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Veterinary professionals’ experiences with human caregivers when providing animal hospice and palliative care

A significant role in veterinary medical practices is the provision of end-of-life (EOL) care to pets and their clients. Yet, U.S. veterinarians report being dissatisfied with the level of training they receive on EOL issues in their veterinary medical programs (Dickinson et al., 2011). At the same time, the ubiquity of veterinary information on the Internet (e.g., “Dr. Google”) has the potential for instilling pet owners with a false sense of expertise that veterinarians must then negotiate when providing EOL care. In this context, we surveyed 86 veterinary members of the International Association for Animal Hospice and Palliative Care (IAAHPC) to explore whether and/or how veterinary medical information clients obtain from the Internet impacts the veterinarians’ delivery of EOL care to those clients’ pets; we similarly investigate the information that veterinarians prefer their clients knew before meeting with them to provide EOL care. In light of the inherent challenges of EOL veterinary care outlined above, we learn from veterinarians what they feel are the most challenging and rewarding aspects of providing palliative and hospice care. Using qualitative thematic coding, our results show, in sum, that veterinary information from the Internet is both helpful and harmful to veterinarian interactions with clients; veterinarians wished clients understood the value of hospice and palliative care as an EOL care option and that grief is normal; and veterinarians report a most positive aspect of dealing with these issues is the gratitude clients show for helping their pets die peacefully.

with them to provide EOL care to their companion animal. In light of the inherent challenges of EOL veterinary care outlined above, we learn from veterinarians what they feel are the most challenging and rewarding aspects of providing palliative and hospice care. This study will attempt to address these queries in the hopes of helping to make the entire EOL experience with the client and the pet more tolerable and satisfying for all concerned-the veterinarian, the client, and the pet.

Method
Survey solicitation was distributed via email list-serve on February 6, 2017, to approximately 400 members of the International Association of Animal Hospice and Palliative Care (IAAHPC) regarding their experiences and preferences in providing EOL care to companion animals. Approximately 95% of those members are practicing veterinarians or veterinary technicians, and thus, 380 of the IAAHPC members were eligible to participate in this study. A follow-up email solicitation was distributed via email on March 2, 2017. A solicitation to this survey was also posted on the IAAHPC's Facebook page on February 2, 2017 as well as the Facebook page for VetTechLife.com.
Survey solicitations included a hyperlink to an electronic survey in Qualtrics. While the survey contains approximately 30 questions, this paper examines respondents' answers to the following four open-ended questions: (1) How interaction with clients is enhanced or complicated by the proliferation of veterinary medical information on the Internet; (2) what the veterinarian wishes all pet owners knew before calling on the veterinarian to provide EOL care to their pet; (3) what the most challenging aspect is of providing palliative and hospice care; and (4) what the most rewarding part is of providing palliative and hospice care.
Qualitative thematic coding procedures were used to analyze participants' answers to the above questions and is a standard analytical process employed in the social, behavioral and health sciences (see Nowell et al., 2017). The analytical process involved the following stages: 1. The data were organized vertically in a column of an Excel sheet-one Excel sheet for each of the four questions. Columns to the right of the data column are used for successive rounds of coding and a "Notes" column serves as a repository for observations, thoughts, analytical questions and to highlight quotable material that can be integrated into the manuscript. 2. The analytical process began by becoming familiar with the data, reading through all responses to all four questions, noting preliminary themes and observations by reading through all responses to all four questions. 3. The data were read again to generate initial codes and to develop preliminary labels for the themes appearing in each response. At this stage, each response will likely contain several initial codes (e.g., a single response to a question might reference "Dr. Google," "frustrated with client," "grief management"). In this stage, the data and initial codes were read through a second time to double-check consistency across initial codes. 4. The initial codes were reviewed to identify, inductively, larger themes that reflect commonalities in these initial codes. At the same time, the published literature and our previous conversations with, and surveys of veterinarians, pointed to themes into which these initial codes might coalesce. For example, our interest in the rewarding aspects of providing veterinary EOL care was based in part on conversations with veterinarians indicating that compassionate EOL care helps to relieve human's suffering as well as the pet's-thus that was a deductive theme into which initial codes can begin to be grouped.
After engaging in the above process through successive iterations, we reached a point of saturation where continued reading and analysis of the data and scrutinization of the codes and emerging themes yielded no new insights. The product of this process is the themes appearing below as subheadings in each of the major sections.

Results
The survey was accessed electronically by 214 individuals, 137 of whom submitted a partially or fully completed survey. Of those, 86 respondents answered one or more of the four questions that are the subject of the analysis below. That only 86 veterinarians completed the open-ended questions is not atypical in survey research given that the open-ended questions appeared at the end of the survey and, in general, survey respondents are least likely to complete open-ended questions due to time constraints and the survey fatigue that is plaguing the social science research world today. Because the survey solicitation was posted and shared via the IAAHPC's Facebook page, it is not possible to calculate a response rate as the population size cannot be finitely measured. The demographic profile of those responding to the survey is summarized in Table 1.
Respondents completed their veterinary medical or veterinary technician training at 36 different institutions in seven countries (U.S., Canada, Italy, England, Australia, Scotland and St. Kitts and Nevis). Most respondents were trained at U.S. universities and those mentioned most often are the University of California, Davis (n=8), Colorado State University (n=7), Ontario Veterinary College (n=6) and Texas A&M (n=6). The veterinary programs at the University of Georgia and the University of Minnesota were each mentioned by four respondents. Cornell, Iowa State University, Kansas State University, The Ohio State University, Ross University and the University of Florida were each mentioned by three respondents.
The participants in this study have extensive experience providing EOL care. The average number of animals euthanized by respondents in a typical year was 239 (with a range between 4 and 1000), with dogs (62%) and cats (36%) constituting the majority of animals euthanized. Thirty percent of respondents felt that they knew the animal and its family well. Sixty-two percent of those responding report that euthanasia was typically performed in the client's home, 21% in the veterinary clinic, and 6% in the emergency veterinary clinic. That clinic-based euthanasia procedures are performed relatively infrequently by our respondents reflects the fact that a majority of them (53%) work in a mobile-veterinary practice or a mobile and clinical practice (13%). Below we summarize these veterinarians' views on the impact the Internet has on their practice of veterinary medicine, what they wish their clients knew or understood when providing EOL care to their clients' pets and the most challenging and rewarding aspects of providing EOL veterinary care. We asked veterinary professionals how their interactions with clients have been complicated and/or enhanced by pet owners consulting Internet information sources before bringing their pet to the clinic. For some there is a love-hate relationship with the Internet as noted by one veterinarian who wrote, "Oh, Dr. Google, how I despise and appreciate you…this is a mixed bag. Of course, it is wonderful for clients to be well informed; however, the down sides to misinformation are numerous." The nuance around this issue is likely why only 13 of the 81 veterinary professionals who answered this question focus entirely on the negative consequences of clients consulting the Internet before soliciting their services. For example, one veterinarian succinctly expressed a view with, "Hate Dr. Google!!!" Another wrote, "…after the client has first consulted 'Dr Google', I wind up having to work even harder than usual to gain my client's trust, undo the Internet damage and educate the client correctly." Still another veterinarian wrote, "Owners go on the Internet prior to a consultation and become very stressed about 'worst case' scenarios by the time they come to the veterinarian. I don't find anyone is better equipped by googling [sic] their animal's symptoms." Another veterinarian outlined the myriad problems with information clients obtain online but concludes with a statement of support for the "education" their clients generally receive from the Internet: Probably the biggest complication is in compliance with medications. I have some clients that research drugs and side effects to the n th degree and ALWAYS see those side effects in their pets. Forums can also complicate, as my clients read about other peoples [sic] experiences with the same disease. Many of these discussions are quick to blame or give credit where it is not due (Miracle supplements, etc.). There are also companies/veterinarians promising miracles with their products. In general, I love the education that the internet can provide for my clients.
In spite of the difficulty of ensuring that clients are accessing accurate and valid veterinary information online, negative evaluations of "Dr. Google" is a minority view among those we surveyed. In fact, one veterinarian reframed the "Dr. Google" dilemma around the attitude of the clinician, writing, "The complication or enhancement of such consultations depends entirely on the attitude of the clinician. Only the most judgmental, arrogant DVMs bemoan 'Dr. Google.'" The overwhelming consensus among those in our study is that veterinary information obtained by clients presents both positive and negative challenges to them professionally (approximately 13% said the Internet is not problematic at all). Having to correct misinformation clients have obtained from the Internet was mentioned most often by respondents as a challenge (approximately 20%), including clients who had developed inaccurate expectations of what euthanasia would be like for their pet, medication compliance (because clients had read about side effects that were exceedingly rare or not clinically accurate) and having to tactfully contradict and correct their clients' misdiagnosis of their pet's condition that was obtained from "Dr. Google." The dominant theme that emerges among veterinary professionals is that the wealth of veterinary information available online better prepares clients for the provision of EOL care to their pets, the dying process and how to recognize changes in their pets' well-being. For example, one veterinarian wrote: They generally are more informed or misinformed. Those who research ahead of time want more detailed explanations of what is going on with their pet and what we are doing. Some need detailed explanations of why what they found online isn't accurate. It feels like a detriment at times, but if I don't fight it and use it as a teaching experience instead of getting offended that they consulted Dr. Google; it can enhance the trust and relationship.
A second veterinarian made a similar point in the following statement: I think the internet has given clients (guardians) a wealth of information and they are more invested in doing what is right for themselves and the pet than they were in the past. They don't leave it up to the doctor to decide (which I think is right)-sometimes they need more guidance than the internet can give them which is where I come in.
The latter veterinarian's view was echoed by several respondents, including veterinarians who explicitly noted that clients regularly consulted with them for clarification of veterinary information they had obtained from an Internet source. In fact, respondents regularly mentioned directing their clients to "approved" veterinary websites (e.g., veterinarypartner.com) or to websites and blogs that they themselves had created to help clients better care for their pets, illustrating the powerful role of Internet veterinary information to reinforce veterinary medical practice. Further, that the Internet can be harnessed to support veterinary practitioners is evidenced by the fact that approximately 16% of respondents indicated in our survey that their clients had found their practice online (especially among respondents whose practices consist entirely of providing at-home euthanasia services). As a result, veterinarians regularly indicated in this study that they purposely invested significant resources to developing their clinic's websites in order to attract clients as well as offer a platform for educating their clients.

What Veterinarians Wish their Clients Knew
We asked veterinary professionals what they wished all pet owners knew and/or understood before they were called upon to provide EOL care to their pets. Seventy-two respondents answered this question. Four issues emerged as the most common and concerning to these veterinarians: 1) pet owners' understanding of the euthanasia process and how animals experience death; 2) that grief is a normal experience for pet owners who should not feel guilty for making the decision to euthanize a family pet; 3) pet owners' understanding of how to gauge a pet's quality of life and how animals display pain; and 4) that pet owners seek help sooner rather than later and, in doing so, be aware of and fully understand the role veterinary hospice and palliative care can play in facilitating a "good death" for pets; We discuss each of these below alongside less often mentioned themes that did not fit into these general categories.

The Euthanasia Process
Approximately 23 of our respondents expressed a desire for their clients to understand the euthanasia process (e.g., how clients' experience at the clinic will be organized), what death looks like for the pet (e.g., the pet's eyes will not close and the animal's bowels and bladder will release), that "death can be peaceful and painless" and occurs quickly but euthanasia also does not always go as planned (e.g., "veins don't always cooperate"). The following quote is illustrative of this category, encapsulating each of these themes while emphasizing the more mechanical steps of the euthanasia procedure: In my initial consult I describe potentially unsettling things that can occur during the process. I stress these are individual differences and do not mean anything is going wrong: react to the first sedation injection, any potential drug reactions, necessity of trying more than once to get venipuncture and place butterfly IV catheter, agonal breathing, muscular twitching, eyes open, urination/defecation.
A second veterinarian's response offers a less mechanical view of the euthanasia process that might help clients prepare for the end of their pet's life, writing, The experience is intended to be peaceful, intimate, respectful and unrushed. It allows the pet to be surrounded by those that love him/her and not be scared or panicked being in a noisy, rushed clinic. It is a time to honor the pet's life.

Grief
Over 20 respondents highlighted the importance of clients' awareness of the grief they will experience after their pet's death, that they should not feel guilty about deciding to euthanize their pets and that the decision to do so is actually a gift to a pet suffering and in pain. In speaking of an at-home euthanasia, one veterinarian writes about both the euthanasia process and how it can ameliorate feelings of guilt: I wish they knew how beautiful the experience could be with music and storytelling and crying together and respect of the pet's body afterward and the relief they will feel that they provided their pet with the best possible 'good' death that is available. That we talk about possible triggers of guilt that may come upon them afterwards and dispelling the reasons for guilt and how we talk about what is normal to feel and that they are not alone in these feelings. How we discuss losing a pet can be harder emotionally than losing a person.
That clients are making a really difficult decision that is in their pet's best interest is, according to several respondents, critical for clients to acknowledge to help ameliorate the guilt and grief they experience. Clients may perceive euthanasia as the "final gift they can give their pet" or, as a decision their pets would be "okay with." The latter is evidenced by one veterinarian who wrote, There is no objective right or wrong time to do this. Each time we make this decision it must be made in the moment (surely informed by past experiences and others' insights). Yet one can never know exactly what the decision is until we make it. AND Whatever the decision is our nonhuman companion will BE OK with it.
Finally, grief is clearly not reserved for the clients but a central part of the veterinarian's professional life, as illustrated by one veterinarian who wrote, "I wish they know that sometimes it is very difficult for me, especially if I have known the pet for a long time and/or have tried to 'heal or cure' them and have been unsuccessful."

Quality of Life and Pain Displays
Another prominent theme among veterinarians is the desire for clients to know how to gauge their pets' quality of life and how animals display pain to aid in the EOL decisionmaking for their pets. Approximately 16 veterinarians referenced some version of this concern. For example, one respondent wrote, Age does not determine quality of life. Death comes slowly if they elect to just 'wait it out' and often the pet is suffering silently. Something as simple as pain management can greatly improve a pet's quality of life. Just because they are not crying in distress, does not mean they are pain free.
Similarly, another veterinarian wrote, I wish more family's [sic] sought help for their painful pets before calling us to schedule euthanasia. I wish family's [sic] had a better idea of how to know if their pet is in pain (we provide an article on this to hospice patients & on our website).

Early Help-Seeking and the Role of Hospice and Palliative Care
The quotes in the preceding section illustrate how clients' awareness of their pets' quality of life is directly connected to veterinarians' wish that clients call them sooner rather than later to ensure pets have access to appropriate care throughout the dying process and not just the euthanasia experience. By seeking help sooner, veterinarians can better help control their nonhuman clients' pain but only if their clients were aware of hospice and palliative care services. These are themes mentioned by 28 veterinarians. One veterinarian exemplifies this point writing: I really wish clients were aware of and used palliative care/hospice services. I also wish clients were better educated about how animals display pain and what constitutes good quality of life. I see so many patients who have suffered greatly before finally becoming so bad the owners realized they needed to be euthanized. It's a serious welfare issue that I think we as a profession have an obligation to address.
The consequence of delayed care for a pet is not just the potential for the pet's unnecessary suffering but the veterinarian is placed in a precarious position weighing the needs of the pet versus those of the pet owner: I wish that owners were aware that I provide in-home hospice/palliative care. Many of my patients could have had a significantly better quality of life prior to euthanasia. Some are likely euthanized prematurely due to inadequate pain relief and other treatments. By the time I arrive, they are already psychologically prepared to euthanize their pet and I feel that it would be unkind and unhealthy for me to broach the possibility of hospice at that point.

Additional Assorted Mentions
There is clear overlap among the above four themes and several others mentioned by respondents that did not fit neatly into the above categories but are indeed noteworthy. Two veterinarians mention that they wished their clients were aware of at-home euthanasia service and two would like their clients to be familiar with palliated natural death as an alternative to euthanasia. Four respondents expressed interest in their clients planning before the euthanasia what to do with their pet's body as well as aftercare for themselves in terms of seeking support for their own grief.
Finally, five respondents wished their clients understood that there was no "right" or "perfect time" to end their pet's life. While this relates to the quality-of-life theme discussed above, we are speaking here more directly to assuaging the psychological discomfort of their human clients (i.e., as a protection against feelings of guilt) rather than the pet's suffering. For example, one veterinarian wrote, Providing end of life care is a team effort and there is no right or wrong way for owners to approach it. We practice so that all owners feel comfortable with their choice and their pet is ALWAYS our priority throughout the entire process.
Another veterinarian wrote, I wish that all clients knew that there is no one magical, perfect 'right time' to euthanize their pet, and that guilt and sorrow are different emotions -while sorrow at a loss is normal, there is no need to feel guilt, shame, or blame at oneself for a decision to end another being's suffering.
As the latter quote shows, there is clear overlap among the information these veterinarians wish their clients knew before asking them to provide EOL care to their pets, demonstrating the many hats and roles veterinarians play in EOL care.

Most Challenging Aspects of Providing EOL Care
We asked veterinary professionals to describe the most challenging aspects of their work providing hospice and palliative care. Seventy-eight veterinarians responded, identifying one or more challenges they face. Given the nature of the IAAHPC membership, it is not surprising the most mentioned single theme revolves around the challenge of educating pet owners and veterinarians about the palliative and hospice care services they provide (mentioned by 19 respondents). This challenge is closely connected in veterinarians' comments to the challenge of being called too late to help suffering pets (mentioned by 13 respondents), not having enough time to spend with each client (mentioned by 13 respondents) and the challenge of operating a business (mentioned by 13 respondents), as exemplified by the following veterinarian's comment: The fact that it is a new, emerging field that is not well known or understood. Marketing and advertising must remain a strong focus for my business, rather than concentrating on the medicine. Also, the fact that I feel like an emergency ambulance driver many days as clients always wait until the last possible moment, when their pet is suffering and dying, and want me to come right away for euthanasia.
That veterinarians' challenges are multifaceted and thus transcend single classification are illustrated by the following which nicely exemplifies the dynamic and complex nature of veterinary care, particularly among those providing at-home EOL care: A lot of people who call me have been to another veterinarian who has told them that the animal is suffering and must be euthanized. Some are angry and want a second opinion, others are unsure what to do and some trust their vet. It is difficult to go to a house, have an animal meet you at the door and then have to euthanize it, because the vet said it was time. If the people are ready, it is different. Most people have not heard of hospice and I have to carefully educate them, some are understanding and wish more time, others have made the difficult decision and just want it to be over with.
Burnout and self-care were also mentioned frequently (17% of veterinarians who answered this question), typically as the only challenge identified by the respondent, using the fewest number of words: "the mental aspect"; "personal burn out"; "self-care"; "dealing with my sorrow"; "isolating"; "draining"; "compassion fatigue"; and "dealing with my sorrow." For those who provided more than a couple of words to describe the challenge of self-care the veterinarian's personality (e.g., "working as a person with a highly sensitive personality and being able to separate these emotions from personal time off"), the bonds they share with clients and pets (e.g., "emotional bonds with owners and becoming too attached with pets/owners"), and the difficulty managing clients' grief ("it can be draining when you put so much effort into families and dealing with their emotional well-being while trying to maintain your own") affects their ability to cope.
A final challenge expressed by veterinarians (8 of the respondents) involves the cost of providing comprehensive EOL care and how that balances against the human clients' perception of EOL care and its financial value. This clearly relates to the issue of burnout that is common among veterinarians, in general, but perhaps more pronounced among those offering at-home EOL services. For example, one veterinarian writes, convincing owners and other vets that what we offer is different then [sic] what they might think and it's not all about keeping pets alive at all cost no matter what til they die naturally or unassisted. that the services have value and they should expect to pay for our time. they will receive much more then [sic] they pay for. i wish i could dedicate myself entirely to this work and not have to worry so much about getting paid, unfortunately this work does not yet pay.
The financial rewards of providing veterinary EOL care was not highlighted by a single veterinarian in our study, which is perhaps why running their own business was also mentioned by 13 respondents as a challenging aspect of their work. This is further illustrated by a veterinarian who writes: Once I do have hospice clients, it is also much more labor intensive in the management of cases compared to euthanasia. There can be a great deal of follow up and consultation as such owners are clearly extremely attached and worried for their pet's comfort. At present I do not charge a fee for unlimited access to me (text/email) but am considering doing so.
The challenge of running your own business and managing the intensive labor required of EOL care is compounded by the general public's perception that veterinarians should be cheap or free because they love animals. One veterinarian counters this potential confusion with clients around cost by setting a fee structure beforehand so that "Finances are clear before I ever come to their house so I don't have to deal with the emotional drain of people telling me I should do things for free if I love animals."

Most Rewarding Aspects
Perhaps not surprising, relieving suffering and providing pets with a "good death" was the reward noted most frequently (38%) by the 80 veterinarians who answered this question, followed by the appreciation they are shown by the pets' families (29%). These two themes are illustrated by this veterinarian who wrote, By far the most personally rewarding is seeing the relief in the pet and when I come to help them transition. (Granted not every pet sees me this way!). This also transfers to the family. It is especially gratifying to hear owners say things like, ''that was so much better than I expected' or 'that was so peaceful' or "thank you so much for making this so much easier for us." A similar sentiment is articulated by the veterinarian who states, "The drain I take on is visible to my families. I have never been so respected or revered as I am by my families. I also know I have given the best death possible to my patients, who deserve nothing less." For most respondents, these themes overlapped and included references to enjoying seeing the human-animal bond, developing relationships with their clients and/or their clients' pets and providing palliative care that extends the quality time that pets and humans are able to spend together. The following veterinarian's comment best demonstrates the confluence of these myriad themes: The Providing EOL care in their clients' homes was explicitly mentioned by six veterinarians in our study as a rewarding part for them but a critical part of providing their human clients and their pets with a stress-free EOL experience. One veterinarian wrote, "I can see the benefit to the pet and to the client by helping them in their home without the stresses of that trip to the veterinary clinic. The clients are most appreciative that someone is willing/able to visit them at home."

Discussion
Veterinarians in our study seemed concerned about their clients feeling guilty about the EOL care they chose for their pets. Our respondents also expressed a desire for their human clients to have thought through the aftercare options-both in terms of the disposal of their animals' remains but also support options to deal with grief-which is consistent with O' Dair's (2015) suggestion that pet owners need to be made aware that support is available to them after death, in addition to making them aware of how to access it if necessary. If euthanasia is the EOL choice by the client and guilt is felt, the veterinarians in our study emphasize-as is consistent with previous research (Dickinson, 2014)-that euthanasia is the final gift the pet owner can give to the animal. And, as Paul notes (2019), euthanasia is the "last arrow" in the veterinarians' quiver.
Regarding Internet information being helpful or harmful for a client's knowledge regarding EOL issues, the respondents tended to feel that such information was usually helpful, though some misinformation exists. Some veterinarians note that their own websites helped to empower the clients before contacting them. A few veterinarians said their clients tended to not seek such information on the Internet. Certainly, Internet information for the most part would stimulate questions, if nothing else, for the client to ask the veterinarian when meeting.
What was it that veterinarians wish their clients understood regarding EOL issues before calling for an appointment? Grief was the largest concern expressed. As noted earlier, reactions to pet deaths do not differ significantly from human deaths, as pets are fictive kin, yet the veterinarians in our study seem to feel that their clients perceive their grief as abnormal. This is an area in which veterinary schools could include information in their curricula and/or offer workshops to deal with this topic. Our respondents report the most challenging aspects of providing palliative and hospice care is the lack of knowledge by clients regarding hospice and palliative care and the emotional needs of both the client and the veterinarian. Pet loss and grief management is a significant source of stress for veterinarians and contributes to compassion fatigue (Burfitt, 2019), necessitating additional training in this area.
Veterinary schools and veterinary tech programs could reduce this concern by providing more information regarding EOL issues. As previously noted, EOL issues are not a top priority in U.S. veterinary education. As palliative and hospice care with animals is relatively new, it simply is not common knowledge that such exists. The second author of this paper in researching veterinarians in England in 2013 learned that many of them had never heard of hospice with pets. Hopefully, they are better informed now. The IAAHPC in the United States has done an excellent job of broadcasting hospice and palliative care with animals.
Many of the issues identified in the literature and from these respondents can be addressed by the IAAHPC's certification program in animal hospice. The veterinarians and veterinary technicians in our study are very familiar with this certification and many have completed it. Overall, these respondents seem to feel rather positive and rewarded in their profession regarding palliative and hospice care with gratitude from their clients and a good feeling about helping to relieve suffering and helping pets to die peacefully. It should be noted that the decision to seek hospice care does not rule out euthanasia, as emphasis should be that a natural death is not necessarily the goal of animal hospice. Animal hospice offers and discusses all options openly, without judgement and with honesty to manage the reality with expectations (Gregersen, 2016).
Veterinary medicine is laden with practitioners who are passionate about science, nonhuman animals, and medicine. Being a good doctor, however, is not just about veterinary science, but it is also about understanding humans (Owens, 2015), a sentiment revealed in the responses of the veterinarians in our study. The strong association between pet owner's burden and measures of psychosocial function align closely with work in human caregiver relationships, and understanding the affective states motivating animal behavior is important to the clinician's effective case management (Spitznagel et al., 2017). To manage potential discomfort in interactions with clients, veterinarians must develop specific impression management strategies such as body language, spoken language, eye contact, and emotion labor (Hochschild, 1983). Veterinarians want to show their competence and make clients feel like they care about their animals; they do not want to be too emotional or not emotional enough when giving bad news, as giving bad news is one of the more complicated aspects of their interaction with clients.
Performing for clients is an interactional tool used to protect the professional self from potential threats toward a positively valued professional self (Hochschild, 1983).
Veterinarians use numerous strategies when interacting with clients who decide to euthanize companion animals, one of which is to protect the self by distancing through humor (Owens, 2015). The symbolic interactionist approach can be utilized when analyzing the interpretive processes veterinarians use when discussing with clients and situations in which the professional self is threatened. Veterinarians must learn how to protect their professional selves to cooperate with difficult people and can address this issue by building trusting relationships and providing performances to clients through verbal and nonverbal communication and becoming more comfortable (Goffman, 1959). The veterinarians in our sample of IAAHPC members seem to realize the importance of developing trust, showing concern about what it is their clients know before coming to them with an ill or dying pet.
They want their clients to understand that grief is normal, whether following the death of a Homo sapien or fictive kin with their pet. They want to know what their client knows about gauging the quality of life of their companion animal and they wish that pet owners would seek help regarding EOL issues sooner rather than later.

Conclusion
While we do not have the answers to the concerns of the veterinarians in this study, studies involving veterinary education reveal 75% of U.S. veterinarians surveyed agreed that veterinary schools should place more emphasis on communication skills with owners of terminally ill animals and only 33% of respondents felt well prepared by their veterinary training to deal with EOL issues (Dickinson et al., 2011). If such an orientation were emphasized more in veterinary schools, perhaps veterinarians would be equipped to better educate the public about their services and what knowledge they should strive to have prior to contacting their veterinarian about an EOL issue. Public relations with consumers might in the end assist clients of veterinarians to better handle the very emotional aspects of EOL issues with their pet. The websites of the veterinarians can provide accurate Internet information which could help to answer many of the queries the client might have and state information such as it is okay to grieve over the death of a beloved animal. The webpage could help the client to better understand how to gauge a pet's quality of life and how animals display pain. Additionally, the euthanasia process could be explained. Such sharing of information with the client could go a long way towards making this whole process more tolerable and less traumatic for both the client and the veterinarian (as well as the animal).
The generalizability of the findings reported here is limited given that the IAAHPC is a unique organization focused exclusively on EOL issues, education, and advocacy. On a personal note, the co-authors of this paper, being sociologists and not veterinarians, have been very favorably impressed with the compassion of veterinarians and veterinary tech professionals after attending the IAAHPC conferences in recent years. These professionals obviously love what they do, though the job is challenging and stress producing. There is information in the media citing various studies which show a high suicide rate among veterinarians in the U.S. Part of these findings are contributed to the fact that veterinarians must deal with EOL issues.
Though our sample is small, these reporting veterinary professionals seemingly receive much praise and gratitude from their work on EOL issues and find their profession to be most rewarding. Perhaps their knowledge gained and participation in the IAAHPC Conferences and workshops gives them needed support, though we have no data to support this. A future study comparing IAAHPC members with veterinary professionals not so affiliated would be worthwhile.