Older Horses Part 6: The Final Decision
- Dec 1, 2007
As a veterinarian, I have spent a good bit of time involved with the care of sick animals, and many times have also attended their deaths. Over the years, it is something I have thought a lot about. Being responsible for ushering an animal into death is overwhelming at times. I understand the need, yet it is still not something that I am always comfortable with. I have taken the attitude that it is something that, as a professional, I should be good at. And, like a lot of things in life, it takes some thought and practice to become good at. However, this article is more than just how an animal is killed. It is about a lot of the things that happen leading up to that moment in time.
Is it Time?
There are a lot of reasons that lead to the decision for euthanasia. Sometimes we can have the luxury of time to think things through, but sometimes the decision hits us in the face with an immediacy that does not give us time to realize the reality.
For some it is the situation of the older horse that has accumulated a long list of medical problems with degenerative arthritis or chronic laminitis being the most obvious as a cause of pain and persistent lameness. We talk about the "quality of life," but in most situations, it really is our human ability to perceive a level of expressed pain by the animal. Some animals seem to endure suffering more than others. A lot of times we allow them to endure a certain level of suffering before we as humans can come to grips with the reality of their pain.
In other situations, a fatal or terminal situation suddenly occurs--the traumatic disruption of the suspensory apparatus or fracture of a leg during a performance or race, or an intestinal rupture from a colic episode--and this places us in the situation of making the decision and allowing euthanasia to be performed.
Those are the "no other way" situations where we are forced into the decision.
The important thing as an owner is to realize that when a professional presents the facts with enough information, you can gather your senses and make a speedy decision to the end the pain and suffering. That is a responsibility that few ever think about when they purchase an animal, but one we all need to contemplate ahead of time.
The line of "when is it time?" is sometimes blurred by advances in medical therapy. I say this as a medical professional, but also as one who has spent years in an intensive care setting watching foals and adults cling to life with advanced medical support.
A variety of severe medical illnesses place us in the life-or-death decision process, but probably none more so than laminitis, a disease that has taken the lives of such heroes as Secretariat and Barbaro. Laminitis is the common final stage for a variety of severe medical diseases of the horse with a spectrum of severity and progression. Some sink rapidly and require destruction in a matter of days, whereas others smolder for years before reaching a level of pain that requires euthanasia.
The question was asked of me when asked to write this: "How do you, as an owner, tell when it is time?"
My honest answer is that no one really knows. It often comes down to realizing whether the pain the animal is suffering is at a level we would consider inhumane.
What is the definition of inhumane?
Dictionary.com says: lacking humanity, kindness, compassion, etc., and the American Heritage Dictionary says: lacking pity or compassion.
So, it really is a reflection of our personal sense of an animal's level of suffering.
My take on this is that not all people are created equal when it comes to perceiving an animal's level of suffering and the reality of it. Some of us are soft-hearted and anthropomorphize a certain degree what we think an animal feels. This is not an argument I want to get into, just a statement that some humans are more sensitized to suffering.
Others might not realize the amount of suffering--possibly out of ignorance of animal behavior, which is something we see more often as society becomes more urbanized. Still others might ignore the animal's suffering.
The other side of the coin is that there is some degree of pain and suffering with many diseases that are curable with medical or surgical care. Colic surgery, for example, is a situation where an animal might have some degree of discomfort after surgery, yet it will go on to lead a productive life for many years.
As a veterinarian, it is my job to recognize a disease process, treat it when appropriate, and alleviate suffering when I recognize it. Part of that process is educating and informing the owner or caretaker as to the severity of the process.
On some occasions it becomes my charge to say it is time to end the suffering. Some professionals are unwilling to make that comment, or they leave it to the owner regardless of the owner's educational level. Yet, we are all--as animal owners--called to the responsibility of dealing with an animal's pain and suffering.
Some individuals are not willing to face it. I have encountered situations where the animal was suffering a terminal or fatal condition, and the owner was unwilling to consent to euthanasia because they just could not come to grips with the reality of the situation. I term that "denial of reality." Some of these occasions occur when the owner is not present to observe the animal and is relying on my description via telephone. This is certainly a trying time for me as a professional and the individual who might not know me sufficiently well to trust what I am telling them in a moment of crisis.
We all hope we have the good sense to make that decision when the time comes, even if it does mean a great deal of anguish on our part.
What are some of those situations that call for the decision of euthanasia? I mentioned laminitis earlier as one of the common scenarios. Colic is another. On occasion, the colic patient might have a terminal problem with massive intestinal strangulation not amenable to surgery, or sometimes the situation is a colic case that has a surgical problem, yet the owner cannot afford a surgical bill. I make no personal judgment in that situation.
The key here is this decision should be guided by sufficient diagnostic information to have the most definitive answer possible. Nowadays, diagnostic ultrasound helps us know a lot more about the condition causing the colic and allows for more helpful information in the decision to pursue medical therapy as opposed to selecting euthanasia.
I think it is more important to recognize the fatal situation for what it is, and to make a decision for euthanasia as an appropriate ending, rather than to allow medical therapy in hope that a terminal condition will miraculously correct itself overnight.
The Stages of Euthanasia
The process of euthanasia is a much-debated issue in human society. For veterinarians, the guidelines come from our educational process and from consensus of some of our professional societies. Perhaps the most well-known document is the "Guidelines for Euthanasia" produced by the American Veterinary Medical Association. This document is recognized as the authority for animal shelters and by the USDA for handling of animals in research environments. The goal of the document is to alleviate animal suffering and to provide a guide in producing a humane death in as rapid a manner as possible.
In all circumstances this means a rapid loss of consciousness, much as would occur when undergoing anesthesia, followed by cardiac or respiratory arrest and the cessation of brain function.
Most readers are familiar with the use of an injectable solution for euthanasia. Most of these solutions contain a concentrated barbiturate compound that induces a rapid loss of consciousness when injected rapidly. There is a bit more art to this than a simple injection.
Euthanasia is a medical procedure that is best performed after careful evaluation of the animal and its mental state, as well as taking into account the animal-handling capabilities of the attendants and the environment. The goal is to rapidly deliver the drug to the brain in a concentration sufficient to induce sudden loss of consciousness.
Several factors come into play, the most important being the ability to rapidly inject the solution into a large vein such as the jugular vein. In some cases placement of an intravenous catheter might be reasonable to avoid the animal moving at the wrong moment and only receiving a portion of the dose. While we might think the animal is anxious about such an injection and prefer that it be sedated, it is known that certain tranquilizers actually prolong the time to loss of consciousness and allow for increased movements after injection. The animal's situation has to be taken into account.
A calm animal might need minimal restraint, whereas a very fractious, injured animal, or an animal with little human handling, might be more prone to movement and actually require some prior sedation for administration of a euthanasia solution. When the drug reaches the brain in sufficient quantity, the animal loses consciousness and collapses to the ground. The reality is the animal is gone before it falls to the ground.
Place of Death
It is important for the veterinarian to evaluate the surroundings where the procedure will take place, to discuss the flow of the procedure with those in attendance, and to be in control of the situation and the environment so that no person is injured.
If an owner or attendant is going to be present, he or she needs to understand what is going to happen and understand that human safety is the veterinarian's responsibility. The person should agree to adhere to the veterinarian's instructions during the procedure.
If the animal is standing it is important that it be an easily accessible area without obstructions and where people involved in handling the animal can maneuver, if needed. The goal is to have the animal go down smoothly without injuring anyone or harming itself further by falling on any obstructions or causing the handler to lose control of the animal. The area should also allow for ease of removal of the body after the animal is dead.
While some in society reject the use of firearms, this remains a very humane method of euthanasia when properly performed by a trained person.
Both gunshot and a tool known as a captive bolt pistol cause death by sudden trauma to vital centers within the brain to produce immediate loss of consciousness. There are certain circumstances where injection of a barbiturate is inappropriate, or even illegal. In geographic areas where predators and scavengers, such as bears and eagles, might have access to the carcass, it could be inappropriate or even illegal to use a barbiturate, making gunshot the most appropriate humane form of euthanasia.
When appropriately administered I believe there is no more rapid onset of death than with a gunshot. Admittedly, it is not for every owner or every situation. Remembering the comments about assessment of the environment the animal is in, this becomes even more important when deciding whether gunshot is appropriate. My point here is that while we as humans might sometimes cringe at the thought, it does not take away from the fact that it is a humane and rapid form of euthanasia.
The injection or gunshot is not the end of the process. It is always important to confirm that death has occurred. That usually means listening to the horse's chest for a heartbeat, observing for any breathing motions, observing the pupil of the eye for dilation, and touching the cornea of the eye to test for a blink response (not present after death).
Probably the most emotional situation for observers is the agonal (pertaining to or occurring at the time just before death) gasping sometimes observed after euthanasia. Most often this occurs when an injectable solution is used. It represents the basal (relating to maintaining the fundamental vital activities of an organism) attempts of the brainstem to continue the breathing process, even in the absence of consciousness.
What about situations where onset of death is not easy? Two situations where onset of death is slow involve poor circulation. Patients with heart failure have poor circulation by definition, and delivery of the drug to the brain will be slower. The same might be the case for animals in severe shock.
In these cases techniques of injection to enhance the rapid delivery of the drug to the brain are helpful, but the onset of death still might be slower. The preparatory discussions about the disease process and the process of euthanasia should cover the possible outcomes, and the veterinarian should be prepared to administer additional medication if necessary.
In some situations, an animal might be insured. Some discussion with the insurance adjuster might be necessary prior to euthanasia. It is important to understand that the insurance company might have the right to request a necropsy or postmortem examination be performed to confirm and document the medical condition that necessitated the euthanasia.
While it is an emotional time, it is important for the owner to inform the veterinarian, if they do not ask, that an animal is insured and that proper communications be carried out prior to the euthanasia, if possible, so as to preserve the insurance policy.
Euthanasia is one of those endings that no one likes to think about. But, just as we would prepare ourselves with a first aid kit and receive training for CPR, it is something that we need to think about ahead of time. For the animal's sake, it is something we need to prepare ourselves for and not shrink from when the time occurs. It is a time when I have gained the most respect for some of my clients as they came to terms with the fatal nature of the situation, and in a manner of personal bravery, made a clear decision in the best interest of the horse they loved.
MAKING THE DECISION: JOHN HENRY'S PEACEFUL END
The decision is never easy. Whether the horse is a champion to an entire generation of horse racing fans or a simply a hero in a child's heart, there comes a day when someone has to take a step back and determine whether the older horse's quality of life is acceptable. Kathy Hopkins, equine director at the Kentucky Horse Park, and a group of John Henry's closest caretakers and friends recently encountered this when the 32-year-old champion Thoroughbred was euthanatized on Oct. 8.
In recent years John Henry had a full diagnostic work-up that established very specific baseline information on his health to help his veterinarians and caretakers notice if anything was awry. John had Cushing's disease, among other endocrine problems, and a calcium-producing tumor, so he started a very intense program of veterinary care. He received Cushing's treatments, medications to boost his immune system, and was maintained on a very stringent diet. Like many older animals, John endured some ups and downs, but he still had a spry step and an apparent will to live.
However, things took a turn for the worse in late summer. John lost a lot of muscle mass and fat tissue while battling the intense Kentucky heat and kidney failure. While his kidney function was getting better, his veterinarians--Nathan Slovis, DVM, MS, Dipl. ACVIM, of Hagyard Equine Medical Institute across the street from the park, and Mike Beyer, DVM, of Equine Health Care in Versailles, Ky.--could not keep him properly hydrated.
The ultimate decision for euthanasia was a combined effort of Hopkins, John Nicholson, executive director of the park, Slovis, Beyer, and John's other caretakers. Hopkins said, "We met and spoke together. The decision was that as long as he was happy, bright-eyed, and energetic, still enjoying himself, still eating well, and if we could keep him hydrated satisfactorily without constant intervention, we would go as long as John was telling us he wanted to go."
At the end the old horse was signaling his caretakers. He needed to go back on constant intravenous fluid therapy if he were to live. His appetite faded. "We were having trouble getting enough meaningful calories in him," said Hopkins.
"The last three days, his energy level dropped, the brightness of his eye had deteriorated, and all the sudden he just seemed very, very tired," she said, her voice cracking with emotion. "We wanted to maintain his dignity and quality of life. And we felt at that point we could just not do that any further, and he was just physically and emotionally tired. He had been fighting, and we wanted it to go with respect and dignity, and while he still had that.
"Keeping him longer would've been selfish," she continued. "He would've passed earlier without our intervention. But we wanted to make sure that until the end he was totally comfortable. Until the last few days he had a wonderful appetite, was still pushing us around, bossing us, still letting us know, 'I'm not ready to go--I want to go for my walk. I'm enjoying life.' "
But in his last few days, John became disinterested in the goings-on of the barn aisle and spent more time out in his paddock, standing "with sort of a faraway look in his eye."
John was euthanatized in that paddock where he had lived for 22 years--he was buried just outside it.
"We were beside him, rubbing his head; he simply lay down and went to sleep," she described. "He was ready. There was never a motion or movement, he just very quietly lay down ... It was very, very peaceful.
"Most horses, they let you know," Hopkins continued. "The people around them just know, because we learn to read them ... they just tell you with their eyes and their body and they let you know that it's okay and it's time."
--Stephanie L. Church
About the Author
Fairfield T. Bain, DVM, MS, Dipl. ACVIM, Dipl. ACVP, specializes in internal medicine and pathology. He is an equine technical services veterinarian at Merck Animal Health.
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