When trust breaks down due to bad communication in palliative care

Canine Consent. Photo by Fabian Gieske on Unsplash

Bad communication, especially in veterinary palliative care, can break bonds between veterinary teams and pet caregivers. 

In the past six months, I have witnessed several stories unfold of patients and caregivers who had to deal with poor communication from their primary veterinary care team. This resulted in feelings of guilt and shame for the caregiver, and an unnecessarily diminished quality of life for the patient. In one of the cases, it even caused serious injuries for both the veterinarian and patient - twice! In this article, I am going to present two cases of failed communication that have left me exasperated. But they also left me motivated to improve veterinary communication and to explore the role of other veterinary professionals as mediators and educators on both sides of the user experience.

Case 1 - A senior cat with diabetes

This big boy is the biggest puddle of love for his caregiver at home. A bruiser outdoors, willing to protect his territory from intruders, he also has warm relationships with the human neighbours he visits regularly. As long as you don’t try to shove a pill down his throat, he is fine and kind. At the vets, though, it is a different story. He is the kind of patient who has a yellow warning triangle next to their name in the CRM system. The vet in the village isn’t too keen on him coming in after a particularly ferocious episode, yet nobody has considered trying him on pre-consultation sedation.

This feline patient had recently been diagnosed with diabetes. After a very difficult consultation trying to draw blood from his jugular vein without sedation, his blood glucose levels turned out to be sky-high, even when taking into account the stress of the consultation.

His caregiver was sent home with a fairly new oral medication to manage blood glucose levels (not insulin, the tried and tested drug for diabetes, which needs to be injected). The take-home message was that if this drug didn’t work, it would mean the end of the line for the cat. On top of that, she was told to test the cat’s urine from the litter box a few days later and keep an eye out for ketoacidosis. Without further explanation, she was handed over a couple of highly marked-up urine analysis sticks and sent home. 

The cat’s caregiver went home confused and scared: scared of not knowing what to do if her cat went into ketoacidosis. Scared of the thought that there was a 60% chance the drug wouldn’t work and that she’d have to say goodbye. And scared of the thought of having to euthanise her big boy in the vet’s clinic, knowing he wouldn’t go down without a fight. She was also confused about how to manage the situation at home. Nobody at the surgery had told her to remove the clumping litter before testing urine. Nobody had told her about the power of diet and weight management in managing diabetes, alongside medical treatment. And nobody had asked her what treatment she was able to do at home, or how she was feeling about the fact that her middle-aged boy was sick and that she might lose him very soon.

Case 2 - A young, active dog with an abscess and a tendency to break paws

This unlucky young and athletic dog has a penchant for running at top speed over lumpy terrains. The first time he got hurt, he shattered several bones in his front paw, and he hadn’t even celebrated his first birthday. The orthopaedic surgeon looked at him in the consultation room and disregarded the dog’s caregiver’s request to escort them to the X-ray room, as the dog was nervous around strangers. Without consent, the dog was lifted by the big, burly man and, within seconds, dropped onto the tiled floor after the dog (out of shock and fear) had snapped at the surgeon. I can only imagine the pain the dog had been in after that drop.

A few years later, the shattered paw had healed, but the memory of the experience was still intact. A recurring abscess caused the caregiver to return to the primary care veterinarian.

The dog was lifted on the metal table, and yet again, the caregiver (a young-looking woman) was disregarded when she told the vet that her dog should be muzzled, as by now, he was really reactive and anxious. She was told to just sit down - the assistant and vet would handle the dog.

The dog’s nervous energy and pain were ramping up as he was being examined, and eventually, when the vet’s guards were down, he bit her in the face.

He was quickly sent home with antibiotics, and his caregiver was told the dog would not be treated again without a muzzle. The caregiver was left feeling guilty and ashamed. She also felt as if somehow, she had failed her dog by not advocating for him loudly enough.

Shortly after this incident, the dog dislocated his shoulder and tore the shoulder ligaments (same leg) and had to be sedated for X-rays and further investigations. By now, the usual cocktail to sedate a dog his size was insufficient. Adrenaline kept raging through his body, fighting the drugs to stay awake in what felt to him like an unsafe environment. 

Similar to the other case, nobody had brought up pre-consultation sedation to make the whole process easier and more comfortable for everyone involved. Nobody asked the caregiver how she was doing emotionally, practically, and financially as a single person taking care of such an energetic dog prone to accidents, who also happened to have a nervous disposition. 

Missed communication opportunity 1 - Listening to the caregiver

From my perspective, the first point of improvement in both these cases concerns listening. The caregivers were not listened to. In fact, they weren’t even asked questions about the pets’ temperaments outside of the vet’s surgery. In both cases, caregivers were told to follow instructions and let the “professionals” make the decisions. It’s such a shame these professionals weren’t geared to treat non-docile animals or approach them as individuals. If the caregivers or patient advocates had been listened to, the consultations had probably turned out differently. The dog patient could have had a much safer and more comfortable experience, where they didn’t feel the need to lash out, out of fear and pain. And the vet wouldn’t have a scar in the middle of her face. The dog’s caregiver would have felt empowered when her suggestions were taken seriously, and her dog was muzzled, thereby protecting the people handling him and him. The cat patient would likely be more mellow and be prescribed pre-consultation sedation; he’d happily lap up from a saucer filled with tasty wet food. His advocate would be heard when she told the vet that she felt things were out of her control. It would be an opportunity to educate her and tell her that if this medication didn’t work, there were other options to manage this form of diabetes. Or they would sit her down and explain how, when all options were considered, and euthanasia was the logical next step, they would facilitate a peaceful death with a proper pre-sedation protocol, so that her big boy didn't need to feel any fear or discomfort. She wouldn’t feel the need to get a second opinion from a competitor clinic in a nearby village. Or get more information online.

Missed communication opportunity 2 - Treating the patient as an individual

Both cases also lacked a ‘looking at the situation from the animal’s perspective’. If I were in pain, scared and manhandled without consent, I would get explosive and start biting as well! In both situations, the patients were treated without any form of consent or agency from their side or understanding of their species’ way of self-defence.

Not every patient we see in the consultation room will fawn. Some will go into full-on fight mode when they are hurting or nervous. We have so many tools nowadays to lower anxiety, take discomfort away, and to limit the chances of escalation. I’m puzzled as to why nobody thought to use such tools in both cases. A muzzle is a tool that protects both the human and the dog. So is treating an animal on the floor, rather than on a raised metal table. Pre-consultation sedation can lower pain - and anxiety.

Veterinary professionals need to ensure that no situation needs to be de-escalated. When we’re de-escalating, things have already gone too far. When you treat the patient as an individual and where they are at, you do that for your own safety, your patient’s current and future experience, and the client’s mental wellbeing.

Missed communication opportunity 3 - Discussing the bigger picture with the caregiver

These patients presented with affliction A, were treated with treatment B, to achieve goal C. What was missing in both cases was a moment of collective reflection on the bigger picture. How can we treat this patient, whilst at the same time addressing the underlying factors that contribute to the problem (e.g. obesity, anxiety and instability due to old injuries)? Do the patients need pre-consultation sedation only to take the edge off before going to the vets, or are they considered “spicy” due to something underlying (e.g. chronic pain)? Why is there so much anxiety? Are the caregivers able to cope with the demands of the only option you give them for treatment? And is it truly the only option for this patient? Are you basing that decision on how the patient presents in the surgery? What can be done in the surgery, and at home, to work towards a stress-less consultation next time?

The solution: Expanding the veterinary care team

When I was providing interdisciplinary care at the Autumn Animals clinic in London, I spoke to several primary care vets who told me it was a “cute idea” to have an interdisciplinary veterinary care team that included people who were trained in compassionate communication and specialist palliative care. They thought it would be a much better idea to teach existing veterinary teams (your standard vet nurse / technician, receptionist and veterinary surgeon) to provide this kind of holistic care.

While I agree that veterinary teams should be able to provide compassionate care, I also believe that having an interdisciplinary team is a more sustainable solution. 

Even if we extended to a 20-minute consultation, it still wouldn’t give enough time to listen and truly understand the patient and caregiver’s context and their bigger picture. 

Compassionate communication is a skill that some people are born with, and others can learn with many years of studying. There is a reason we have access to interdisciplinary palliative care teams in human healthcare. The surgeon is usually not the most suitable person to hold space for all the other (often messy) stuff a family deals with. Having someone on board who can distil an “as long as you need consultation” into an executive summary for the veterinary team would make a difference of day and night for the care providers, the pet caregivers and the patient.

I’d argue that every primary veterinary surgery should hire a specialist case worker: someone not necessarily veterinary-trained, but able to listen intently and ask the difficult questions. Someone to forward a family to when they have just received a challenging diagnosis for their pet. And someone who can be the spider in the web, who can refer a family to the right practitioner when they are struggling with veterinary finances, their pet’s behavioural issues, practical care or intense anticipatory grief. I don’t care whether this person is officially trained as a veterinary social worker, psychotherapist, or is just amazing in customer service. The most important thing is that they can listen, be compassionate and great at communicating next steps.

It's not fair to the veterinary team to expect them to be everything to everyone. It’s not fair to the pet’s caregivers to be made to feel shame and guilt and confusion when receiving costly veterinary care, which is causing more stress than relief. And it’s definitely not fair to the pets in our care to receive suboptimal care by someone who isn’t willing to try to understand them and treat them like just another number. They should be treated like they are the most important person in their family’s life. Because they are.

Sies.

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About me

My name is Sieske Valk (pronounced as Sees-kuh Falk). I started my career as a veterinary nurse in the Netherlands. After a short stint working as a social science researcher, I set up an animal care company in London, called Sies Petcare. This grew into Autumn Animals, the UK’s first holistic palliative and hospice care organisation. Trained as an end-of-life doula for companion animals, I supported numerous families through the autumn of their furry friend’s life, and after. I live with my husband Jamie, in beautiful Devon and have a Lewis-shaped hole in my heart.

I now support veterinary businesses that want to improve their palliative and hospice services and support their team through challenging cases. If you’d like to have a chat about this, go to www.calendly.com/autumnanimals or visit autumnanimals.com for more information.

A note on AI use: I write all the articles on this website myself. All the flowery and long sentences are completely my own. I use Grammarly (an AI application) to correct spelling, grammar and the occasional literal translation from Dutch to English.

I use Google Gemini AI to write the metadescription and excerpt.