engagement between veterinarians and owners.

The review team said, in some cases, an end-of-life decision may have to be made quickly, such as in a medical emergency where there is no hope of treatment and the animal is suffering intensely.

“However, in many cases, this stage of the decision-making process could be the longest, drawn out over an extended period of weeks, months or even years, for example, when there is a slow deterioration in quality of life.

“This stage of deliberation may especially cause considerable stress for both veterinarian and owner due to uncertainty or conflicting opinions.”

Despite the importance of this first stage, the other two should not be neglected, they said. “Explaining and planning for enacting the euthanasia decision may help reduce owner anxiety, which in turn could facilitate the procedure going more smoothly.

“When veterinarians have successfully facilitated a ‘good death’, they feel this supports the wellbeing of both themselves and the client.”

Likewise, aftercare is an important consideration, they said. Some pet owners have concerns regarding after-death body care, including costs and the way their pet’s body is to be handled.

“Planning for this could reduce anxiety around the process and prevent owners from making rushed decisions they may regret or finding only after euthanasia that they cannot afford their preferred option for disposal.

“In addition, the death of a companion animal can be immensely distressing, but societal attitudes towards the status of animals can lead owners to experience disenfranchised grief.”

Veterinarians, they said, are in a position to validate and normalise their clients’ grief, and following up after euthanasia, such as with a phone call or condolence card. It can increase owner satisfaction. “Another consideration is that clients who are less satisfied overall with euthanasia are more likely to change veterinary practices,” the review team said.

Future published models would benefit from addressing all three stages where possible, rather than just the first.

The authors said companion animal end-of-life decision-making appears to be an emerging field gaining increasing interest, and it is hoped it will continue to receive further research attention. “However, there is still a lack of published original research studies, with a complete absence of original studies specifically on equids.”

The review team developed a list of terms that future researchers could include in their keywords to help make their publications more discoverable to others.

They said more studies were required that investigated all three stages of end-of-life decision-making. Research is also needed to test models in a practical setting.

The authors called for more end-of-life studies focused explicitly on equids and equine-specific issues.

Further investigation into the development and refinement of end-of-life decision-making models that can be applied in a practical setting has the potential to decrease stress and uncertainty felt by owners and veterinary staff, they said. It would also support appropriately timed decisions to promote animal welfare at the end of their lives.

The full review team comprised Cameron, Kristian Pollock, Eleanor Wilson, John Burford, Gary England and Sarah Freeman, all with the University of Nottingham.

Cameron, A, Pollock, K, Wilson, E, Burford, J, England, G, Freeman, S. Scoping review of end-of-life decision-making models used in dogs, cats and equids. Vet Rec. 2022;e1730.

The scoping review, published under a Creative Commons License, can be read here

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