The Case Study
Oswald, a 10-year-old neutered male crossbreed dog (suspected German shepherd dog/pit bull terrier), was presented after attacking his owner. The owner was sitting next to and petting Oswald (a common occurrence with no history of aggression) when the dog reacted explosively without an obvious trigger or significant warning other than a momentary transition to a rigid body posture. The owner was bitten several times on the arm and leg. The bites broke the skin, but injuries were lessened by Oswald’s lack of canine teeth, which had been previously extracted due to damage sustained while trying to escape a crate when confined and left alone.
Two years prior to the current presentation, Oswald was evaluated by a board-certified veterinary behaviorist for aggression directed toward unfamiliar visitors to the home. A treatment plan that consisted of management (eg, basket muzzle, confinement when visitors were present), counterconditioning, and desensitization was initiated. Care was transferred to his primary care clinician for ongoing implementation.
It was unclear from the incident description whether Oswald aggressed toward his owner because of physical discomfort associated with a cruciate ligament repair that had occurred ≈1 month prior, a new expression of resource guarding, or other medical factors (eg, endocrine dysfunction). Oswald was not receiving any medication at the time of the incident.
Although the owner’s physical injuries were minor, several questions should be addressed.
Why did Oswald aggress, and will he aggress again?
Can Oswald be trusted?
Is it safe to leave Oswald temporarily in the care of a family member?
Is rehoming an option if Oswald cannot stay in the home safely?
Should euthanasia be considered due to safety concerns?
Behavioral Euthanasia
Personal Perspective
Reactions of veterinary professionals to behavioral euthanasia are likely informed by previous patient outcomes and personal experiences. Those reactions may range from “this is unsafe, and euthanasia is the only option” to “I’m sure there is a way to make this work for everyone.” It is important to acknowledge the personal and professional emotions, as well as the unique perspectives, that inform individual viewpoints. Ethical dilemmas, including those related to euthanasia considerations, can positively or negatively impact the sense of well-being and satisfaction experienced in the workplace and are some of the leading causes of work-related stress.1,2
Discussion of behavioral euthanasia will vary depending on participant role (eg, pet owner/caregiver, shelter/rescue employee, trainer/behavior consultant, member of a veterinary team) and perspective. The focus of the discussion may also vary, whether initiated during a comprehensive and proactive discussion of options, as an alternative to placement or rehoming, or in direct response to a client’s questions about safety. These conversations may occur at various points within a professional consulting relationship but often follow an incident or heightened quality-of-life concern.
Initial Approach
Behavior cases should be approached like any other patient evaluation. Examination should start with assessment of client concerns, physical examination and/or observation, and discussion of potential diagnostic and treatment options, including feasibility. Clients are not always able to follow every recommendation, and clarification of what can be done based on each client’s unique situation and/or limitations should be considered.
In clinically healthy patients, quality of life and safety risks should be considered when evaluating potential interventions.
Quality-of-Life Assessment
Patients with significant fear, anxiety, or emotional distress may benefit from treatment specific for those conditions. Consideration should be given to whether the proposed interventions (eg, confinement away from the family when visitors are in the home) or treatment plan may negatively impact quality of life for the patient or members of the household.
Safety Risk
Behavioral modification and medication typically take time to implement and reach effectiveness. Management strategies (eg, basket muzzle, leashing in the home, reducing exposure to a trigger) may reduce risk to the patient and surrounding humans while waiting to determine whether the treatment plan will be successful. The degree to which safety risks can be eliminated or reduced may affect client decisions.
Assessing Risk
Consideration of behavioral euthanasia is frequently influenced by an overall risk assessment of the patient that factors in size, bite/incident history, perceived predictability of behavior, and exposure level to potential recipients of unsafe behavior, including risk status of exposed humans (eg, young children, elderly individuals, other individuals at greater risk for complications from bites) and level of difficulty preventing contact with at-risk individuals.
There is no specific formula that reliably determines safety within the discussion of risk. Each factor should be considered relative to the client’s ability to manage, avoid, or reduce the behavior to an acceptable level of risk suitable for continued management and/or treatment. In most cases, the final decision of what constitutes acceptable risk belongs to the client. Recommendations should generally be avoided, focusing instead on reframing relevant risks and considerations for the individual, unique situation. For example, “The decision of how to proceed is up to you. Based on what has been shared, I’m concerned about the dog’s lack of bite inhibition and potential contact with nonfamily members, as well as the ability to physically control him if or when he aggresses. Moving forward with a treatment plan that keeps him in the home will require a solution to manage those concerns safely.” The conversation should keep decision-making with the client and identify the safety risks that must be addressed. This approach allows discussion about which interventions are feasible based on the situation or limitations and whether additional support is needed.
Contemplation of behavioral euthanasia often carries significant emotional weight for all involved. The conversation should thus ideally be framed so clients can thoughtfully process available options, which is not consistently easy or even possible in all cases.
Having the Discussion
Unique challenges are associated with discussing problem behaviors in general and behavioral euthanasia specifically. Clinicians have the opportunity to provide options based on clients’ unique circumstances.
What Would You Do?
A common question asked is, “What would you do if this was your pet?” It is important to remember that the decision on how to proceed ultimately belongs to the client, not the clinician, and professional support should focus on outlining available options rather than projecting or unduly influencing the client’s decision.
Caregiver Burden
In one study, caregiver burden was a strong predictor of euthanasia consideration, second only to patient quality of life.3 Discussing caregiver burden in practical terms (eg, stress and discord among family members; financial and time expenditures related to medication, behavioral modification, and management strategies) can create space for the client to acknowledge how the pet’s behavior or available treatment options are likely to impact their own life.
Acknowledging Limitations
Specific considerations may include discussion of whether resources are available to support ongoing care or treatment or whether the client can carry out the sacrifices or adjustments necessary to maintain safety and quality of life for themselves and their pet.
Clinicians should also recognize their own limitations regarding behavior cases and be willing to inform clients when they are at the limit of their expertise.
Addressing the Practical Aspects
Optimal timing for discussion of the practical aspects of behavioral euthanasia is case-dependent. Some clients have a baseline awareness of issues (eg, state rabies law) and initiate discussion. With other clients, especially those navigating concerns within the household (eg, differing opinions on how to handle problematic behaviors), it can be challenging to address issues without appearing uncaring. It can be helpful to mention there are practical matters to address, asking whether the client prefers discussing them at the moment or delaying to another time. A more direct approach can also be used, in which the clinician acknowledges the situation is emotionally charged and asks permission from the client to temporarily put those emotions aside so practical issues can be discussed.
If behavioral euthanasia is discussed but not pursued, clients can be reassured the clinic is a safe space to discuss the option at a later time if current management strategies (eg, training, rehoming) are no longer viable.
Emotional Impact
It may be necessary to navigate the strong emotional responses (eg, guilt, shame, grief, anxiety, embarrassment) of clients while staying within the bounds of training and professional expertise. In one study, ≈50% of clients reported feeling guilty about deciding to euthanize their pet4; perception of the professional support provided was a factor that affected the grief response. It is important to be aware of potential impact without accepting excessive or inappropriate emotional weight for the client’s decision.
The difficulty of the situation can be acknowledged without labeling the client’s emotions and while maintaining appropriate communication boundaries. Emotional support should be provided by family members, friends, and/or licensed professionals (eg, therapist). Clinicians can express empathy and encourage clients to rely on their support network or otherwise seek assistance, but it should be made clear that veterinary staff are not trained as counselors and cannot fill the role of licensed mental health professionals.
Navigating Professional Burnout & Compassion Fatigue
Euthanasia discussions and the care provided to patients and clients can be emotionally taxing. Resources are available to help navigate professional burnout and emotional fatigue. Strategies for supporting clients through challenging situations without taking on added burden or perceived responsibility for outcomes are also available. Awareness of how end-of-life conversations should be conducted can reduce burnout and compassion fatigue and enhance professional satisfaction.5
Ethical Dilemmas
Behavioral euthanasia is not typically pursued for natural end-of-life reasons, has different variables and influences, and is often considered due to safety risks or quality-of-life considerations for humans and/or other animals. Patients may be young, clinically healthy, and/or capable of living for an extended period except for the behavioral concerns. Resources to help understand these factors and their influence on the behavioral euthanasia discussion are available (see Suggested Reading).
It can be difficult to advocate for both the client and the patient presented for potential behavioral euthanasia. Behavioral issues can result from a patient living in an environment not conducive to their needs. Feeling as if only the client can be advocated for, disregarding the patient’s needs, may lead to moral distress and burnout.
As noted within the risk assessment, some situations also require advocacy for individuals (eg, children, elderly household members) at increased risk for injury. Contacting social services for input and assistance may be necessary if the client expresses a persistent lack of concern for at-risk household or community members.
In some cases, the decision to euthanize for behavioral reasons may appear to be one of convenience, but there may be additional layers of consideration not immediately visible. Meeting clients with compassion and empathy rather than judgment or contempt can help reveal solutions or outcomes not apparent at first glance.
The Case Outcome
A risk assessment was performed for Oswald.
Size
The dog is large enough to inflict significant injury if sufficiently motivated.
Bite/incident history
Multiple bites occur within individual incidents.
Aggression is persistent, rather than biting and retreating.
Warning signals may not be given or perceived in time to take meaningful action.
Lack of canine teeth lessens potential injury, but significant injury is still possible.
Perceived predictability of behavior
Predictability was considered high before the most recent incident but is now less certain.
Exposure level to potential recipients of unsafe behavior
Aggression was previously directed only toward nonhousehold members but has now been directed toward a member of the immediate family, thereby increasing the potential exposure and subsequent risk.
Management options, lifestyle changes, and possibility of modifying pharmaceutical interventions were discussed. Due to the perceived unpredictable nature of Oswald’s aggression, lack of a clear trigger, severity of injuries inflicted, and uncertainty of how additional medication changes might impact behavior either positively or negatively, the owners decided they could not safely live with Oswald in their home and chose to pursue behavioral euthanasia.
Oswald’s case could be considered as having a sad outcome, but knowing his owners were presented with viable options in a compassionate and empathetic manner that provided space for quality-of-life discussions, safety considerations, and a comprehensive discussion of possible outcomes allows the veterinary team to continue having these difficult conversations and provide professional support for future clients and patients.
Listen to the Podcast
Dr. Pachel joined Dr. Watson on the podcast to have a conversation about the many challenging factors surrounding these cases and keeping compassion and empathy at the forefront of these difficult decisions.