Contributors: John Dodam, Kathleen Cooney, Sheilah Ann Robertson
Species: Feline | Classification: Miscellaneous
How do we know it is time?
- One of the most common questions a veterinarian receives from a client with an elderly cat, or a cat with diseases such as osteoarthritis or chronic kidney diseases is “when will I know it’s time?”.
- The American Association of Feline Practitioners has developed an End of Life Toolkit to assist veterinary teams and owners during this time. The 2021 Senior Care Guidelines also contain information on chronic diseases, comorbidities and End-of- Life decision making. Another source is the American Animal Hospital Association and International Association for Animal Hospice End of Life Care Guidelines (Bishop G et al, 2016).
- 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 . It is the duty of the veterinary team to support owners during this difficult time.
- Euthanasia is considered acceptable when a disease has become unmanageable, and suffering is present or imminent.
- Patient-centered aspects to consider include:
- Is the cat still eating/drinking enough to sustain energy?
- Does the cat respond to attention from his owners?
- Is the cat still performing its favorite activities?
- Can pain be well controlled?
- Owner-centered considerations include their “budgets”. There are 4 budgets to consider:
- Owners should not feel rushed or pressured into making the decision to euthanize, although in some cases it may be necessary to expedite the process, for example after major trauma and if the cat is in the process of dying. The veterinary team should not be judgmental at this time, because owners are often unaware of how sick their cat is, are in denial, or may hold beliefs (religious or cultural) that do not support euthanasia.
- Legally an owner may request euthanasia of a cat for any reason. The reasons may include behavioral issues which are just as detrimental to a cat’s wellbeing as physical diseases. Other situations when euthanasia of a cat may be requested include when it is no longer wanted, it is destructive towards furnishing, or owners are moving and cannot take their cat with them. This is often referred to as “convenience” euthanasia and can present a moral and ethical dilemma for veterinarians. In many cases, there are underlying reasons for the request, and these should be sought, and the owners should not be quickly judged. In the case of true “convenience euthanasia” all veterinarians have the right to proceed, or to refuse; either decision should be carefully considered as it may impact on the cat itself (what will the owners do if you refuse) and the veterinarian (moral stress if you proceed).
Print off the owner factsheet on Saying goodbye - information and guidance on euthanasia to give to your client.
Consent for euthanasia
ALWAYS get a signed consent before undertaking euthanasia of animals. This can be a physical form or an e-consent form.
- The only exception to the above rule is if an animal has a condition that will be fatal, is in uncontrollable pain, AND the owner cannot be contacted. For example:
- Severe trauma.
- Extensive necrotic or neoplastic tissues 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 (check the legal age for consent to euthanasia in your jurisdiction).
- 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, 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 home burial, group, or private cremation. In some geographical locations pet aquamation centers are available.
- Make sure the owner has read the form and ask them if they have any questions prior to signing it.
- 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:
- 1. Sedation or anesthesia.
- 2. Euthanasia.
- With this method, the owner may prefer to say goodbye after sedation when their cat is resting peacefully, but before euthanasia.
- When present for euthanasia, the owner should be told what to expect so there are not surprised by what they may experience. It is helpful to describe what to expect and assure the owner these signs of death as normal and natural. The things that could be disturbing for owners to witness include agonal breathes, the cat’s eyes remaining open, urination/defecation, etc. 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 in their home as there are an increasing number of veterinarians offering home visits, both for care and for euthanasia. 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. Do not underestimate the value of the “small touches” to a grieving owner.
- Alert staff and people in the waiting area that a euthanasia is in progress and request they avoid loud conversations. In the staff area various techniques can be used such as hanging a sign on the door of the room and in the waiting area a sign and candle (battery operated) can be lit .
- 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 or shaving hair for placing a needle and syringe, 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; explain what to expect as the cat relaxes.
- Placing the cat in a comfortable position.
- Tucking an absorbable pad underneath absorb urine and catch feces.
- Consider having all forms signed and payment collected before this stage.
- Clipping or shaving hair for placing a needle and syringe, or to place a catheter or butterfly needle.
- It is advantageous to sedate the animal first and this can be done intramuscularly, subcutaneously, with oral or transmucosal drugs 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 cat 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 cat to the back to place a catheter” can be extremely stressful for the owner and cat.
- The advantages of sedation or anesthesia is that it allows the owner to leave at this stage, having seen their cat at rest, or if they stay, to hold and touch their cat during the euthanasia process. Sedation or anesthesia improves safety for all parties, increases the chances of performing a successful intravenous injection, and if anesthetized, other routes can be chose to administer euthanasia solution. It also allows more time for owners to come to terms with losing their pet. If the cat has been struggling, for example breathlessness due to congestive cardiac failure, vomiting frequently due to end stage kidney disease, or 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 assist with handling of the animal to help the procedure go more smoothly.
- Always use a stethoscope to verify that the heart is not beating. Wait until you are sure cardiac activity has ceased, before pronouncing death. If needed, wait a few moments, and listen again. When in doubt, give more euthanasia drugs (eg pentobarbitone, pentobarbital Pentobarbital/phenytoin Phenytoin).
- Explain post-mortem phenomena such as muscle fasciculations, reflexive gasping, and urination. Assure the owner this is normal and natural.
- Tell the owner that their cat has died; however other words or phrases such as “passed peacefully”, “gained their angel wings”, can be used at this time depending on the owner. Offer privacy even if the owner does not requests it. In a clinic setting you can quietly step out of the room for a few moments and in a home setting return to your vehicle.
- If the owners are leaving their cat at the clinic for you to arrange body care, or you are performing home euthanasia, the last memory of their cat should be positive. Place the cat in a basket lined with soft blankets and tuck them in . If they are taking the cat with them for home burial invest in esthetic boxes (pet burial boxes) and add an absorbable pad, or purpose designed bags (eg Euthabag®; Euthabag Pet Body Bag).
- If possible, in a clinic setting, 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 cats 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) in solution. Depending on the geographical location other products such as Cinchocaine Hydrochloride and Quinalbarbitone Sodium Secobarbital / Cinchocaine (Somulose®, Dechra Veterinary Products. NOAH Compendium |) and Pentobarbital /phenytoin combinations may be available (United States). Drugs used for euthanasia are controlled or scheduled Controlled drugs: legal requirements for storage, prescription and supply and must be ordered and stored according to local laws and regulations. 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.
- Typical intravenous injection sites in cats include the cephalic Cephalic 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.
- When venous access is not possible, such as in severe dehydration or peripheral edema, other techniques can be utilized.
- Intraorgan injections (under general anesthesia) including intrahepatic and intrarenal are also viable options when intravenous access is not possible. In cats, intra-renal injection is simple to perform unless the cat is obese. Palpate the kidney (left or right depending on how the cat is positioned), gently hold it in place with one hand and insert a 1-inch, 22-gauge needle attached to a syringe of euthanasia solution with the other, penetrate the kidney and inject. Another technique is to use an extension set between the needle and syringe to allow more flexibility to maneuvre. Due to the vascularity of the kidney death occurs quickly (< 1 min). The technique is shown in , and a towel or blanket can be used to cover the cat’s abdomen and hide the needle and syringe from the owner, as the procedure is done by palpation, not visually.
- Intracardiac injections are acceptable when the cat is fully anesthetized. Care should be taken to prepare the owner for the procedure as would be done for others. It is recommended to lay a blanket or towel over the cat to hide the injection area from view.
- Intraperitoneal injections take the longest on average and are best reserved for those cases when no other method is possible.
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 (see drug shortages for more information).
- 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 (AVMA guidelines for the euthanasia of animals) the American Veterinary Medical Association list intravenous Potassium Chloride (KCl) or Magnesium Sulphate (MgSO4) solutions in anesthetised cats acceptable alternatives. Both these solutions cause death by cardiac arrest therefore can only be used after a general anesthetic has been administered. 1-2 mmol/kg (75-50 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).