Learning Objectives

Discuss the management and the rational of handling owners/clients during emergency circumstances in small animal patients.

General Aspects of Emergency

By definition, medical emergencies are unexpected situations or events that "merge" suddenly where necessary or "urgent" to act immediately is, often involving a critical event for everyone involved. In recent years, the friendship and closeness between humans and small animals has been intensified in response to social changes that have affected the family structure and the pathways of emotional support of individuals. For many people, pets are an additional source of affection, social support and emotion, turning them into a member of the family, and in many cases, like in senior people, best friends and true partners.

To communicate effectively with our customers under this circumstances, requires ability, commitment and knowledge of the various reactions of human beings facing a crisis, as well as appropriate communication strategies, in order to intervene quickly, useful, determined and above all calm. Our goal as veterinarians is to stabilize the situation so that the client provide us with the necessary information about the condition of the pet, to inform us their concerns and worries; and above all to understand the condition of the patient, in order to make coherent decisions about the different treatment options and what they are able to afford.

How to Gain Control in a Critical Situation

Although some people remain calm and work effectively when facing a critical situation, the large majority behave in an irrational and disturbing way. Usually, people in crisis experience fear, anger, guilt, confusion, often they are out of control, have difficulty to understand the information that is given to them, and find it very difficult to communicate and/or interact appropriately with its surroundings or with other people.

In larger clinics or veterinary hospitals, the person in charge of giving the primary support is often the secretary or receptionist, who is responsible for stabilizing and gaining control of the situation to obtain the relevant primary information, and to serve as a communications link between the owner and the veterinarian. This role can also be fulfilled by a student or young medical intern, but it will fall on us when it comes to a small clinic. However, the discussion about the patient's condition, and the different treatment options, is the sole responsibility of the veterinarian.

A simple strategy that allows them to recover that capacity is to ask them to decide about trivial things, such as if they want to sit down, a glass of water or if they want to call a family member or their regular veterinarian.

Communicate Without Words

If we want to provide structure to an owner in crisis we must ensure a proper atmosphere. It is essential to adapt the physical space, providing a comfortable, quiet, and private atmosphere. For this purpose we can adapt an area of the waiting room, an office or an examination room. Always provide easy access to a phone, and if possible to have tissues. A calm environment, free from noise and interference, allows the individual to feel safe and secure, reducing the burden of stress to which it is subjected. However privacy should not be confused with isolation, lack of communication of what is happening to their pet can give both false expectations and additional uncertainty.

Certain Clues

 Show interest in the other, making eye contact should be kept permanently, an open posture, and nodding to show that the information is being received.

 Respect certain distances. All individuals have a personal space or intimate distance. If possible, this space should not be invaded, as it may be interpreted as a threat and provoke a reaction of rejection.

 Physical contact should be used properly, and can provide comfort and safety. There are certain areas of "safe" contact, these include the shoulders, arms and sometimes the hands. However, it is important to respect the sexual, cultural and religious differences.

 Use of language: Learn to listen and recognize the client's emotions, without being judgmental.

 Gather information. Open specific questions can be very valuable in understanding circumstances and help identify certain obstacles that interfere with decision making.

 Mediate and confront the situation. Not refuting aggressively; which would take us even further from solving the problem; but to confront them with reality and try to make them understand that what is really bothering them is the situation, not our actions.

 Decision taking. The goal is to meet in the best way possible the patient and the owner needs, helping them understand and prioritize the situation and allow them to explore all the alternatives.

Economic and Financial Aspect

When discussing different treatment options is important to inform the client about the costs and financing possibilities, discussing some primary aspects such as the responsibility of the owner to pay for the treatment, because frequently the wrong concept exists that the veterinarian has the moral obligation to provide treatment, even when the owner does not have the financial means.

It is important to show with real examples what are the costs involved in the total budget, explaining the different procedures, and detailing the reasons for the professional fees.

Relatively often we will be faced with clients that cannot afford any treatment alternatives. Unlike human medicine, there are no security systems or state health insurance. In this context, the solution of the problem lies within the ethical or moral concept that each veterinary clinic has, and the analysis of each particular situation.

Natural Death and Euthanasia

Sudden death and Resuscitation Guidelines

The death of a patient in our clinic may occur immediately or after prolonged hospitalization. Facing the sudden death of the patient on arrival or a few minutes later can become a real challenge for us and for the owner.

Patients should be then included in categories as in, non-resuscitation, closed-chest CPR and open chest CPR. This must be clearly established both in the clinical history and in the chart accompanying the patient at all times.

Euthanasia

Euthanasia is a medical maneuver and its main objective is to avoid further suffering to those patients with no chance of recovery that will allow them to maintain a reasonable quality of life. The definition of "quality of life" may have certain variations.

If the owners decide to witness the euthanasia, we must explain the whole process step by step, including the amount of drug to be administered, and what are the expected reactions (defecation, urination, presence of muscle contractions, inspiratory movements, etc.). This will reduce anxiety during the procedure.

During a face-to-face euthanasia, it is convenient before the owner enters to place a venous catheter (try to prevent the owner from witnessing venipuncture), place the patient in the most comfortable position and covered with blankets, this will give emotional tranquility to the owner. If the patient is connected to some control device it is vitally important to disconnect all the alarms. You can suggest the owner to stay some time alone, before or after the procedure.

The client´s resolution to practice euthanasia as well as resuscitation directives should be documented properly in a signed document and clearly identified with the patient and owner information. It must be filled out in handwriting by the owner.

Conclusions

The practice of emergency medicine and intensive care turns out to be an intellectual and emotional challenge. Constantly, we will be confronted not only to the handling of patients who have a critical medical condition, but also to owners in a deep emotional crisis.

The successful resolution of these situations requires skill and commitment. Some of these skills can be learned or educated. When working with clients in crisis, it is necessary that all medical and support staff of the clinic acknowledge and commit to implement the clinic policies. Therefore it is essential to take the time necessary to discuss these issues with all staff.

Although the use of consents, orders and authorizations signed is still limited in Veterinary Medicine, these documents must be implemented with increasing frequency in our daily practice, especially when it comes to emergency and intensive medicine. These documents allow owners to consider different alternatives; become interested, comprehend and get involved in the various treatment options and become responsible for the financing.

On the other hand, the use of these documents will provide veterinarians a clear guide as how far to go in providing medical or surgical support to a patient, according to the demands set by its owner, as well as legal support if necessary, in case of a lawsuit from alleged malpractice, or in case of trying to collect our fees.