Geriatric horses (over 15 years of age) represent a growing proportion of the total equine population, as reported by several studies of equine populations in various countries (Brosnahan and Paradis, 2003; Ireland et al, 2011a; van Proosdij and Frietman, 2022). Geriatric horses are prone to developing chronic diseases that can have severe health and welfare implications, such as weight loss, dental problems, lameness, laminitis and pituitary pars intermedia dysfunction. Owners, caregivers and other equine professionals, such as veterinarians, all have a responsibility to care for and monitor the welfare of the horses under their supervision (McGowan, 2011; Ireland et al, 2011b; Ballou et al, 2020; Ireland, 2020; van Proosdij and Frietman, 2022). As a horse ages, the horse's owner will inevitably face a decline in the animal's overall health and welfare. At some point, owners of geriatric horses will need to make the difficult decision for euthanasia during the end-of-life stage of the horse. Such a decision can be a heavy burden for the owner, who will often rely on their veterinarian for advice (McGowan, 2011; Preshaw et al, 2018; McGowan et al, 2016; van Proosdij and Frietman, 2022). The role of the veterinarian at the horse's end-of-life is poorly studied, and no study covers all the stages of this process (Cameron et al, 2022). This article outlines the role of the equine veterinarian as an adviser for end-of-life decisions and provides a guideline for the different stages of this role.
Stages in the end-of-life phase
If an animal is faced with severe illness or another problem that could result in death, the owner may turn to a veterinarian for advice. The veterinarian is requested to have a part in the decision-making process for treatment and possible euthanasia of the animal (Christiansen et al, 2016).
The role of the veterinarian in the end-of-life phase of a horse (and every other animal) has four stages (Shaw and Lagoni, 2007; Christiansen et al, 2016; Cameron et al, 2022):
- Making the decision by both the owner and the veterinarian
- Communicating the decision with the owner
- Enacting the decision by the veterinarian
- Aftercare, consisting of body aftercare and emotional support.
Making the decision
Any decision regarding a horse's medical treatment or euthanasia has to be made by both the owner and veterinarian involved (Shaw and Lagoni, 2007; Christiansen et al, 2016).
The owner
Although the horse is still legally classified as a farm animal in most countries (Endenburg et al, 1999), the bond between owner and horse is more like the emotional bond found in companion animals. The decision for euthanasia may be affected by the personality of the owner, as well as the strength of the bond between owner and horse. If the owner has previous experience with the euthanasia of a horse, this may also have an effect on their decision (Endenburg et al, 1999; McGowan, 2011; McGowan et al, 2012).
Older horses are prone to developing chronic disease such as weight loss, dental problems, lameness, laminitis and pituitary pars intermedia dysfunction, among others (McGowan 2011; Ireland et al, 2011b; Ireland et al, 2020; Ballou et al, 2020; van Proosdij and Frietman, 2022). However, chronic disease is not the only potential welfare issue found in the geriatric horse. Geriatric horses can potentially be faced with insufficient involvement and preventive care by a veterinarian, as well as with possible misdirected dedication by their owner (McGowan, 2011). All geriatric horses will, at some point, develop health issues which cause their welfare to decline. At that time, their owners will be faced with the dilemma of interfering with their welfare (such as by sourcing veterinary intervention, or by changing the management of the horse in terms of feed, stabling and the like), or even euthanising the horse (McGowan et al, 2012).
As a veterinarian, establishing some general criteria for horses that could be recognised and managed by their owner can help with monitoring the horse's welfare. These criteria can, for example, include the development of health problems that result in discomfort or pain, a decrease of more than 20% of their initial body weight, behavioural changes and a difficulty or an inability to get to food and water. For example, a geriatric horse with normal appetite may slowly lose weight over a period of time, even though all efforts have been made by their owner to provide the horse with appropriate, and even extra, food and water. This weight loss can be because of diseases like neoplasia, pituitary pars intermedia dysfunction, dental disease and others (Dickinson and Lori, 2002). Horses with these issues need veterinary involvement to maintain a good welfare status (McGowan, 2011; Lavan, 2013; Stull, 2013; Ireland, 2020). A horse can also be monitored via these criteria to evaluate treatment effect and, in an end-of-life situation, to set a humane point for the horse's euthanasia. Defining these points will help evaluate the progression of health issues and the effect of any treatment. This information can help the owner in making decisions about treatment or euthanasia (McGowan, 2011; Lavan, 2013; Stull, 2013; Ireland, 2020).
Alongside factors directly associated with the horse, economic factors can also influence the decision of the owner to euthanise a horse. The financial burden of keeping an older horse or the cost of treatment of a health problem can influence the owner's decision making. The owner of a geriatric horse is more likely to choose euthanasia than start on costly or long-term treatment of a health issue. A study by Ireland et al (2011b) showed that when the owner knew a concurrent disease was present in their geriatric horse, 40% said that this pre-existing health issue influenced their decision to euthanise their horse instead of starting treatment.
The choice of starting medical treatment may also affect the welfare of the owner. For example, the obligation to give an animal medication multiple times a day decreases the welfare of the owner. Carefully assessing the effect of an animal's treatment on the owner beforehand may highlight the potential negative result of the treatment of their animal in advance. This might result in different treatment options or euthanasia being considered (Fulmer et al, 2022). Owners can also delay treatment or euthanasia of their horse as a result of personal fears about doing the right thing, or the fear of the distress it will cause them or their family. Some owners, however, are simply guilty of neglecting their geriatric horse (McGowan, 2011; McGowan et al, 2012).
In case of the decision making for euthanasia by the owner of a geriatric horse, the most important influencing factor is when the horse's current welfare status is compromised or when its welfare is likely to decrease in the near future. Other important factors include if the veterinarian suggests a poor prognosis; however, in horses facing more chronic conditions, veterinary advice was identified as a less important factor by owners (Ireland et al, 2011b; Preshaw et al, 2018).
The veterinarian
When giving advice in an end-of-life situation, a veterinarian has to take more into consideration than just the animal and its potential future welfare. They should also consider factors concerning the owner, such as their personality, the strength of the bond between owner and their horse and the past experiences of the owner with euthanasia of a horse. The personal judgement of the veterinarian is also of importance (McGowan, 2011; McGowan et al, 2012).
Every euthanasia is unique, and despite guidelines and algorithms, the veterinarian has to make their own judgment. For example, when looking at veterinary opinions on refusing euthanasia of dogs, the most common reasons for refusing were the lack of disease, convenience and the possibility of treatment, but according to ethical guidelines, the euthanasia of an animal for one of these reasons could be justified (Yeates, 2010; Yeates and Main, 2011). Springer et al (2019) found that equine veterinarians find not only medical but also social and economic aspects to be relevant in their decision making for advising and performing euthanasia. Generally, veterinarians have knowledge of the emotional bonds of an owner with their horse and the financial situation of the owner. Euthanasia for owner convenience is typically refused by equine veterinarians (Springer et al, 2019).
In previous studies on causes of death in geriatric horses, ‘convenience’ was never mentioned, and financial or economic reasons were found to be relevant in a small percentage of cases (Ireland et al, 2011b; Ireland et al, 2011c; Preshaw et al, 2018; van Proosdij and Frietman, 2022).
According to Green and Mellor (2011), five outcomes should be possible in the welfare assessment of an animal. Two of those are clear positive results; either the best possible outcome, ‘a good life’, or a slightly less positive, ‘a life worth living’. If the welfare state is in ‘point of balance’, positive and negative factors are equally present. The negative welfare results are either ‘a life worth avoiding’ or the worst possible welfare state ‘a life not worth living’. If a veterinarian is faced with a horse with a poor quality of life, two options are available: if the outcome is ‘a life not worth living’, euthanasia should be advised by the veterinarian. If a veterinarian finds the result of a welfare assessment to be ‘a life worth avoiding’, veterinary treatment or rapid management changes should be made. If these interferences with an animal's welfare are not possible or wanted, euthanasia should be advised (Green and Mellor, 2011; Mellor, 2016). The most important factors influencing the choice of treatment by the owner for a geriatric horse with a severe compromised welfare were (Ireland et al, 2011c):
- The expected welfare aft er treatment
- The presence of life-threatening problems
- The pain and stress caused by treatment procedures
- The advice of a veterinarian.
If the owner of a geriatric horse believes that there is no treatment available to improve their animal's welfare, they may be less likely to ask for veterinary consultation and advice (Ireland et al, 2011d). This could result in the animal not receiving appropriate veterinary attention in a timely manner and possibly compromising the welfare of their aging horse (Ireland et al, 2011d; 2012; McGowan, 2011; Ireland, 2020). Experienced stable personnel can detect diseases in geriatric horses early and adapt management for these horses, leading to lower incidence of chronic disease and higher welfare compared to other management systems (van Proosdij and Frietman, 2022).
Communication with the owner
Communication with owners is a major part of the daily job of an equine veterinarian. Bad news can result in stress for the owner, and giving the news can be stressful for the veterinarian. A systematic communication protocol for the veterinarian could make giving bad news less stressful and more effective. With a communication protocol, the veterinarian can share information effectively while being aware of the owner's emotions (Decloedt, 2020).
One model of giving veterinary advice in general and, more specifically, communicating bad news to an owner is the COM-FORT protocol. This model is originally designed for human medicine but can easily be adapted for veterinary use. The model contains the elements of communication that are essential for effective transmission of a message (Villagran et al, 2010; Nickels and Feely, 2018; Decloedt, 2020). The main elements of the model are found in the acronym COMFORT:
- C: Communication: refers to the quality of the communication between the veterinarian and the owner.
- O: Orientation: refers to the possible treatment options for the animal.
- M: Mindfulness: the veterinarian must be present (both physically and mentally) during the conversation, and the conversation is had without a previous script or checklist.
- F: Family: caretakers and other stakeholders should be included in the decision-making process.
- O: Ongoing: the dialogue about care needs to be ongoing, even aft er the diagnosis. The veterinarian should stay available for the patient and caregivers, even aft er euthanasia.
- R: Reiterative: communication should be adjusted to be appropriate to the patient and its caregivers. Repetition is an important factor for understanding and explaining a diagnosis.
- T: Team: most of the time, more than one professional provides medical care, for example veterinarians and veterinary nurses. The communication of a team is not only with the patient and family, but also within the team.
The elements of the COMFORT protocol do not have a fixed order. When looking at the order of bringing bad news, the following steps can be made via the SPIKES protocol, while keeping the COMFORT protocol in mind (Shaw et al, 2007; Villagran et al, 2010; Nickels and Feely, 2018; Decloedt, 2020). The elements of the SPIKES protocol are found in its acronym:
- S: Settings: create an appropriate setting for the conversation.
- P: Perception: ask about the perception of the problems of the patient.
- I: Invitation: ask permission for sharing news about the illness or problems.
- K: Knowledge: provide the diagnosis, extra information and a plan.
- E: Empathy: show empathy for the emotions. Providing information will cause an emotional reaction from the owner. If the reaction is too strong, continuing with sharing extra information will be senseless. By showing empathy for the situation, the emotion will decrease and information can be shared again. The sharing of knowledge and showing empathy will alternate with each other (Figure 1).
- S: Summary: summarise the plan.
Aft er communicating the bad news, advising euthanasia and the decision of the owner to perform euthanasia, the next phase is discussing the euthanasia itself. The veterinarian should discuss the following considerations with the owner before enacting the decision (Endenburg et al, 1999; Chur-Hansen, 2010):
- Does the owner want to be present during the euthanasia? If so, do they want other people, like friends or family, present? All the people present need to be prepared by the veterinarian with information about the euthanasia process and how it is done.
- On what day and at what time of day should the euthanasia be performed? The veterinarian and owner should come to an agreement about the best time so there is no sense of rush for both owner and veterinarian.
- Where should the euthanasia be conducted? At the client's stables, a veterinary hospital or another location? When the client chooses their own place, where can the euthanasia be performed safely for owner, veterinarian and horse?
- Do the owners want to spend time with the animal immediately beforehand, and perhaps collect some keepsakes from the horse like a photo, hair or a shoe?
- After euthanasia, what options of body aftercare would the owner like to consider?
- If the euthanasia takes place at a veterinary hospital, does the owner want some time alone after the death?
- Does the veterinarian advise and does the owner want a post-mortem examination of the horse? Most of the time, this has to be arranged before euthanasia and can influence the options of body aftercare.
- When should the payment be made? Sometimes an invoice can be sent afterwards, but another option is direct payment on the day of the euthanasia.
After the questions have been answered and the proper arrangements made, the next step of the process can begin.
Enacting the decision
For equine veterinarians, considerations of the medical and technical aspects of a procedure have an important focus, and this is also the case for euthanasia. A well-performed and technically flawless euthanasia is of particular importance, not only for the animal but also for the owner and veterinarian (Springer et al, 2019). With regards to the experiences of the owner during the process, this is based not only on the process and service, but also on the interaction and support from the veterinarian (Smith et al, 2021). Horse owners find the loss of their horse more distressing than the actual procedure of euthanasia itself (McGowan et al, 2012). In general, horse owners reported that witnessing the procedure of euthanasia of their horse was more acceptable than distressing to them, but some owners should protect themselves against the distress produced by witnessing the euthanasia of their horse. As previously mentioned, the euthanasia procedure should be clearly and carefully described to the owner by the veterinarian before the euthanasia of a horse. After the death of the horse, the veterinarian should offer support to the owner (Endenburg et al, 1999; Chur-Hansen, 2010; McGowan et al, 2012). Horse owners were significantly more content with a friendly and compassionate veterinarian during euthanasia. Of clients that change their veterinary practice, two-thirds of changes can be linked to an unfriendly or insensitive handling of the animal, owner and a lack of compassion of the veterinarian during and after the process (Endenburg et al, 1999).
Aftercare
Aftercare post-euthanasia is an important aspect of the process of saying goodbye to an animal. Aftercare consists of at least two parts: body aftercare and emotional support. In literature, little attention is given to body aftercare in horses, and the options for body aftercare and disposal vary by country. If the details of these options and the decision of the preferred manner of euthanasia are made before the euthanasia, the place and protocol can be adjusted to facilitate or ease the preferred method of body disposal (Cooney et al, 2012). In the Netherlands, the most popular method of body aftercare is destruction or cremation. In the author's experience, only 0.5% of horses get slaughtered. The carcass disposal can be organised via privately run crematoria that collect the body of the horse in a private vehicle with a trailer. The other, cheaper, option is via the government-run destruction programme for horses and farm animals that collects the body, with multiple bodies collected in the same truck.
The bond between owner and horse can be strong, so saying goodbye to a horse can be very emotional. Every horse's owner will have a different grief response. These responses will vary as a result of a number of factors, including not only human factors such as personality, culture, religious orientation and perceived emotional bond with their horse, but also other social and economic influences (Chur-Hanssen, 2010).
There is little literature about grief and emotional aftercare for horse owners (Cooney et al, 2012; McGowan et al, 2016; Cameron et al, 2022). Veterinary students are taught about the subject, and emotional aftercare is considered useful not only for the owner, but also for the veterinarian to improve their job satisfaction. In the curriculum, multiple suggestions are given for owner support: follow-up phone calls, sympathy cards, flowers and the like (Stull, 2013; Littlewood et al, 2020).
Owners do appreciate active support from the veterinarian directly after euthanasia and a follow-up phone call a few days later, but one study found that a sympathy card was only appreciated by 22% of clients (Endenburg et al, 1999).
Conclusions
The role of a veterinarian during the end-of-life phase can be divided into four stages: making the decision (both the veterinarian and the owner), communicating the decision to the owner, enacting the decision and aftercare of the body. Equine welfare is not easy to measure, and there is currently no standard protocol available; however, euthanasia should be advised if a horse has ‘a life not worth living’. This decision is made in consideration of the horse's welfare and in conjunction with the owner. Communication of the decision should be done systematically, using the COMFORT and SPIKES protocols to ensure effective communication around the discussion, and the logistics of the euthanasia should also be discussed. The euthanasia itself must be handled delicately, with proper support from the veterinarian to the owner and the horse. Methods of aftercare of the body vary from country to country – these options (including individual cremation and government-run destruction programmes) should be discussed, so that the owner can choose their preferred method. The last two stages are very important for owners, and mishandling of these cause owners to change veterinary practices in two-thirds of cases. Aftercare, especially, is a stage that has had little attention in research, but because of its importance in client satisfaction, future research is warranted.
KEY POINTS
- Many horse owners and veterinarians will have to consider end-of-life options for a horse at some point.
- The decision-making process leading up to the euthanasia of a horse can be difficult and upsetting for owners.
- Veterinarians must be able to handle these situations delicately and with empathy for the owner.
- Using the COMFORT and SPIKES protocols will help ensure that communication with owners is respecful, sympathetic and informative.
- All four stages (making the decision, communicating with the owner, enacting the decision and aftercare of the body) have to be performed.