The Sound of Resilience: Dispelling the Myths of Crisis
Mark Cushing and Dr. Dani McVety-Leinen wrote recently of "The Quiet Crisis" in veterinary medicine. Respectfully, I disagree with their proposed solution.
In a recent article in Today’s Veterinary Business, lobbyist Mark Cushing and Lap of Love founder Dr. Dani McVety-Leinen, put forth the proposal for the adoption of a model legislation that allows credentialed veterinary technicians to perform in-home euthanasia for pets, under real-time video supervision of a licensed veterinarian, struck a chord with me. At first glance, it may seem like a reasonable solution to the so-called "quiet crisis" of access to in-home end-of-life pet care. But when I dig deeper, I find there's a more nuanced debate here, about professional expertise, ethical obligations, and the influence of economics on our profession.
Geoffrey: Why, you chivalric fool, as if the way one fell down mattered.Richard: When the fall is all there is, it matters
“The Lion in Winter” by James Goldman
First and foremost, I must address the gravity of the act of taking a life. Euthanasia is a final and irreversible decision. Making the choice to euthanize demands the same professional knowledge as a diagnosis of disease, and even more in the way of ethical and moral considerations. Veterinarians receive extensive training not only in the medical aspects of our work but also in the ethical decisions that come with it, and we receive much more of both than technicians. This training, this expertise, cannot be supplanted by a technician's qualifications even with specialized training regarding euthanasia. I don’t know a veterinarian who hasn’t, at some point, talked an owner out of the choice to euthanize their pet because medicine can provide a better quality of life for the pet. A precise diagnosis can avoid unnecessary euthanasia, and this discernment can only be carried out by a fully qualified veterinarian.
A technician, even one trained to perform euthanasia or supervised through telemedicine, doesn't possess the depth of knowledge, experience, and intuitive understanding a veterinarian earned through our more intensive, extensive education. The relationship between pet owners and veterinarians is built on trust, and the pet owner must be confident that all possible diagnostic routes have been exhausted before euthanasia is considered. This level of trust cannot be replicated with someone with only the limited training of a technician because that level of trust is founded upon a doctor’s much more extensive expertise and training.
Mr. Cushing takes to criticizing decades old practice acts that did not consider the economic expedience of having a less-trained person perform a euthanasia. I wonder if these acts did consider that while it would be cheaper to have a less qualified person perform a task, it is in the public’s best interest limit that activity to a more qualified person. The acts don’t exist to protect the staffing needs of a lobbyist’s supporters, the acts exist to protect the citizens of a state from unqualified and subpar veterinary medical care. It is in this way that Mr. Cushing has worked to erode the quality of veterinary care in the United States by diminishing the standards of the veterinary-client-patient relationship in Arizona and elsewhere. I don’t know Mr. Cushing, but I disagree with many of the changes he seeks to affect in our profession because I believe that the interests of the pets and the pet owners will not be served for the better.
The proposal offered by the authors can, of course, lead to unforeseen consequences. For instance, if an animal reacts unexpectedly during euthanasia, a technician may not possess the necessary skills to intervene effectively. In essence, the technician, despite being supervised remotely, is alone in dealing with any emergency that might arise without the direct supervision and potential aid of a veterinarian. But truly, the technical side of the job’s performance is not my greatest concern. Veterinary technicians are frequently some of the best hands in a practice. It’s the motivations of the proposal’s supporters that give me pause.
So I turn attention to the economic aspect, it is essential to critically examine the motivations behind this proposal. Dr. Dani McVety-Leinen, the founder and CEO of Lap of Love Veterinary Hospice, is a key supporter of this initiative. It's worth considering how this change could benefit companies like hers. Could it be that the so-called "quiet crisis" is, at least in part, a narrative shaped by financial motivations of a CEO’s own interests? I am not so cynical to believe it to be her only concern, but neither I am so naïve as to believe it isn’t a consideration.
The proposal would potentially allow businesses like Lap of Love to replace veterinarians with technicians, thereby decreasing their payroll and increasing their profit margins. Such a practice raises questions about whether the wellbeing of the pets and the wishes of the pet owners are genuinely at the heart of this initiative. Or is it a question of economic demand, rebranded as a “quiet crisis” and moral imperative?
It is understandable that the veterinary profession, like any other, faces pressures due to technological changes, staffing shortages, and rising costs. But these issues should not lead to compromised solutions that potentially endanger the welfare of our beloved pets or undermine the trust of pet owners in our profession.
In the interest of full disclosure, I used to work for Lap of Love. I did not enjoy the work, though the most vicious criticism I can honestly offer against Dr. McVety-Leinen is that I disagree with her proposal of this article. The work done by hospice veterinarians is important and necessary, but it shouldn’t be offloaded to technicians. After I returned to clinical practice, there was a demand in the area to which I’d moved. And for the last several years I’ve worked part-time as an on-call veterinarian for a local pet crematory. The demand and pay is not substantial, but I believe it’s important to serve my community this way. It’s my responsibility to the people and pets of my hometown. Each and every one of the euthanasias I perform scrapes my soul. I hate to have to do them, they always hurt. But it’s vital that they’re done right and done well, and that takes more than a correctly calculated dose and a well-placed catheter. More times than I can count I have talked owners out of euthanasia to address a simple disease process with treatment that offered months or years of quality life and health to a pet. I keep those thank you notes in a different box than the others, because I need to use them to remind myself of the importance of doing this difficult part of the job.
I say all this not to boast, but because before I am a writer, a speaker, a practice owner, or anything else in my professional life, I am a veterinarian. And a veterinarian steps up to do what is right for their patients. I still practice medicine, I still perform surgery, I still perform euthanasia. Not everyone who has an opinion about the profession needs to do these things, and not everyone who has an opinion does, but it’s important to me that I do.
Ultimately, while the affordability and accessibility of in-home euthanasia are important issues, they should not overshadow the necessity for professional judgment, the ethical responsibility towards our pets, and the ethical concerns regarding financial motivations driving such proposals. A thorough and balanced debate is needed to ensure that any reforms truly serve the best interests of pets, their owners, and the veterinary profession as a whole, and that debate should not be shaped by lobbyists and executives alone. Veterinarians must speak up, not only for the good of our profession and its long term health, but also for the clients and patients we serve.
Wholeheartedly agree. I view euthanasia as a professional obligation, a terrible necessity, and also a gift: the gift of a smooth exit from this plane of existence to the next. There are few things worse than screwing that up and adding suffering in the final moments. If one wants to see what euthanasia without appropriate medical care looks like, take a look at how often it goes grievously wrong in prisons with lethal injection. As physicians have essentially boycotted assisting with the death penalty (separate conversation), executions are carried out by people without medical training who often don’t know what to do when things go awry, and the descriptions of some of those botched cases are harrowing. I don’t feel great about convicted murderers going through that, and I *certainly* would never want innocent animals to experience a fraction of that torture
We know that the shortage of trained professionals in clinical practice makes it necessary to change the way we do things. Title protection and defined scope of practice for licensed techs that differs from that of our unlicensed assistants, I feel, is a critical part of the equation.
I would whole heatedly oppose allowing licensed techs to perform euthanasia (plus a long list of other services/procedures) in clinic or at home on a patient and for an owner who have not been previously approved for euthanasia by a licensed veterinarian.
As much as I hate euthanasia, I do believe it is often (not always) better for both patient and family if it can be performed outside the walls of a veterinary facility. If I have discussed the situation with the owner and had an opportunity to assess the patient (we schedule quality of life assessments, not euthanasia appointments unless they have already had a recent QoL assessment and a vet signed off on the decision to euthanize), I would love for my licensed techs to be able to go out to a patient rather than having them dragged in to see me.
I try to accommodate in home euthanasia when I can but when we are turning away patients in need every day, it's hard to justify taking a vet off the floor to do a house call.
I don't know how Lap of Love handles their cases but I always squirm when a patient I have never seen before wants to come to me for their final visit. When they used to get scheduled as a euthanasia appointment it was MUCH more uncomfortable talking them out of it than it is when their are scheduled for a QoL assessment because the client understands that I haven't agreed to perform the procedure yet.
We know we can't keep doing things the way we have been doing them. Doing things differently will require some legislative changes. I personally would not oppose this one asing as the procedure is approved after an in person exam by a licensed vet who signed off on the need for the procedure. Currently in my state, a licensed tech can't even euthanize patients in my facility. I live 15 min away and have had patients suffer longer than the would have if I could have approved it over the phone.