Contributors: Kyle Braund, Kathleen Cooney, Sheilah Ann Robertson
Species: Canine | Classification: Miscellaneous
Making the decision to euthanize
- Euthanasia is considered acceptable when a disease has become unmanageable, and suffering is present or imminent. A decision to euthanize may be necessary after severe trauma. One of the most common questions owners ask is “when is it time”? It can be extremely challenging to decide when this point is reached and there is often a grey area anchored by white and black at either end .
- As veterinary professionals it is our duty to support owners during this difficult time.
- Aspects to consider include:
- Is the dog still eating/drinking enough to sustain energy?
- Does the dog respond to attention from its owners?
- Is the dog able to participate in the things it likes to do?
- Is there uncontrollable pain?
- Has caring for the dog become too difficult for the owners? Fecal/urinary incontinence, mobility issues and cognitive dysfunction syndrome can take an emotional and physical toll on owners.
- Can the owner afford to continue care?
- It is imperative that the owners do not feel rushed into making the decision to euthanize, although it may be necessary to educate about pain and suffering if the owners are not aware of it. Providing a Quality-of-Life assessment tool and working through this together can help owners to make decisions and understand why they must make a difficult decision.
- There are other situations when euthanasia of a dog may be requested such behavioral issues, especially aggression. Often these owners have tried treatment (eg behavioral modification and medication) but are often judged for their decision. Mental health and physical health are both important when making euthanasia decisions. When a dog has unpredictable behavior, the safety of everyone it has contact with must be considered.
- Owners may request euthanasia when the dog is no longer wanted or their circumstances have changed (housing, financial, etc). In these situations, the veterinarian must decide whether they will perform the euthanasia based on their own moral or ethical compass. They may be able to offer alternatives such as rescue groups or rehoming centers. To help with these challenging cases the British Veterinary Association has developed a Decision Tree: bva_guide_to_euthanasia_2016.pdf.
- Legally, if it is performed humanely, an owner may request euthanasia of a dog for any reason. Ethically, we aim to offer euthanasia when no other options are possible.
- In a recent study in the United Kingdom, the top three disorders with greatest odds for death by euthanasia were poor quality of life, undesirable behavior and spinal cord disorders (Pegram et al, 2021).
- For shelter animals, risk of infection and insufficient holding space are additional reasons.
Consent for euthanasia
ALWAYS get a signed consent before undertaking euthanasia of an animal.
- The only exception to the above rule is if an animal has a condition that will be fatal, is in pain that cannot be controlled, AND the owner cannot be contacted, for example:
- Severe trauma.
- Extensive necrotic or neoplastic lesions of major organs found on emergency exploratory surgery.
Requirements of the consent form
- Identify the animal in terms of its:
- Microchip number if present.
- Note the reason(s) for euthanasia.
- Identify the owner in terms of their:
- Phone number.
- Age (must be 18 years of age to sign).
- Owner status - owner or agent of the owner.
- Date of agreement.
- The form should state that the person signing is the owner of the animal or an agent of the owner. If the person is an agent of the owner, then have them state their relationship to the owner on the form.
- The form should describe what euthanasia is to minimize confusion and avoid ambiguity. For example, avoid the term “put to sleep” as it can be confused with general anesthesia. Be truthful but avoid harsh words such as terminate. Explain that euthanasia is to help the pet die peacefully and painlessly.
- The form should specify the owner's wish for body care, such as body retainment for burial, group, or private cremation or aquamation.
- Make sure the owner has read the form and understands what they are signing.
- Signed consent for euthanasia forms should be retained for 7 years.
The euthanasia procedure
- The goal of any euthanasia procedure should be to facilitate euthanasia in a professional, compassionate, and efficient manner, causing as little distress as possible to both animal, client, and veterinary staff.
- The owner should always be given the option to be present, but there should be no requirement to stay. A two-step process is recommended for euthanasia:
- Sedation or anesthesia.
- With this method, the owner may prefer to say goodbye after sedation when their dog is resting peacefully, but before euthanasia.
- When present for euthanasia, the owner should be told what to expect so there are minimal surprises, especially those that could be disturbing to see: agonal breathes, eyes remain open, urination/defecation, etc. It is helpful to describe the expected signs of death as normal and natural. There is no need to describe everything that could happen; however, you may find it useful to add “if anything else happens I’ll explain it to you”.
- Determine where euthanasia is to be performed. To minimize noise and distractions, a quiet room in the clinic should be chosen or owners might decide to have the procedure done at home. Some clinics have a dedicated euthanasia room which can be set up like a room in a home. If an examination room is to be used, it is easy to quickly transform this to a less clinical and sterile or cold environment by dimming the lights, turning on soft music and placing blankets or cushions on the floor.
- Reassure the family that everything you do is for comfort and safety. You have everyone's needs in mind.
- Gently explain to the owner the technicalities of the procedure. Some examples include:
- Clipping hair for the injection or to place a catheter or butterfly needle.
- Note: the hair clipping can be placed in a small envelope as a memento.
- Sedation or anesthesia if desired (what to expect as the dog relaxes).
- Placing the dog in a comfortable position.
- Tucking an absorbable pad underneath for bladder/bowel release.
- Consider having all forms signed and payment collected before this stage.
- Clipping hair for the injection or to place a catheter or butterfly needle.
- In some cases, it may be advantageous to sedate the animal first Sedation sedative protocols.
- Choose the technique that best matches the animal's health and the veterinarian's skills.
- Once the euthanasia process begins (including sedation) the dog and owner should not be separated. Owners have described how upsetting it is to lose any time with their pet at the end of life and the practice of “taking the dog to the back to place a catheter” can be extremely stressful for the owner and dog.
- The advantages of sedation or anesthesia is that it allows the owner to hold or touch their pet during the euthanasia process, and it improves safety for all parties. It also allows more time for owners to come to terms with losing their pet. If the dog has been struggling, eg has breathlessness due to congestive cardiac failure or has been in pain that could not be well controlled, this allows the owner to see them at peace ad have this be their last memory.
- You can describe each step of the process as you perform it to keep the owner informed or remain silent but let the owner know they can ask a question at any time. Each owner is different.
- Take time with the procedure to help the owner and pet feel relaxed and safe.
- When necessary, have a nurse to assist with handling of the animal to help the procedure go more smoothly.
- Always use a stethoscope to verify cardiac beats have stopped. Wait for complete silence before pronouncing death. If needed, wait a few moments, and listen again. When in doubt, give more euthanasia drugs (eg pentobarbitone, pentobarbital/phenytoin Phenytoin).
- Tell the owner that the dog has died; however other words or phrases such as “passed peacefully” can be used at this time. Offer privacy if the owner requests it.
- Explain post-mortem phenomena such as muscle fasciculations, reflexive gasping, and urination. Assure the owner this is normal and natural.
- If possible, let the owners leave the building via a backdoor to avoid other owners and animals in the waiting room.
- Owners should receive a follow up email, call, or card expressing your condolences at the loss of their pet.
- Make sure deceased dogs are removed from the vaccination and visit reminder lists. This prevents sending reminders that could bring about sadness to the owner. It is also a good idea to note which room the euthanasia took place in and avoid using that room when they return with their other pets or a new pet.
- Euthanasia in companion animals is most commonly achieved with the rapid administration of the barbiturate pentobarbitone (pentobarbital) Pentobarbital in solution. Depending on the geographical location other products such as Cinchocaine Hydrochloride and Quinalbarbitone Sodium Quinalbarbitone / Cinchocaine (Somulose®, Dechra Veterinary Products) and Pentobarbital /phenytoin combinations may be available (United States). Drugs used for euthanasia are controlled or scheduled and must be ordered and stored according to local laws and regulations Controlled drugs: legal requirements for storage, prescription and supply. Follow the dosing information contained in the product information sheet.
- Pentobarbitone can be given intravenously or via other approved routes. Death should occur very quickly (< 2 mins). The cause of death is a sequential and irreversible depression of brain activity, respiration, and cardiac function.
- Intraperitoneal injections take the longest on average and are best reserved for those cases when no other method is possible.
- Typical intravenous injection sites include the cephalic Cephalic catheterization, lateral Lateral saphenous catheterization, or medial saphenous veins Medial saphenous catheterization. Clipping the hair over the vein or wetting the hair with water can make it easier to visualize. In some breeds of dogs (eg Basset Hounds and Dachshunds), the limb veins are difficult to locate but because of their large ears, the later auricular vein is a good alternative .
- Another useful vein is the dorsal pedal; it can be found on the forelimb below the carpus and on the hindlimb below the hock .
- When venous access is not possible, such as in severe dehydration or peripheral edema, other techniques can be utilized.
- Intracardiac injections are acceptable when the dog is fully anesthetized. Care should be taken to prepare the owner for the procedure as would be done for others. If necessary, a drape or blanket can be placed to shield the injection area from view.
- Intraorgan injections (under general anesthesia General anesthesia: overview) including intrahepatic and intrarenal are also viable options when intravenous access is not possible. Sufficient needle length to locate the organs should be used.
New challenges in Euthanasia
- The global supply chain of active pharmaceutical ingredients (APIs) is vulnerable to many external forces. The main source of APIs is China and India. The COVID-19 pandemic led to multiple drug shortages due to demand outstripping supply and restrictions placed on global transport of goods.
- An incident in a factory that supplies pentobarbital sodium powder, the main ingredient for most euthanasia solutions, occurred in late 2020 and led to a shortage of euthanasia products in the United States by the start of April 2021. Canadian veterinarians have also been warned of impending shortages and it is not clear how severe the shortages will be, nor when they will be resolved.
- The ability to provide euthanasia by a humane and painless method is an animal welfare priority, therefore in the face of commercial drug shortages, acceptable alternative methods must be available and conveyed to veterinarians and euthanasia technicians. In their 2020 Euthanasia Guidelines, the American Veterinary Medical Association list intravenous Potassium Chloride Potassium chloride/gluconatee (KCl) or Magnesium Sulfate Magnesium sulfate (MgSO4) solutions in anesthetized dogs as acceptable alternatives. Both these solutions cause death by cardiac arrest Cardiac arrest therefore can only be used after a general anesthetic has been administered. 1-2 mmol/kg (75-150 mg/kg, 1-2 mEq K+/kg) of KCl will cause cardiac arrest whereas it is difficult to find a recommended dose of MgSO4 in the literature.
- More information can be found by watching this podcast: Facebook Live: Addressing the Pentobarbital Shortage.mp4 (dropbox.com).