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Wednesday, October 12, 2011

Is Euthanasia Painful?

Stefanie sent me this email...
 
I have been reading "No Compromise" by Melody Green (a non-fiction book - an account of Keith Green's life and ministry) and towards the end - in just a very brief paragraph, it is discovered that Keith and Melody's dog becomes ill and they take it to the vet who tells them she has advanced cancer and the dog can either be euthanized at the vet office or taken home and shot. The vet strongly urged Keith to take it home and shoot the dog because it was more humane. I was a little taken aback by this and wondered - since this had happened in the early 80's - just how far humane euthanasia has come? I mean, were the injections given at that time painful or ineffective? 

Some of my older readers may be able to help with this.  I started working for a vet in 1984 and remember euthanasia as a simple, painless injection.  I had dogs euthanized before that, but wasn't present.  Still, I don't remember hearing it as a painful procedure.  Readers older than me may be able to give a different perspective.

The American Veterinary Medical Association does have guidelines for humane euthanasia of all animals.  Believe it or not, a properly aimed and delivered gunshot is considered a humane method of euthanasia.  However, you have to do it the right way and have the right caliber of gun in order to provide an instantaneous kill, and because of this I really don't recommend anyone trying it.  I've seen and heard of euthanasias attempted in this way going horribly wrong and the animal suffering.

For all of my studies and practice, euthanasia on companion animals is done by an intravenous injection of pentobarbital (sold under various brand names).  In more dilute solutions, pentobarbital can actually be used as anesthesia, though not really safe anymore compared to other modern drugs.  In human medicine it has been used to treat seizure conditions and similar brain disorders. The concentrated euthanasia solutions therefore induce a sudden and deep anesthesia, followed in seconds by cessation of brain activity and then heart activity.  Because we're basically overdosing the pet on anesthesia, they literally fall asleep and don't wake up, hence the common term "putting them to sleep". 

The procedure is generally considered quick and painless, no worse than being induced for anesthesia.  In most cases the only pain involved is the quick needle poke from the injection or IV catheter (which I prefer to do, especially if an owner wants to be present).  That doesn't mean that every case goes well.  I have had pets suddenly move, pulling the catheter or needle out of the vein (another reason I tend to use IV catheters, as this is less likely to happen), requiring a second poke.  Occasionally a pet will need a higher than normal dose, which is why I typically go ahead and give a little more than the calculated amount, and also keep the bottle in my lab coat pocket in case I need to give a little more.

Very rarely does the injection go horribly wrong. My worst experience was during a routine euthanasia on a cat.  As soon as I gave the injection the cat screamed, launched itself straight up off the table a full 1-2 feet in the air, and then landed on the table dead.  It happened suddenly, and I was at a loss.  It freaked me and the owner out, and I had no explanation for the sudden reaction seconds before death. In my so-far 14 years of practice that was the worst one, and I hope the only one like it.

The huge majority of euthanasias are smooth and quick, with the pet quietly passing away within 10-20 seconds of giving the injection.  Obviously this is the way we want it, as a dignified, peaceful exit from their life.  And that's the way I've observed this procedure for a little under 30 years.  If it wasn't so painless and easy, I wouldn't feel as comfortable doing it when the end of life comes.  But with the drugs available, it's a way to end suffering, not cause more.

23 comments:

  1. I agree that the most painful part appears to be the needle poke. We place catheters if owners a present, butterfly catheter if they don't. We do expired propofol first which works very quickly and I tend to give it fast to get quickly through (or skip over) the "excitement" phase of the anesthesia. Then I overdose them on the pentobarb. This is generally a very fast process. I think the propofol first helps to eliminate any potential pain, though I don't believe there is any. I don't know if I'd offer euthanasia if I believed it hurt.

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  2. A question got "The Other Vet".....how does proppfol "eliminate any potential pain"? As I'm sure sure you know, proppfol is an anesthetic, not an analgesic and has no effect on pain. It can never be given as the sole anesthetic in for painful surgeries or procedures; it must be combined with an analgesic. This is how it works in human medicine....I can't imagine it is different in veterinary medicine.

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  3. When I worked in the OR, patients complained bitterly about how much IV Propofol burned @ the onset. Some anesthesia providers mixed it with Xylocaine. If I were a client, I would certainly question why it would be administered first.

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  4. I had a vet euthanize my horse 10 years ago by cutting his throat. That is also considered a legal and humane way to euthanize an animal. I was not told before hand, so I was unprepared, there were still horses around as well. I can say that it was very traumatizing. I would much prefer an injection. In all the animals I've had euthanized that was the most horrifying.
    I've worked as a vet tech for 11 years and assisted many vets who had different methods, but never once have I seen one of their euthanasias be as traumatizing.

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  5. I'm kind of hoping for Dr. Chris's opinion on the propofol now :/

    And Nicole, that honestly sounds awful. Sorry you had to witness that. I have very little knowledge of veterinary practice, especially when it comes to large animals, but surely there's a better way than a knife to the throat? :(

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  6. I have to add that the other horses wouldn't go through the gate where the horse was killed. He was a draft horse and they have a lot of blood. I had to take down part of the fencing to get them out. I ended up having to have the ground dug up before the other horses would go near it.

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  7. For those readers who aren't aware, propofol is a very common anesthetic induction agent in human and veterinary medicine. In my practice it's our default induction medication because of its speed and safety. Personally, I love the stuff as it works very quickly, is eliminated from the body quickly, and can be titered to effect for short procedures.

    I know many vets who give propofol prior to euthanasia. The idea is that it induces light anesthesia, making the passage to death easier and with less disorientation. Personally, I've never seen a need for it. If a pet is truly so stressed that we can't give the euthanasia solution or put an IV catheter in, I'm going to give an intramuscular sedative such as Dexdomitor or Telazol. The patients I euthanize pass away within seconds in most cases, and do so very peacfully, which to me means that propofol isn't necessary. I've never given it and don't plan to start, but I don't begrudge those who do.

    Oh, and to Unknown, by definition "anesthesia" includes analgesia. So if a pet is truly anesthetized, there will be unconsciousness, amnesia (they don't remember the episode) and analgesia (lack of pain); this is the "textbook" definition of anesthesia. Propofol can give light anesthetic depths, and I will use it for quick suturing or small mass removals with a local anesthetic such as lidocaine. If your dosage of propofol isn't high enough, you won't get the analgesic component; however too much can be dangerous.

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  8. Propofol is NOT analgesic at any depth. It can produce general anesthesia at sufficient doses but if a human undergoes surgery with Propofol as the sole anesthetic, he will show signs of pain such as tachycardia, hypertension, and tachypnea. The fact that the patient is not awake to acknowledge the pain does not mean that the deleterious effects of the sympathetic surge caused by PAIN do not occur. Too much Propofol will cause respiratory and cardiovascular depression but that doesn't mean there is no pain.

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  9. Exsanguination ("bleeding out") is an acceptable means of routine euthanasia only after an animal is rendered unconscious. (I don't want people thinking that us horse vets just go around cutting throats.) Nicole, I'm sorry you had to be present for that procedure, I can only imagine how traumatic it was for you and his herdmates.

    I have had several equine patients have what I would consider a transient "panic" type reaction just as the pentobarb took effect. Due to this I prefer to sedate (and potentially even induce them into anesthesia) prior to administering the euthanasia solution in order to cut down or eliminate my patients' anxiety.

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  10. Unknown, I guess it depends on how we're defining "surgery", and how significant physiological differences are between species (which can indeed be very significant). I certainly would never do an invasive surgery such as a spay or neuter under propofol. However, I've performed plenty of small laceration repairs and mass removals without any of the physiological signs of pain (as you mentioned, tachycardia, tachypnia, etc.). Now, we can't ask our patients afterwards how they felt, but for minor "surgeries" (you may not consider such things as true surgeries since they are minimally invasive) I have seen no signs of pain when at an appropriate depth and dose of propofol. Again, this is not for major or invasive procedures (it's too short acting for these things in any case).

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  11. Yes, for minor procedures such as laceration repairs, WITH local anesthetic, propofol works well (in human anesthesia, it's called "local with" meaning local anesthesia with sedation) and these procedures are well tolerated because of the local anesthetic administration. Anesthesia for human surgeries of any length can be done with a continuous propofol infusion (as well as other anesthetic adjunctive medications). This is called TIVA (total intravenous anesthesia). The short-acting nature of propofol can be overcome by a constant infusion (and of course, appropriate monitoring by properly trained personnel).

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  12. JA-RN: While a burning sensation upon IV administration of propofol is a common side effect in humans, this is not the case in dogs. It's a species difference. IIRC from my small animal anesthesia rotation (long long ago), the original research in dogs and pigs did not predict that this would be a major complaint in humans. Animals aren't stoic about things like burning veins. Unlike humans, they tend to attempt to bite the catheter and/or handler. These are not commonly observed behaviors upon administration of propofol to veterinary patients.

    Nicole: Oh, dear, I'm sorry. Honestly, I think euthanasia should be humane for owners, too, and most of my colleagues and I make an effort to do so.

    When I euthanize a horse, I almost always sedate first with xylazine, a drug commonly used in horses from the same family as Dexdomitor. I do this for all euthanasias, but this is especially beneficial if it's an emergency situation and the horse is painful (e.g. colic, fracture, etc.). Xylazine has analgesic properties, in addition to being an agent of sedation and my first choice for pre-med prior to induction of general anesthesia. That said, I administer xylazine for sedation and a smoother drop, and sometimes for the purpose of relieving painful underlying conditions prior to euthanasia, NOT for pain associated with the euthanasia itself, which IME is painless. Do we know for certain that the moment of death by pentobarbital is painless? I don't know that anyone can accurately answer that question. Would gunshot or captive bolt be less painful? Theoretically (though marginally) yes, but only in the hands of a skilled person. Over the years, a handful of my hunter and/or farmer clients have shot their horses or livestock. I've never been present and usually hear after the fact, so I can't contribute any firsthand observations.

    On occasion, I have given a low dose of pentobarbital to several horses in status epilepticus (continuous active seizure). Again, I've never seen pain or distress associated with low-dose pentobarbital.

    The only time I've heard the argument that death via pentobarbital is inhumane is in discussions re: the death penalty. Obviously, I have no experience in the execution of humans. Unfortunately, however, one of my classmates committed suicide using pentobarbital, and this is not the only case of veterinary suicide via pentobarbital of which I am aware. Among veterinarians who commit suicide, many choose euthanasia solution. While I don't condone suicide, after observing hundreds if not thousands of (animal) deaths over the years, I understand why a veterinarian might select euthanasia solution as a method of suicide: quick, reliable, clean (for the one who discovers the body).

    Though I haven't read the book that inspired this question, I'd speculate that the writer has an agenda that has nothing to do with the euthanasia of companion animals. If her veterinarian actually advised her husband to shoot their dog, I think this was irresponsible at best, and possibly worthy of discipline by the board of registration in veterinary medicine.

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  13. I want to say thank you for everyones kind words.
    I wanted to add that my horse was old, pushing 30, had been battling cushings, and one morning he went down and couldn't get up. Even when we got him up he went back down. It was definitely time. After the fact the vet told me he thought the horse was "out of it" enough that he didn't need sedation.

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    1. UNBELIEVABLE !!! I Hope he receives the same considerate care in his final moments! What he meant was "the horse was so incapacitated that he couldn't resist, so he was free to kill him in the most convenient way to himself"! I would have had him arrested! That was NOT euthanasia ! And he suffered terribly, from pain and the shear terror of slowly choking to death on his own blood! This vet should be arrested !

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  14. Maybe mid-80s - there was a back order of Euthasol? I know that it happened sometime in the past 20 years, and veterinarians were forced to rely on KCl and other methods for euthanasia.

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  15. Unknown: As Dr. Bern noted, the propfol is an anesthetic. I will admit that the nerves still sense pain, but because the pet is anesthetized, they are not aware of it. Never had one so much as flinch at the propfol and I too was taught it wasn't painful to inject if you've got a good IV catheter in. Not only that, but I can see why it wouldn't be a sole anesthetic agent for an animal that will be waking up just because the nerves are still sensitized to pain. Hence why we use medications for pain control prior to induction in our routine anesthetic protocol but not in our euthanasias. The deleterious effects of propofol you speak of, as I am aware, really only matter to those waking up afterwards. If I for a second thought it was painful or found a "better" protocol, we'd change.

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  16. we just put down our mini Schnauzer. He was ready to go. He'd been living with a bad heart for two and a half years. And was unable to eat or drink at the end. We did an in home Euthanasia. We tried to give him a good life and a dignified death. But after the Dr. released the drug into his system he sat up and cried and acted like his leg was hurt. We felt like we had botched his death. It was traumatizing and horrible to witness.

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  17. I just came across this question because our 5 year old Schnauzer, Bix, has cancer and it looks like it is "time"...
    I'm super concerned about it because his father, Gus, had cancer (nasal tumor) last year and he was executed by the vet (our previous vet died and this one had taken over his practice.) My husband went with Gus (I could not handle it) and just last week my husband told me it was HORRIBLE!! and my poor Gus suffered terribly before his death! He still won't tell me the details, but he has handled many of our animal's deaths and never saw anything like it. (I have PTSD and if I had been the one to take Gus in, they would have had to put me in the hospital if I witnessed that!) I talked to the front office staff in that office and found out that vet routinely does not give any sedative before the injection! I'm making an appointment to talk to that vet soon.

    The thought of having to take Bix in, even to the new vet (who does sedate) is making me ill! Especially since he is my husband's dog...and he witnessed Gus' death that way! It's just making the whole sad situation worse. I wish there were some guarantees that it would be painless...but I guess that can't be done.

    oicoicoic, I am so sorry about your Schnauzer. I can certain sympathize.

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    1. I am so sorry Nina about your Gus.:(

      The same thing happened to our sweet Neddy who we took in last October 29, 2012 and the PTSD and guilt has been enormous. She lived 15.5 years with a gentle hand and her last moment was not good, no need to go into detail. My son and I stayed with her to comfort her. I don't regret that part but we are left with the nightmares and guilt. I also will be talking to the vet because Ned's sister Caroline is 16 and have other furs to consider. I will expect and demand some sort of sedative/anesthesia from now on. I didn't even know it had to be asked for in this day and age.

      My Pom Daniel was sedated and there was no incident at all with him, he appeared to leave this life peacefully. The sedation makes a world of difference both for the furkid and the pawrents.

      BTW, I do agree with the well-placed bullet as humane, but it's illegal in the city.

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  18. I have had to put down a good few horses, dogs, and cats in my life. To be honest with you from my own experience I believe a well place bullet is much more humane than the pink needle.

    With horses a shot from a 45 caliber pistol is more than adequate. To put them down with no twitching or contorting. Its instant. Head on at point blank range aim one inch above the eyes in the center. This penetrates the brain and the spinal cord directly behind the head.

    With even a large dog a 22 caliber stinger or hollow point works quickly. In my experience with dogs they have been my companions and I could not look them in the eye as I pulled the trigger so I did it from behind. More execution style. I know this sounds awful but hear me out. Aimed directly below the smart knot or base of the skull you would need to angle the shot so it penetrates the brain. This provides instant death.

    I have seen animals euthanized by drug and its not nice at all. From my experience its not like going to sleep at all. Even with a sedative prior to the euthanasia it looks like they are fighting for their lives. I'm no vet but will tell you what I see happen. First they start to twitch then its like they are fighting for air. I guess it just shuts down their nervous system. Given all this happens in 15-25 seconds it seems like an eternity when your watching your friend die. With a well placed bullet you can end theirs pain in one quick shot. Its like flipping a light switch. Its instant.

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    1. We've seen in the "execution" video made by Tim Sappington (formerly of Valley Meats, who have applied to be the first horse slaughterhouse in the US since 2007) there is considerable "twitching" and involuntary movements after being shot in the head. I've always watched numerous videos taken in horse slaughterhouses and very few of those horses shot with a rifle ceased involuntary movements until several minutes after being shot. I have never seen any of my animals - horses, dogs, cats pass away in any manner other than peacefully when sedated and euthanized by injection.

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  19. The problem with a bullet is that it has to be well-placed. The AVMA recognizes a gunshot as a potentially humane way of euthanasia. However, there are tons of stories of this going wrong and the pet suffering. Also, most people don't want to shoot their own pet and see the blood and trauma.

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  20. I had to put my beloved cat down (high grade lymphoma with massive liver enlargement and ascites). I had no concern about the final IV pentobarb or whatever. But before giving that one, she gave a sedation injection in the hind-leg that seemed painful. She asked me to hold him tightly during the injection and he struggled for a moment. Then he relaxed. Then a second struggle right as he went off to sleep. I wondered if what she gave was ketamine, asked specifically about that & she said, "something like it". It's been torturing me as I've been replaying the scene over in my mind during the two weeks since having that dreadful duty. I really loved that cat & miss him every day.

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