What questions to ask your patient: Guidelines for the medical team

13

Respect for and recognition of the important role the animal plays in the life of his caregiver must be reflected in the way the veterinarian communicates with his client and be incorporated into all aspects of care offered.
By Dr. vet.. Alexandra L. Winter, USA

The veterinarian’s ability to communicate in clear and understandable yet compassionate terms helps the pet owner to make sense of the often very complex medical information and the options available for treatment. He or she must present all necessary information and options in order to enable the client to make the best decisions for their pet, not based solely on his illness, but also his quality of life.

How the healthcare team communicates and responds to a client’s grief after the loss of a pet can in fact be a key factor in the client’s continued loyalty to the practice.

Form: How you communicate

13.1

  • Ask the right questions concerning the needs and goals for the pet owner.
  • Listen to the dog owner’s concerns.
  • Inform the dog owner in a comprehensible manner of how to provide the best care for his pet.
  • Discuss and elaborate a personalized written treatment plan for the client.
  • Listen to and respect the dog owner’s decisions.
  • Communicate with empathy and show comprehension for your client’s emotionally strong reactions.
  • Be a contact person and partner for your client and his/her animal.

Training in such effective, helpful and empathetic communication should be incorporated as a core component of veterinary professional education.

The veterinarian should describe the diagnosis, tests and therapies in a language that the client can understand and minimize the use of clinical terminology, abbreviations, or acronyms that can be overwhelming or intimidating to the client.

Although the client’s medical knowledge may be limited, if the veterinary team explains outcomes clearly and completely, in understandable language accompanied with written hand-outs, the client can still make informed decisions and exercise control over their pet’s treatment plan. 

Conversations about EOL (the end-of-life stage), death, and grief with a bereaved dog owner are never easy, especially when urgent measures have to be taken immediately. Therefore: 

The veterinarian should take his time to listen and ask open-ended and empathetic questions.

Open and empathetic communication

13.1.1

Here are some open-ended and empathetic questions showing interest:

  • What are your concerns?
  • How do you feel?
  • Are you overwhelmed by the diagnosis?
  • To what extent will you be able to accept the caretaker’s burden?

Reflective listening:
Reflective listening is a technique involving repeating what clients say or suggest, thus showing interest in their thoughts and feelings, and making sure that you have understood their concerns. By paraphrasing clients’ meaning, you show empathy and clarify their understanding.

You may start these responses with standard phrases such as “So, you’re saying that…” and “It sounds like…” Reflective listening can also be communicated non-verbally, with nods and smiles, thus acknowledging what has been heard.

If you want a pet owner to expound without your input, try repeating the client’s last word or phrase. If a client says, “Alice has just been acting crazy,” you may respond with a simple, “Crazy?” The pet owner will instinctively elaborate for you.

Resource:
→ CLIENT COMMUNICATION: A PROCEDURE YOU CAN MASTER

Supportive communication

13.1.2

The following chart illustrates an integrated approach to supporting a caretaker who is experiencing a negative diagnosis or bereavement over the loss of their pet. 

  1. The four client support roles (left box) can be taken on by the attending veterinarian or delegated among members of the veterinary healthcare team.
  2. All healthcare team members should observe the client support principles (right box) when taking on any of the support roles.
  3. Certain phrases should be avoided (bottom box) because they may not be true, the client may not agree, or they represent a commitment that the veterinarian may not be able to keep.

 

What to avoid when communicating with the caregiver

13.1.3

Verbal communication

  1. Excessive use of complex vocabulary, jargon and/or abbreviations.
  2. Incorrect pronunciation of words.
  3. Too much information or too little information.
  4. Unclear or contradictory messages.
  5. Speaking too quickly.

Non-verbal communication (how you deliver the message)

  1. Lack of eye contact.
  2. Non-supportive or disinterested facial expressions.
  3. Inappropriate gestures and/or body posture.
  4. Busy, noisy environments.
  5. Lack of enthusiasm or empathy in facial expression.
  6. Emotionless, mechanical or flat voice tone or body language.
  7. Fidgeting with a pen, the computer etc. during the discussion.
  8. Distractions from your conversation (phone call, questions from healthcare team etc.).
  9. Not noticing that the listener loses focus of the message
  10. Distracting filler words: Um’s, Ah’s & Urrs; slang, cursing.

How to improve communication skills with the caregiver

13.1.4

Non-verbal communication

  • You can enhance effective communication by using open body language: Arms uncrossed, standing with an open stance or sitting on the edge of your seat, maintaining eye contact with the person you’re talking to.
  • The tone of your voice should be different when you’re addressing a child than when you’re addressing adults. 
  • Take into account the emotional state and cultural background and beliefs of the person you’re interacting with.
  • Consider age and gender.

Verbal communication

  • Develop and provide client education in a clear and accurate manner, at a level a non-expert understands (i.e., oral and written form, including educational handouts which can be reread at home).
  • Give a small portion of the information at a time and then check in with the client to see how he or she is doing.

For example: “Whether a dog develops hip dysplasia is influenced by many things. It might be due to genetics, something in the environment, or even diet. So it’s possible that your dog may even be the only dog from his litter to have clinical signs of hip dysplasia.”

= TOO MUCH INFORMATION IN ONE CHUNK!

  • Speak slowly and in terms clients will understand: Keep in mind that the information is new to them and that medical terminology is frequently like a foreign language.
  • Use open-ended questions: How, when, why, where …?

What are “open-ended questions?

13.1.5

Close-ended questions are yes-or-no-questions. To really build a relationship with your client, you need more than a one-word answer—which means you need to ask an open-ended question. Then you can ask follow-up questions using either method, depending on what has piqued your interest. With yes-or-no questions you could cut the conversation short, leaving you with an incomplete evaluation.

•••••••••••••••••••••••
1. Relationship-building questions

These questions help the veterinarian to get to know the caretaker and get a clearer picture of the pet's general environment. These informal, open-ended questions also relax the atmosphere.

  • How did you decide on your pet's name?
  • Tell me about Alice's typical day.
  • Tell me a bit about your household. What activities do your family members do? Who lives there? What other pets do you have?
  • Tell me about where you live. Are there stairs? A fenced yard? Where does Alice sleep? 

•••••••••••••••••••••••
2. Questions assessing the caretaker’s needs and concerns
These questions help find out what the caregiver is looking for. For example, does he or she want peace of mind, comfort, or a financial estimate?

  • What concerns you the most about Alice?
  • How does Alice's problem affect the activity and living conditions in your home? 

•••••••••••••••••••••••
3. Questions probing the pet's needs

With these questions, you're pinpointing changes in the pet's life. What does the animal need now? These questions also help clients understand that their pet goes through different life stages.

  • What changes have you seen in Alice in the last year? Eating habits, activity level, sleeping habits, playfulness?
  • What are Alice's favourite foods?
  • What does Alice do for exercise? Have you seen any changes in her energy level?
  • What other people/pets does Alice come in contact with?

How to discuss bad news with the pet caregiver

13.1.6

  • Choose a quiet place. Ensure there will be no distractions.
  • Provide a preliminary warning (e.g:“I have difficult news to share”).
  • Be attentive to your own and your client’s nonverbal messages.
  • Make eye contact.
  • Sit at the client’s level, but not too familiarly: think about the social status of the person in front of you: he/she is a client.
  • Respond appropriately and facilitate a discussion on the bad news (e.g. “I see that this is shocking to you. Should I go on or do you need a moment?”).
  • Finish with a plan for the next contact. Give the caretaker a handout with a summary of the information given. 

Did the pet caretaker understand the information?

  • Offer to help the caretaker to understand the extent of the bad news: “Do you want to go through it once again so I can help you with anything that you are unclear about?”
  • Encourage clients to ask questions by reassuring them that confused reactions are normal: “This is a pretty complex topic, and most people have many questions about it. It is pretty challenging to explain, too, so I want to make sure we are on the same page. Do you have any questions?”
  • Provide handout information to take home. Presentations using visual and written aids are 43 percent more persuasive then unaided presentations.

Timing the discussion with the caregiver

13.1.7

The best time to discuss the pet’s disease with the client is not necessarily when the individual has just been informed of a terminal or progressive-disease diagnosis for their furry friend. Depending on the degree of attachment between the pet and its owner, the impact of such news will often evoke a strong emotional reaction. Practitioners should anticipate this reaction, respond to it by expressing empathy, and consider setting up a follow-up appointment to discuss EOL treatment options. This gives the owner time to come to terms with the new reality and to participate more fully in the development of a realistic, mutually acceptable treatment plan.


Provide handout information to take home. This way the caretaker can prepare himself for the follow-up visit and ask appropriate questions.


The follow-up visit is then an opportunity for a two-way information exchange between the veterinarian and client. An effective approach for conducting an EOL follow-up discussion is to schedule the appointment so as to give the veterinarian and caretaker time for an uninterrupted, open-ended discussion.


The client should be invited to ask questions and should not feel rushed or pressured into making treatment decisions. Regardless of the decisions that are made, the client should never feel judged.

Checklist for the discussion with the pet caregiver

13.1.8

It is often helpful for both the veterinarian and the caretaker to have a checklist of questions to ask and issues to discuss. The following chart provides a list of issues to discuss with the caretaker when an EOL or palliative care treatment plan is developed. Such a chart could also serve as a helpful handout for the client.

Practical Issues in Implementing a Palliative or EOL Care Plan:

 Issue

 Topics to Discuss with Client

Treatment locations

  • Division between in-hospital and home care
  • Maximizing home care
  • Frequency and time points for physical exams and treatment

Individual responsibilities

  • Specify who will provide palliative and end-of-life services

Client education

  • Specifics of client information on administering palliative home care
  • Hands-on instruction on specific home care tasks
  • Assessing client willingness and proficiency to provide home care

Environmental modifications

  • Photos or videos of home environment to assess suitability for home care
  • Home modifications to ensure patient comfort and safety
  • Other family members or pets in the household

Owner safety and hygiene

  • Responding to pet’s incontinence
  • Managing secretions from non-healing lesions
  • Safe handling of pet’s medications
  • Safe and humane handling of pet with acute or chronic pain
  • Prevention of bite injury

Periodic plan assessments

  • Avoidance of pet suffering due to compliance shortfalls or lack of response to treatment
  • Ongoing assessment of pet’s quality of life (physical, social and emotional)
  • Client input and impressions of plan efficacy
  • Video documentation of pet’s behaviour in the home environment
  • Veterinarian’s assessment of plan
    efficiency
  • Plan modifications and re-statement of prognosis and expectations

Medication, nutrition, and activity review and assessment

  • Evaluate extent of pet owner compliance and plan deviations
  • Revise palliative and EOL care interventions
  • Consider advisability of euthanasia or assisted natural death

How to discuss death with the caregiver?

13.1.9

It is the veterinarian’s duty to recommend humane euthanasia to relieve the patient’s suffering when palliative care no longer meets the animal’s physical, social, or emotional needs.
However, for some pet owners, euthanasia may not be an acceptable procedure. In such cases, high-dose palliative sedation combined with adequate analgesia is an ethical alternative = supported natural death.
An ongoing empathetic dialogue with the pet owner is essential during this stage in order to adequately communicate to the caretaker what to anticipate with the dying process as well as the post-mortem duties.

  • Never rush the process—clients want, and need, your undivided attention and you have an obligation to give it to them.
  • Consider the use of language: Subtle word differences can have a huge impact. Instead of saying, “When you are ready,” say “When you are as ready as you can be.”

 

The following communication guidelines will help the veterinary healthcare team to engage in ethical, collaborative EOL decision-making:

  1. Take your time to discuss calmly all euthanasia and natural-death options with the pet owner (do not exclude or minimize any single option). This is an extremely stressful and painful time for the dog owner and this is not the time to rush because the waiting room is full.
  2. Recognize that while many pet owners rely on the veterinarian’s recommendation for the best approach to their pet’s end of life, others prefer to take the primary decision-making role.
  3. Describe the options to pet owners in language they can understand.
  4. Describe the options in a factual and non-judgmental manner, articulating pros and cons of each option.
  5. Avoid a biased presentation of information designed to steer a client’s choices in the direction of the veterinarian’s preferences.
  6. Summarize the pet owner’s decision to make sure you have understood and support this decision for their pet, accepting that their values and beliefs may be different from the veterinarian’s.

Content: Give practical, helpful, hands-on information

13.2

It is helpful for the bereaved pet owner to express their emotions to an empathetic listener, the medical team. Regular, empathetic communication is the hallmark of effective support of the dog owner during EOL treatment and also after a patient’s death. The veterinary healthcare team has a responsibility to see the EOL case experience through the client’s eyes and take enough time to provide non-judgmental support.

Informing dog owners about the patient’s disease and possible out-come is particularly important in end-of-life cases. The more the caregiver understands about the disease progression, the better he or she will be able to cope with their expanded EOL caregiving role. The veterinarian should advise the client about the expected trajectory of the pet’s disease. This should include a thorough discussion of diagnostic and treatment options, interventions to ensure the pet’s comfort, and a realistic prognosis.

One of the major goals is for the pet owner to have a clear understanding of all diagnostic and treatment options. Decisions on EOL care should be made only when the pet owner has achieved a clear understanding of the situation and the options.

A thorough description of each diagnostic test, treatments and therapy, including how the results will influence patient care, will allow the dog owner to make an informed choice about whether or not to authorize the recommended procedure. It will also enable the dog owner to ask the right questions.

 

What do clients expect from the veterinarian

  • Give detailed information on the future scenario of what will actually happen during the 4 stages, diagnosis, treatment, end-of-life care and death, in order to prepare the caregiver intellectually and psychologically. Being aware of what will happen will attenuate the shock and immense grief, thus mean less caretaker’s burden.
  • Give a detailed diagnostic of the dog’s symptoms and list what other reasons could be the origin for certain symptoms. The caregiver has to be given the certainty that all diagnostic possibilities have been exploited to find the correct diagnosis.
  • If in doubt, offer other detection techniques (x-ray, ultra-sound…) to make the diagnosis even more precise. It will give the patient the reassuring feeling that all possibilities in favour of a correct diagnosis have been exploited. Explain how and why these screening techniques will be used.
  • Inform the caregiver in detail about these detection techniques and the course of these techniques in simple terms.
  • Offer the possibility of a 2nd opinion by another veterinarian or specialist if in doubt.
  • Give detailed information about the unwinding of the future treatments and therapy.
  • Give detailed information on how the dog might develop due to these treatments, what new symptoms he might show and at approx. what time period. What can be done to relieve the dog if needed? Why are these treatments necessary? What are the aims, risks, side effects etc.? The caregiver wants detailed and realistic information.
  • Give detailed and realistic information on the course of end-of-life stages in the caregiver’s dog:
  1. Which stages will the dog go through?
  2. How exactly will the dog’s health evolve and what will the new symptoms and reactions be?
  3. How much time approx. will remain?
  4. How will his quality of life evolve?
  5. What will the scenario of declining quality of life be like?
  6. What will the dying-scenario look like?
  7. Which medication will help the dog to peacefully go through his last hours of life before his natural death? Or when will euthanasia be necessary?
  8. Offer practical hands-on help and material preparation for the care at home to overcome the new situation (for example, in the event of incontinence, loss of movement, pain-management, rattle-noise during the dying stage etc.)

  • Give the client information, in an empathetic manner, that includes the cost of services and alternative choices and avoids giving false hope.

 

Resources and further readings
→ AAHA/IAAHPC End-of-Life Care Guidelines for Dogs and Cats (PDF)
→ AAHA/IAAHPC End-of-Life Care Guidelines
→ Communication Solutions For Veterinarians, Wendy Myers
Textbook: Client Satisfaction Pays ,Dr. Carin A Smith, AAHA Press.
→ Veterinary Communication websit
→ Magazine: Veterinary Team Brief
→ Key Communication Techniques for the 7/27/2014 Veterinary Health Care Team