16 June 2021
How veterinary nurses can support clients through pet bereavement
The veterinary nursing role has evolved substantially, with a wide variety of CPD opportunities available to further develop skills for us to utilise in practice. One such opportunity is to become a pet bereavement advisor and emotionally support clients throughout the process of saying “goodbye” to their pet. It has long been a trend that pets are thought to be part of the family, suggesting losing a pet can be likened to losing a family member. The RVN can play a key role in supporting the client through this difficult time by helping prepare them and keeping the communication line open after the euthanasia.
Being a member of the BVNA family means you have a free Veterinary Nursing Journal in the post every month, providing expert written content, and online access to all past issues with topic search facilities for easy research. Join us today to access all of our VNJ content!
The Registered Veterinary Nurse (RVN) role has evolved substantially since the title was first used in 1984. There are many opportunities to develop and expand new skills which can be used within practice to strengthen the standard of care we provide to our patients. Furthermore, we can learn skills to better the service and support we provide our clients with throughout the lives of their pets. A pet bereavement course can assist an RVN in developing the knowledge and skills to support pet owners and the author believes it is an area in which RVNs can assume a key role.
The human-animal bond
There are multiple studies which unanimously highlight that pets are seen to be a crucial part of the family. One such study, conducted by American Animal Hospital Association (1996), found pets are viewed as importantly as any other member and for most, primarily fulfil a childlike role. Although a dated and American study, this trend appears to persist in Britain today, with an estimated 20 million households owning pets (Pet Food Manufactures Association (PFMA), (2019). Moreover, the Petplan Pet Consensus 2018 found 44% of owners refer to their pets as their “baby” and 50% have made at least one change to their work routine to accommodate their pets. Without doubt, this indicates we are an animal loving society.
The human-animal bond is comprised of many facets, including pets having family member status; pets having a unique personality; the perceived reciprocity (including talking with pets and sharing affection) and the proximity and compatibility of the owner and pet. An animal can play a diverse number of other roles, such as best friend, sole companion, a link to a loved one who has passed or a purpose to interact or exercise. These roles can often be in conjunction with another.
The bond created by owning a pet provides many physical, emotional and lifestyle benefits to us as humans:
- Decrease in stress
- Decrease the risk of cardiovascular illness and a decrease in blood pressure
- Boosts companionship
- Eases depression
- Promotes activity and routine, in turn enabling us to socialise more
- Combat loneliness
It is therefore understandable that losing a pet is a significant loss which will affect the lives of their owners drastically. As veterinary professionals, we witness daily the bond that owners have with their pets and perhaps for most of us, we too have, or have had, such a bond with a pet. The author believes this subsequently places RVNs in a prime position to be able to support owners through grief – we can play a vital role in providing emotional support to clients before, during and after the euthanasia process.
Owning a pet is a responsibility that pet owners choose to have. They become an integral part of the family – the author often hears within practice “I can’t imagine life without them.” Devastatingly, an inevitable part of the circle of life is death and for many pet owners, euthanasia will be one of the hardest decisions they will ever have to make.
One of the most common questions is usually; “How will I know when the time is right.” The answer to this question is subjective and the “right time” will be different to each owner – one factor that must be taken into great consideration is the animal’s quality of life. The author recently had to make the heart-breaking decision to have her cat, Miesha, euthanised at 16 years of age (Figure 1). Miesha suffered a short illness and whilst a formal diagnosis was not made, it was believed she was facing a terminal illness. Investigations and treatment were deliberated, but the spondylosis in her lumbar spine had evidently become very painful for her. With the constant gastrointestinal upsets, she had difficulty mobilising and grooming herself. Furthermore, Miesha did not like to be handled. Therefore, euthanasia was decided as the kindest option.
Figure 1. Miesha, the author’s pet.
We must not judge an owner’s decision and we should refrain from expressing any negative feelings we may be feeling, such as if we disagree with when they decide to proceed (whether it be too soon or too late in our opinion). We can provide tools to aid the decision-making process and whilst we cannot legally diagnose, we can share our clinical knowledge on any disease or injury a pet may be suffering with to help.
Many veterinary surgeons have put forth ideas to help a client assess their pet’s quality of life. We can introduce the client to the following tools:
- Using two jars, label one as “good days” and one as “bad days.” At the end of each day, decide whether the day was good or bad and for what reasons. This can help visually see the difference and notice when bad days begin outweighing the good. This can also be done using a calendar
- List five things the pet loved to do (play fetch in the park, run downstairs when they heard food being prepared, jump up to their favourite spot) and decide whether the pet is still able to do those things
- Compare how your pet looks now to videos and photos of when they were in full health – this is especially useful as change often tends to be gradual and can be harder to notice when you perhaps are not looking for signs or are in denial that they are occurring.
- Dr Villalobos’ HHHHHMM scale (Figure 2) rates each criterion from 0 to 10. A score of 5 in one category, or >35 overall indicates the pet’s quality of life is acceptable. There is no guidance on how frequently to complete this scale, but as the score gets lower, this can suggest it needs completing on a more regular basis, often daily.
Figure 2. Dr Villalobos’ HHHHHMM scale. (Villalobos, 2007).
It is common practice for veterinary surgeons (VS) to take the animal through to the preparation/clinical area so an intravenous catheter can be placed. For the euthanasia itself, it is often just the VS present in the room with the owner(s). However, this varies between different practices and cases – some owner’s may request a certain RVN to be present if they have built a relationship with them through their animal’s treatment for example.
It is important to allow the client to express their emotions how they see fit. If your practice has a dedicated euthanasia room, utilise it as privacy is invaluable in this situation. Some clients may feel embarrassed to express their emotions, so we can help them feel at ease. For example, offering them a tissue and leaving a tissue box present is a gesture that can reassure a client that it is okay to get upset and cry (Gardner & McVety, 2016). A beverage can be offered, but the author has found that although it is appreciated, it is not usually accepted.
If a private room is not available, there are plenty of ways to adapt a standard consult room. Prior to the client’s arrival, switch the computer off and tidy the room so it is clean and does not appear like the room is being “borrowed” for the euthanasia. Laying down a vet bed and a blanket for the pet to lie on will provide comfort to both the pet and their owner. Often, consult rooms can be tight on space, but where possible placing one or two chairs in the room can be helpful, particularly for those clients who are elderly, disabled or may not wish to be directly with their pet as they go to sleep.
An RVN can play a part in preparing the owner for the euthanasia by briefly discussing what to expect. For some clients, this may be their first time having an animal euthanised. Making them aware that their eyes will remain open and they may experience some involuntary movements will reduce the likelihood of them feeling confusion and shock if this does occur. Asking them if they have any questions is also ideal – a lot of clients ask how long it will take and is it painful. All answers and discussions should be kept short and basic – it is unfair to give the owner a lot of unnecessary information as, respectfully, they will be unlikely to be listening for very long. Afterwards, ask the client whether they would like more time with their pet ahead of the euthanasia.
At the author’s practice, an electric candle is used and is lit when euthanasia is taking place. It is positioned next to a sign on the reception desk, informing clients that a family is saying goodbye so to please wait patiently and quietly for their appointment. The author has found this to be thoroughly appreciated by owners and well received by clients in the waiting room. It plays a big part in creating a peaceful and respectful environment for the client at a distressing time.
It will be a day of mixed emotions for the client: sadness, anger, disbelief, numbness. There is the potential for an emotional outburst, so it is key to remember that this will be due to the current circumstance and not a personal attack.
This is an area RVNs can be heavily involved in. It can begin immediately after the euthanasia, by a gentle discussion of after-body care. Most owners will have decided, but some may be unaware of the options available to them.
There are three options for the owner:
- Home burial
- Communal cremation – the owner will not get their pet’s ashes back
- Individual cremation – the owner will get their pet’s ashes back in a casket or urn of their choice.
Giving the owner time is key. If they are undecided on what to do, they should not be rushed to decide. There are a wide range of memorials now available for pets and it is possible to split the ashes into a few different caskets or urns. The author chose to have her cat’s ashes put in a teddy bear and a small heart which rests on a stand (Figure 3). This may not be to all owner’s preference, but it is worthwhile making them aware it is possible.
Figure 3. The keepsakes where the author’s pet ashes are kept.
There are other keepsakes available at most pet crematoriums, such as fur plucks and paw prints. This is something we can offer in practice too. For paw prints, using either stamp ink or paint is effective. For fur plucks, it is worth investing in some small jars (or adapt and reuse vaccine bottles) so it does not look too clinical.
There are other ways that the pet’s family can memorialise their pet (Figure 4). Multiple methods can be employed to suit each family member’s preference.
Figure 4. Ways to memorialise a pet.
The author would highly recommend having one or two members of the team dedicated to providing bereavement support to owners. However, it is important to note that most courses will qualify you as an advisor able to provide emotional support. It is misleading to address yourself as a counsellor if you have not undertaken the relevant training, as advisors are unable to offer the psychological help a counsellor can. At the time of euthanasia, mentioning to the client that this is a service offered by the practice can be greatly appreciated by the owner. Although, they may forget that it is available so create and give them a card or leaflet so they can refer to it when at home.
Bereavement support can be provided face-to-face or via telephone or email. One factor which is vital to consider whilst providing the support, is self-awareness. You need to set boundaries to protect yourself and be able to recognise your own emotional triggers. Boundary setting involves limiting personal involvement with the client, minimising self-disclosure, accepting the nature of your supportive relationship with them and refraining from analysing their thoughts and feelings. Without boundary setting, we can become vulnerable and put ourselves at risk of compassion fatigue and burnout. Take time out when you need it, so you can strengthen your ability to continue to emotionally support others. If you do find yourself struggling, it is vital to look after your own mental health and seek support when you need it. We are in a challenging environment every day, where our own emotions can run high – we must take care of ourselves too.
Grieving is a process of adjustment to loss and is very much an individual process. When talking to a client about their grief, the author’s training advised the person-centred model is the best approach which was developed by Rogers (1957). This places the client at the centre of the process by focussing on their feelings, allowing us to provide relevant emotional support. We must allow the client to be themselves and effectively communicate that we genuinely accept and respect the client’s reality. This can be done using empathy and the internal frame of reference, allowing you to perceive things as if you were the client to fuel your connection.
Different techniques can also be employed, the key ones being paraphrasing and open questions. Paraphrasing is reflecting the same thing back to the client, keeping close to their language to show you are listening and understanding. Open questions allow the client to explore and reflect on their own feelings and where possible should begin with: what, where, why, when or how. If we simply just reflect exactly what the client said, this can come across as “parroting” which can be perceived as insincere. On a similar token, closed questions can come across as an interrogation and make the client feel like the conversation is being rushed to a close. Moreover, repeating exactly what they have said but in question form for example, “you feel weak and overwhelmed?” can appear rehearsed, insincere and even comical if overused.
Nonetheless, if you believe the conversation is becoming repetitive, do not be afraid to summarise what you have discussed and draw it to a close. It is unhelpful and draining for you both to continually repeat what has already been said without resolution.
See Table 1 for recommendations on “do’s and don’ts” during a conversation with a grieving client.
|Listen more than you speak||Inertia – “think of the positive times” as this is only a temporary relief and isn’t a person-centred approach|
|“Sound like a human” – Whilst maintaining professional boundaries, speak to the client in a friendly, trustworthy manner||Constantly touch/hug the client – use sparingly if at all, as some clients may not like it|
|Allow silence – let the client lead and remind them “I’m ready to talk when you are” “I’m still here”||Hold the silence|
|Give them “permission” to talk – “Would you like to tell me more please?” “Can you tell me how you’re feeling?”||Come across as sympathetic as it drives disconnection – “ it’s bad isn’t it?,” “at least they had a good life”|
|Lubricate comments to ease flow – “take your time,” “it’s ok if you need a moment”||Silverline something|
|Use their pets name||Rush the conversation, clock watch or fidget during a face-to-face conversation|
|Acknowledge their feelings “It was a difficult decision for you, this is a real loss”|
Another important point is to not forget about the client after your discussion. If they only send one email, make one call, or have one face-to-face session, this is okay and may have been enough for them. Other clients may require more interaction for longer. It does no harm to follow up with a client, via email or phone, and ask them how they are and remind them that you are still there for them if they need a chat. Keeping the communication line open is kind and useful for many clients.
The author recommends the following CPD/further reading:
- Blue Cross Pet Bereavement Advisor Course – this eight-week course is accredited by NCFE to enhance the support veterinary professionals can give to owners. Available online: https://www.bluecross.org.uk/pet-bereavement-support-course-professionals
- Innovet Pet Loss and Bereavement Support Advisor Course – this seven-hour course is accredited by the CPD Accreditation Group to enable veterinary professionals to provide more proactive care and have a deeper understanding of the bereavement stages. Available online: https://www.innovet-cpd.co.uk/online-pet-loss-and-bereavement-support-advisor
Notes on contributors
Beth Lee BSc (Hons) RVN
Beth graduated from Harper Adams University in 2019 with a BSc (Hons) degree in Veterinary Nursing and Practice Management. She now works in a small animal, first opinion practice in Derbyshire – the same practice she trained with. Her key interests are in-patient care and consulting and she enjoys continually learning new skills to be able to offer new clinics within practice. Outside of work, Beth enjoy travelling, going to the gym and reading. Sadly, she has just lost her only pet, Miesha. This opened her eyes to just how important providing a pet bereavement service is.