Proscription medicine

Feb 10, 2016

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There’s a bit of a trend for blog titles at the moment – not mine, I generally go for puns. Everyone likes a good pun. Except… well, everyone except me.

PC mouse — **Clickbait:** a sensationalised headline on the internet designed to entice people to follow a link to an article on another web page.

Anyway, for normal people’s blogs, the trend a few years ago used to be “The five best reasons why you should change your oven colour scheme”, or similar, but that has fallen by the wayside recently in favour of the rapidly-becoming-ubiquitous formula “Why I started taking my morning coffee as an enema (… and you should too!)”.

Clickbait

Now, there’s nothing necessarily wrong with that – blogs are opinion pieces, after all, and that sort of title is certainly attention-grabbing and intriguing. However, I have seen a few medical and veterinary blogs have recently started using such a tactic and… well, maybe it’s because I’m British, getting old, or just plain stubborn, but the idea of “I do this (and you should too!)” sticks in my craw a little when it comes to something as complicated and delicate as veterinary medicine, balanced as it is on such a precarious evidence base in the first place.

Let me give you an example. I recently read an article entitled “Why I sedate every pet for euthanasia – and you should too”. The article implied when we decide not to sedate an animal at the end of its life, that’s a decision we’re making for ourselves – we’re putting our own interests before those of our patient.

Well, a blog is an opinion piece – so, for what it’s worth, here’s my opinion on the topic…

Whenever I’m performing euthanasia, I always offer sedation and here’s how I put it to the client: “We can sedate him for it, but it takes a little longer and might make him feel a little sick. If he seems to be getting stressed, I would suggest we’ll go that way – he’s the important one today and whatever is right for him, that’s what we’ll do.”

Not only do I say that, but – as with everything I say to clients – I mean it too.

Different strokes

I put it like that because, in my opinion (and I don’t think this is a controversial suggestion), there isn’t a blanket method that’s correct for everyone. Some patients are so stressed with being restrained for an intravenous injection a sedative is appropriate. Some are not. Sedatives are unpredictable, occasionally unreliable, not painless to give and not always pleasant to endure, even if it sometimes appears like it is – there’s a reason we no longer fill our patients with acepromazine for fireworks, isn’t there?

I’ve had good experiences with sedating patients for euthanasia, and I’ve had very bad ones too. If I am the only vet that has waited uncomfortably on a house visit watching an aggressive family pet filled with enough medetomidine to fell a Brontosaurus stagger unsteadily around the room while everyone present silently, desperately prays for it to finally stop pacing, sit down and give in already, then I will eat my stethoscope (and it’s a Littmann, too).

Yes, if you give pentobarbital injection intravenously, its very, very quick – so I would suggest you tell the owner it’s going to be before you give it. In fact, that would be my general advice for euthanasia – tell the owner everything that’s going to happen, explain what is happening when things aren’t going according to plan and remain calm.

Opinions matter

Well, that’s my opinion on sedation for euthanasia, and it’s just that – my opinion. Yours may vary, and that’s fine. However, my broader point is things are very, very seldom black and white in medicine, even less so in veterinary medicine.

We are so bereft of evidence in our field – so hungry for it – if you can prove something works, or doesn’t work, we will pounce on it. Finally the stress is out of the decision! Finally we have a definitive right or wrong answer! Such blessed reliefs are few and far between for us. In everything else there’s room for debate, discourse and opinion.

We’re so unsure of so many things and we’re all just trying to get through the day. Tell me your opinion. Let’s discuss it. Don’t make me feel like a bad person because my opinion differs from yours. The job is stressful enough without that.

Comments

3 responses to “Proscription medicine”

Bonnie

March 20, 2016

I’m sorry you feel frustrated with presedation before euthanasia, but you’re right it is not a black and white procedure. We’ve tried different protocols at our hospital and at my ferret shelter. We’ve used dexmedetomidine and decided against it as pre-sed because of the amount of agonal breathing and spasm we saw in dogs and cats. It has worked great for ferrets IM however. Never do we try injecting these drugs without the use of a catheter in cats and dogs, placed before pre-sed. Everything is kindly explained to the owner, a catheter placed, and when ready a pre-sed of butorphanol and ace in equal measure are used. I am comfortable setting a cephalic or saphenous catheter in the room if the client wishes, or we take the pet out to set and return it immediately after, whatever the client wants. I’ve seen too many bad experiences (gasping, fear, crying out, pain reaction-pulling the leg away) with pento alone to make me feel like pre-sed with an appropriate med combination is a better way to go.

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DWest

September 22, 2017

I still vividly remember a euthanasia at home for one of my beloved boys. I was new to this. He was given no sedation. A couple seconds after the euthanasia started, as I was petting him and talking to him, he suddenly pulled away and tried to leap up… I still picture it clearly, as if it was yesterday. I still feel him jerking away from me. I still feel his coat sliding though my hands (I had to grab for him…). And I still can feel him slumping back against me. He knew something was terribly, terribly wrong and reacted instinctually, and, to this day, I still feel horrible for having put him in that situation. Now I insist on sedation. I always bring it up, even though I know they plan on doing it. I want to be sure. Totally sure. The last seconds should be peacful, not filled with terror. All subsequent euth procedures have resulted in peaceful, gentle passings.
(That said, I’m aware there are cases where it is just not possible or not the best thing to do in certain situations.)

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BoRepay

November 1, 2017

I think I too was mostly annoyed with the ‘I do it and you should too’, does that mean I am getting old?…seriously it’s completely a case by case basis. I may sedate 10 percent of the time before euthanasia and that’s because (in my opinion…)they aren’t necessarily ‘ready’ to go. Every one that I have had the best experience with are pets that I believe have given the go ahead, I am ready sign. They put their heads down, let you hold their paw and don’t give any indication that they want to fight it. Sedation may make the clients feel better, the doctor may feel better, but I can’t agree that the pet feels better because I don’t really know what the pet is feeling after getting an injection to sedate it. In fact, when I have to give sedative, it makes me question on whether it’s really ‘time’. I euthanized a little chihuahua once on the passenger seat of an elderly mans truck. The elderly owner was sitting in the drivers seat, the little dog curled up in a ball on the passenger seat. It was a completely overcast, wintery day. Not a sunbeam in sight. The old man didn’t want to look in our direction, choosing instead to look out the driver window. My assistant held the little dogs leg, not really disturbing her curled up position and she was looking at us in a way I believe gave me the impression she knew what was going on and was ready to go. The vein held off, the injection given. As soon as she was gone the biggest beam of sunlight came through the clouds and lit that little dog up! I said ‘look at that’ rather stunned (I didn’t meant to be so loud but couldn’t help myself) and the owner looked over and saw the sunbeam bathing his little dog in bright light. Tears streaming down his face, he actually smiled. I will never forget that day. Euthanasia is a very personal experience for all those involved. To make a statement like that article did with ‘I do it and you should too’ in such a way that it implies veterinarians who don’t sedate EVERY euthanasia are committing some heinous disservice to their patients and clients is very offensive to me. I’ve been euthanizing dogs and cats for 20 years, I think I am pretty knowledgable with what I need to do to make it as easy as possible for my patients and their owners and pre-sedation is definitely not always necessary. I appreciate you sharing your thoughts.

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