All pet owners are not the same

Sara Hoummady, Laureline Chaise, Marion Guillot, Nancy Rebout

► To cite this version:

Sara Hoummady, Laureline Chaise, Marion Guillot, Nancy Rebout. All pet owners are not the same. Topics in Companion Animal Medicine, 2025, 65, pp.100960. 10.1016/j.tcam.2025.100960. hal-04949115

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Research Article

# All pet owners are not the same: End-of-Life caregiver expectations and profiles.

Sara Hoummady<sup>a, ∗</sup>, Laureline Chaise<sup>b</sup>, Marion Guillot<sup>c</sup>, Nancy Rebout<sup>d, ∗</sup>

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ARTICLE INFO

Keywords:

End-of-life

Euthanasia

Dogs

Cats

Human-animal interaction

Veterinarian education

Grief

A B S T R A C T

The study aims to explore the specific needs of French pet owners who have experienced the loss of a pet, recognizing the limited focus on end-of-life and palliative care in veterinary practice. By characterizing owner profiles, the research seeks to enhance veterinary approaches and education to better address the unique challenges and emotional aspects associated with pet care and loss. An anonymous online survey was distributed to 302 French owners who already experienced the loss of an animal, including demographic information and feelings about their experience of a pet's end-of-life (EOL). Data were analysed using descriptive and qualitative analysis (including the use of AI chatbot ChatGPT). 56.6% of participants reported a relatively smooth pet death, yet 67.0% found the end-of-life period challenging. Three distinct owner groups emerged, each with varying needs. The first group expressed high guilt and a greater need for support, emphasizing the necessity for information and improved training. The second group, more informed and independent, benefits from veterinary support, while a leaflet suits them. The third group, competent in pain evaluation, requires less veterinary support. These differences highlight the importance of personalized owner support. The study proposes essential pillars for veterinarians and nurses' training, forming the EPITO system: Emotional support, Personalization, Information, Training, Tools, and Open discussion.

Introduction

The extended life expectancy of pet dogs¹ has led to a burgeoning interest in geriatric medicine, introducing concepts like frailty adapted from human geriatric medicine to dogs.²,³ Despite this, end-of-life and palliative care in veterinary practice are relatively recent areas of focus. The International Association for Animal Hospice and Palliative Care, established in 2009, has limited representation in Europe, and guidelines were only published in 2016.⁴ The subject is sparse in French veterinary literature, highlighting the need for more in-depth study. In human medicine, cultural differences impact end-of-life therapies (EOL),⁵ underscoring the importance of understanding such variations in veterinary care.

Animal palliative care, as defined by Loscos and Marignac, is considered as “*the support of a dog or a cat with a life threatening disease, intended to treat clinical symptoms, pain and suffering without curing the*

patient, giving its quality of life a high priority.”⁶ Palliative care must be differentiated from hospice care, which is a program that addresses the physical, emotional, and social needs of animals in the advanced stages of a disease.⁴ Palliative care can be applied to curable or chronic conditions, as well as end-of-life situations, whereas hospice care is provided from the time of a terminal diagnosis until death.⁴ These approaches prioritize the well-being of pets and caregivers, considering physical, psychological, and social aspects.⁷ Effective communication between the veterinary team and caregivers, at every step (during the diagnosis of a terminal condition, just before euthanasia, during euthanasia) is crucial, requiring an understanding of psychological and emotional consequences.⁸ The aim is to make the end-of-life experience positive for both the owner and the animal. Emotional support is vital throughout the hospice and palliative period and extends beyond the pet's death. The grieving process for pet loss, often equivalent to human loss,⁹ presents unique challenges, including their shorter lifespan, the presence of

<footnote><sup>a</sup> Institut Polytechnique UniLaSalle, Transformations et Agro-Ressources, ULR 7519, Université d'Artois, Collège vétérinaire76130 Mont-Saint-Aignan, France.</footnote>

<footnote><sup>b</sup> Hex-Data, 69400 Villefranche-sur-Saône, France.</footnote>

<footnote><sup>c</sup> Territoires et Société, VetAgro Sup, Clermont-Ferrand, France.</footnote>

<footnote><sup>d</sup> Université Clermont Auvergne, INRAE, VetAgro Sup, UMR Herbivores, F-63122 Saint-Genès-Champanelle, France.</footnote>

<footnote>* Corresponding author at: Université Clermont Auvergne, INRAE, VetAgro Sup, UMR Herbivores, F-63122 Saint-Genès-Champanelle, France
*E-mail addresses:* sara.hoummady@unilasalle.fr (S. Hoummady), laureline@hex-data.io (L. Chaise), marion.guillot@vetagro-sup.fr (M. Guillot), nancy.rebout@vetagro-sup.fr (N. Rebout).</footnote>
anticipatory grief (grief can be anticipated from the start of the pet-human relationship),¹⁰⁻¹² and the repeated experience of bereavement in the case of multiple pets. Pet loss also differs from human loss due to the experience of euthanasia decisions: owners are real decision-makers in the death of their animals, often associated with the guilt of the decision.¹³,¹⁴

"Disenfranchised grief" describes the often overlooked grief experienced by pet owners, as society may not readily acknowledge it and owners often do not get the emotional support they need because their family members or friends do not feel this experience as legitimate.⁷ Veterinary students receive limited education on grief and end-of-life management,¹⁵ despite the increasing recognition of its importance. The gap between the limited curriculum hours and the growing body of research highlighting the association between inhibited post-traumatic grief and pet loss suggests a need for enhanced teaching in veterinary programs.¹⁶ The need for improved teaching on grief and end-of-life management for veterinary students has been recognised,¹⁷ and an increasing number of universities are adapting their programs for this purpose.¹⁸ Recognizing individual needs in hospice and palliative care aligns with the era of precision medicine, emphasizing tailored approaches for pet owners. To bridge this gap, understanding owner needs is crucial, allowing universities to adapt programs and train practitioners accordingly.

The purpose of this study is to delve deeper into the real needs of owners within the French population, with the objective to characterise the profile of pet owners regarding their needs to better assist veterinarians in adapting their approaches.

## Materials and methods

### The questionnaire

A 15-item questionnaire was distributed (three open-ended questions, six multiple-choice questions and six questions on a Likert scale of 1 to 5; Table 1). The aim was to assess satisfaction with end-of-life support, to identify the nature of this support (whether medical or emotional), to identify the essential elements associated with the process and to solicit opinions on aspects of end-of-life support that might be missing or inadequate. This questionnaire was distributed mainly via social networks, in particular LinkedIn in the first instance and Facebook in the second instance.

It was possible for participants to respond multiple times if they had contrasting experiences with different pets regarding the end-of-life journey. However, in compliance with GDPR regulations, we did not implement any mechanism to track or identify participants who may have responded multiple times. This choice prioritised data privacy and anonymity, but at the same time limits our ability to confirm whether some responses came from the same individual.

### Descriptive statistics

For each question (other than 14 to 15), we provide descriptive statistics, i.e. numbers and percentages of answers. In order to analyse the major axes of variability in our dataset for the quantitative variables and also detect distinct "types" of owners that may be contrasted in their end of life, Principal Component Analysis (PCA) followed by cluster analysis were used. This analysis was carried out on six questions formulated according to the Likert scale (questions 6, 8, 9, 10, 11 and 12) using the PCA function from the FactoMineR package¹⁹ in the R software version 4.3.1 (R Core Team, 2023). Following the PCA, we performed an Ascending Hierarchical Clustering (AHC) using the hcpc function from the FactoMineR package in R. This method aims to detect and define groups of individuals with similar responses. It enabled us to determine the number of clusters formed and to characterise their nature. The desc.var output was used to offer a quantitative description of the clusters. This output provided, for each significant variable, both the

<table><caption>**Table 1**
Summaries of respondents' answers to the questionnaire by question.</caption><thead><tr><th>Questions (scale and headcount)</th><th>Options</th><th>Total number</th><th>Percentage (%)</th></tr></thead><tbody><tr><td rowspan="10">Question 1 "What country are you from?" (n = 324)</td><td>England</td><td>2</td><td>0.617284</td></tr><tr><td>Belgium</td><td>6</td><td>1.851852</td></tr><tr><td>Canada</td><td>4</td><td>1.234568</td></tr><tr><td>Spain</td><td>1</td><td>0.308642</td></tr><tr><td>France</td><td>302</td><td>93.209877</td></tr><tr><td>Luxembourg</td><td>1</td><td>0.308642</td></tr><tr><td>New Caledonia</td><td>1</td><td>0.308642</td></tr><tr><td>Switzerland</td><td>6</td><td>1.851852</td></tr><tr><td>NA</td><td>1</td><td>0.308642</td></tr><tr><td rowspan="3">Question 2 "Where do you live?" (n = 302)</td><td>In the country</td><td>183</td><td>60.59603</td></tr><tr><td>In the city</td><td>119</td><td>39.40397</td></tr><tr><td>No</td><td>10</td><td>3.311258</td></tr><tr><td>Question 3 "Have you ever lost at least one pet/have you ever experienced the death of a pet?" (n = 302)</td><td>Yes</td><td>292</td><td>96.688742</td></tr><tr><td rowspan="6">Question 4 "How did your experience go?" (n = 297)</td><td>Good</td><td>168</td><td>56.56566</td></tr><tr><td>Badly</td><td>129</td><td>43.43434</td></tr><tr><td>cat</td><td>120</td><td>39.867110</td></tr><tr><td>dog</td><td>139</td><td>46.179402</td></tr><tr><td>horse</td><td>21</td><td>6.976744</td></tr><tr><td>New pets</td><td>21</td><td>6.976744</td></tr><tr><td rowspan="5">Question 5 "What type of pet did you have?" (n = 301)</td><td>1</td><td>110</td><td>36.666667</td></tr><tr><td>2</td><td>91</td><td>30.3333333</td></tr><tr><td>3</td><td>70</td><td>23.3333333</td></tr><tr><td>4</td><td>27</td><td>9.0000000</td></tr><tr><td>5</td><td>2</td><td>6.6666667</td></tr><tr><td rowspan="5">Question 7 "Did you feel sufficiently supported at the end of your pet's life?" (n = 298)</td><td>Good emotional and medical support</td><td>90</td><td>30.201342</td></tr><tr><td>Good emotional support and little medical support</td><td>15</td><td>5.033557</td></tr><tr><td>Good medical support and little emotional support</td><td>104</td><td>34.899329</td></tr><tr><td>Little emotional and medical support</td><td>89</td><td>29.865772</td></tr><tr><td>Question 8 "Do you think an information leaflet from your vet with points to discuss with him/her would be useful?" (scale from "1: Very bad" to "5: Very good"; n = 300)</td><td>1</td><td>8</td><td>2.649007</td></tr><tr><td rowspan="5">Question 9 "What is your main reaction when faced with a difficult situation, such as the announcement of an incurable disease?" (scale from "1: You ask your interlocutor the questions you have directly" to "5: The questions don't come to you at the time and you think about them later when you get home"; n = 302)</td><td>2</td><td>15</td><td>4.966887</td></tr><tr><td>3</td><td>43</td><td>14.238411</td></tr><tr><td>4</td><td>66</td><td>21.854305</td></tr><tr><td>5</td><td>170</td><td>56.291391</td></tr><tr><td>1</td><td>59</td><td>19.53642</td></tr><tr><td rowspan="5">Question 10 "Do you feel able to assess your pet's physical and emotional pain/discomfort?" (scale from "1: Strongly disagree" to "5: Strongly agree"; n = 299)</td><td>2</td><td>44</td><td>14.56954</td></tr><tr><td>3</td><td>68</td><td>22.51656</td></tr><tr><td>4</td><td>75</td><td>24.83444</td></tr><tr><td>5</td><td>56</td><td>18.54305</td></tr><tr><td>1</td><td>85</td><td>29.72028</td></tr><tr><td rowspan="5">Question 11 "When deciding whether or not to euthanize your pet, how did you feel?" (scale from "1: Supported/legitimate" to "5: Guilt-ridden/guilty"; n = 286)</td><td>2</td><td>53</td><td>18.53147</td></tr><tr><td>3</td><td>70</td><td>24.47552</td></tr><tr><td>4</td><td>38</td><td>13.28671</td></tr><tr><td>5</td><td>40</td><td>13.98601</td></tr><tr><td>1</td><td>32</td><td>11.30742</td></tr><tr><td rowspan="4">Question 12 "Did you feel well informed about the steps involved in euthanasia?" (scale from "1: Strongly</td><td>2</td><td>48</td><td>16.96113</td></tr><tr><td>3</td><td>53</td><td>18.72792</td></tr><tr><td>4</td><td>60</td><td>21.20141</td></tr></tbody></table>

(continued on next page)
<table><caption>**Table 1 (continued)**</caption><thead><tr><th>Questions (scale and headcount)</th><th>Options</th><th>Total number</th><th>Percentage %)</th></tr></thead><tbody><tr><td>disagree" to "5: Strongly agree"; n = 283)</td><td>5</td><td>90</td><td>31.80212</td></tr><tr><td>Question 13 "Was euthanasia carried out at the vet's?" (n = 297)</td><td>No</td><td>81</td><td>27.27273</td></tr><tr><td></td><td>Yes</td><td>216</td><td>72.72727</td></tr></tbody></table>

cluster mean and standard deviation (1) and the mean and standard deviation of the entire dataset (2). Additionally, it included the V-test value and p-value (3). This information was crucial for assessing whether a group's mean significantly differs from the overall mean for a particular variable. It is important to highlight that PCAs are sensitive to missing data. Consequently, individuals with incomplete data were excluded from these analyses, resulting in a reduced sample size of 276 respondents.

## Qualitative analysis

ChatGPT (version 4) was employed to standardise the synthesis of responses to open-ended questions,²⁰ thereby defining our own methodology. Specifically, ChatGPT was tasked with generating summaries for the answers to the two questions. Due to the character limit constraints of each prompt, the responses were first divided into manageable blocks. ChatGPT was therefore asked to summarise each block individually. In a subsequent step, these block summaries were provided to ChatGPT to create an overarching "summary of summaries". Regarding the leaflet's content, responses were categorised into three blocks, whereas the lack of end-of-life support prompted the division of responses into five blocks. These divisions, three versus five, were determined empirically due to the constraints of character limits in each prompt.

For each question, the prompt instructions given to ChatGPT were as follows:

a. "Please summarise the following text, highlighting key points while retaining the gist. The summary should not exceed 1365 characters."

b. "Please summarise the following text, underlining key points while retaining the essence. The summary should not exceed 800 characters."

Finally, for the overall synthesis, the guidelines were:

a. "Please summarise the following three texts, emphasising key points and retaining essential information."

b. "Please summarise the following five texts, emphasising key points and retaining essential information."

Subsequently, we added verbatim excerpts directly from the answers — as is standard practice in qualitative analysis — enclosed in quotation marks, to illustrate each topic identified by ChatGPT.²¹

## Additional analysis

To investigate potential variations based on pet ownership, specifically between dog and cat owners, we conducted additional analysis to identify response differences attributed to the type of pet. Specifically, we employed chi-square tests to examine the relationship between the responses to "What type of pet did you have?" and several other variables. These variables were derived from the questions "How did your experience go?", "Did you feel sufficiently supported at the end of your pet's life?" along with the variable representing cluster attribution. P-value < 0.05 has been considered as significant.

## Results

### Descriptive statistics

The questionnaire results are presented in the following table, in the order in which the questions were answered (Table 1). Following Question 1 ("What country are you from?"), we retained the data from only those respondents who answered "France" (Table 1).

56.6 % of owners report a smooth EOL experience for the pet, but most owners (66.7 %) consider that this moment have been quite difficult for them (responses 1 to 2 on the Likert scale).

Only 29.8 % of respondents felt they had received good emotional and medical support.

Even so, 34.4 % of those surveyed felt they had received little medical support ("good emotional support and little medical support", "little emotional and medical support"; Table 1). A majority of respondents (78.1 %) consider a leaflet to be useful (responses 4 and 5 on the Likert scale; Table 1). When faced with a difficult situation, such as the announcement of an illness, there don't seem to be any predominant patterns of behaviour (Table 1). 31.7 % of respondents have difficulty assessing their pet's pain (values 1 and 2 on the Likert scale; Table 1). Regarding the feeling of having been supported or guilty/blamed for the euthanasia decision (question 11 of the questionnaire), 30 % of respondents felt largely guilty (options 4 and 5 on the Likert scale; Table 1). Concerning the feeling of being well informed about the steps to be taken on the day of euthanasia (question 12), 28.3 % of owners said they were insufficiently informed (1 and 2 on the Likert scale; Table 1). Based on our questionnaire, most of the euthanasia took place at the veterinary hospital (72.7 %; Table 1).

### PCA

The first dimension summarised 46.5 % of the inertia (Fig. 1). The AHC performed after PCA revealed three groups of respondents (Fig. 2). Groups 2 and 3 are closer to each other than they are to group 1 (Fig. 3).

Cluster 1 (composed of 91 individuals, representing a percentage of 33.0 %) had a significantly higher mean for the euthanasia decision than the whole data set (3.64 ± 1.23 vs. 2.63 ± 1.40; v = 8.47, p < 0.001), which means they felt more guilty. Interest in the leaflet in this cluster was significantly higher than the overall data (4.80 ± 0.45 vs. 4.27 ± .04; v = 5.96, p < 0.001). Perception of the animal's pain was significantly lower in this cluster than in the overall data (2.80 ± 1.38 vs. 3.24 ± 1.22; v = -4.21, p < 0.001). Feeling sufficiently informed about the steps involved in euthanasia was significantly lower in cluster 1 than in the whole data set (2.60 ± 1.30 vs. 3.45 ± 1.39; v = -7.11, p < 0.001). Cluster 1 members showed a significantly lower appreciation of their pet's end of life compared with the overall data (1.29 ± 0.50 vs. 2.07 ± 1.02; v = -8.86, p < 0.001).

In cluster 2 (composed of 98 individuals, representing a percentage of 35.5 %), appreciation of the end of life is significantly higher than in the overall data (2.95 ± 0.86 vs 2.07 ± 1.02; v = 10.63, p < 0.001).

Interest in leaflets was also significantly higher in this cluster than in the overall data (4.63 ± 0.56 vs 4.27 ± 1.04; v = 4.30, p < 0.001). The mean for information concerning euthanasia steps was slightly but significantly higher in cluster 2 than in the whole data set (3.71 ± 1.22 vs. 3.45 ± 1.39; v = 2.32, p = 0.021). The mean euthanasia decision was significantly lower in cluster 2 than in the whole data set (2.22 ± 1.14 vs. 2.63 ± 1.40; v = -3.58, p < 0.001), meaning that they felt more supported/legitimate.

The cluster 3 was composed of 87 individuals, representing a percentage of 31.5 %. The mean for information on the steps involved in euthanasia was significantly higher in this cluster than in all the data (4.05 ± 1.22 vs. 3.45 ± 1.39; v = 4.80, p < 0.001). The perception of the animal's pain was significantly higher in this cluster than in all the data (3.54 ± 1.00 vs 3.24 ± 1.22; v = 2.75, p = 0.006). Cluster 3 members had a slightly but significantly lower appreciation of the end of life compared with the overall data (1.89 ± 0.82 vs 2.07 ± 1.02; v = -1.98, p = 0.048). The mean euthanasia decision was significantly lower in
<figure><img src="image_3.png" /><figcaption>**Fig. 1.** PCA variable factor map: representing variable correlations and contributions in component axes. Abbreviation: "pet_end_life_evaluation" for "Was the end of your pet's life good or bad for you?", ""leaflet_usefulness" for "Do you think an information leaflet from your vet with points to discuss with him/her would be useful?", "hard_announcement_reaction" for "What is your main reaction when faced with a difficult situation, such as the announcement of an incurable disease?", ""pet_pain_assessment" for "Do you feel able to assess your pet's physical and emotional pain/discomfort?", "euthanasiaDecisionFeelings" for "When deciding whether or not to euthanize your pet, how did you feel?" and "euthanasia_information" for "Did you feel well informed about the steps involved in euthanasia?".</figcaption></figure>

cluster 3 than in the whole data set (2.02 ± 1.23 vs. 2.63 ± 1.40; v = -4.89, p < 0.001), meaning that they felt more supported/legitimate.

Interest in the leaflet was significantly lower in this cluster than in the overall data (3.30 ± 1.22 vs. 4.27 ± 1.04; v = -10.46, p < 0.001).

ChatGPT summary about open-ended question 14 "If there were an information leaflet on end-of-life care for our pets, what would you expect?"

* Technical and procedural aspects:

Euthanasia: It's essential to understand the euthanasia process, the drugs used and to ensure that the animal doesn't suffer. Detailed explanations of when and how to make the decision are crucial.

"Understanding and knowing when euthanasia should be considered to stop suffering."

"Explaining the effects of the molecules injected for euthanasia."

Recognizing Suffering: Owners need guidelines for identifying signs of suffering in their animal. Breed-specific indicators can help assess pain.

"Key methods for assessing your pet's pain, to provide it with more comfort."

"How to detect signs of discomfort or limits not to exceed when deciding on euthanasia."

Post-Euthanasia Options: Owners seek information on cremation, burial, and other funeral options, along with the associated costs.

"Prevention/complete information on burial/incineration + transparency (example: choosing a coffin = better to plan ahead)."

"Process, recovery and conservation or even scattering of ashes".

Euthanasia at home: The possibility of euthanizing a pet at home can reduce stress for the animal.

"Is it possible to have euthanasia performed at home so as not to stress the animal any further?"

"Systematically propose euthanasia at home, explaining upstream the possible solutions for afterwards."

* Emotional and ethical support:

Emotional support: The loss of an animal is deeply felt. Owners can benefit from psychological support and recognition of grief, equivalent to that of a human family member.
<figure><img src="image_4.png" /><figcaption>Fig. 2. PCA scatter plot of individuals: illustrating data point distributions in components space.</figcaption></figure>

"Psychological support to cope."

"Possible resources for help, testimonials, explanation of grieving processes."

**Ethical decisions:** Assistance is required to strike a balance between preventing therapeutic overkill and avoiding the initiation of euthanasia.

"Emphasising the act of love and not selfishness rather than relentlessness."

"Knowing when to make the decision to euthanize, existing palliative care."

**Veterinary support:** Veterinarians must be clear, empathetic and provide detailed information. Their role is essential in supporting the owner and the animal.

"Just vet support will be fine."

"It should be given as soon as the animal is taken in, not just when a serious pathology is announced. An animal can die accidentally, and that can be prepared for too."

## Resources and Communications:

Resources: QR codes, testimonials, book recommendations, support groups and other resources can help owners cope with this difficult situation.

"Links via QR with contacts of organisations or professionals who can provide support in the end-of-life of the animal (dog and/or owner), as well as the steps to take before/after decisions are made."

"Advice on how to relieve our companion as much as possible, a guide on gestures or recommendations to relieve pain, the creation of an online group to exchange ideas on the best way to help our pet, a guide on what to do before and after euthanasia."

**Communication:** Questions to ask the vet, as well as expectations in terms of empathy and support, are essential.

"Important questions to ask"

"Practical details on the steps, decisions to be made etc."

ChatGPT summary about open-ended question 15 "In your opinion, what is missing in end-of-life care for our pets?"

Pet owners consider the end of life of their companions to be a delicate period, requiring appropriate emotional and informative support. Key points and needs expressed include:

### Emotion and decision:

The decision to euthanize is extremely difficult for owners and is often compared to losing a family member.

"On the big day it always remains a shock, a trauma, for me it's the equivalent of losing a human loved one."
<figure><img src="image_5.png" /><figcaption>Fig. 3. Dendrogram of ascending hierarchical clustering: unveiling the structure of data groupings.</figcaption></figure>

"There's also a lack of criteria/benchmarks for knowing when to stop. A consideration of the usual lifestyle that will be disrupted until the end (eating, cleanliness, behaviour, medicalization...)."

### Empathy and Humanity:

Owners expect greater compassion and empathy from veterinarians, with better emotional care.

"Kindness. After spending more than 13 years at the veterinarian, spending thousands of euros, on the big day, barely 3 words were said to me. I was left alone in tears without a gesture or word of comfort. They just handed me the bill."

"A human capable of accompanying another human with kindness and alone time of contemplation with their animal."

"Kindness, explanation, talking about money to be paid quickly after the act. It's violent."

### Clear Communication:

Transparent and accessible information about the disease, the euthanasia process, warning signs, and post-mortem options is essential.

"In my case, it was more the lack of medical information, relentless medication for two weeks watching my animal suffer. I would have preferred that the veterinarian informed me from the start of the fatality of his condition rather than seeing my animal suffer."

"Not enough information on support, particularly on the relief of old age pain (osteoarthritis, etc.)"

"The impression of having gone directly from yes it's an old dog to we have no choice but to euthanize."

### Home Euthanasia:

Many owners wish to be able to choose euthanasia at home to limit the animal's stress.

"The possibility of euthanasia at home."

"Home euthanasia seems best to me to avoid any stress on the animal at the end of its life."

"Possibility of carrying out euthanasia at home, in the animal's living space, in an environment that it knows and which does not add stress."

### Psychological Support:

The importance of psychological support before and after euthanasia
is highlighted, with the suggestion of collaboration between psychologists and veterinarians.

“Psychological support.”

“A little more emotional support although most veterinarians practise with passion and are therefore understanding and empathetic.”

“Psychological support that does not necessarily come from the veterinarian.”

### Societal Recognition:

It is essential that society recognizes the emotional pain felt by owners, even considering days off for mourning.

“Social support.”

“Society’s awareness of what the end of life is sorely lacking (whether it concerns humans and even more so animals). Consideration for animals, sensitive beings who suffer and deserve support, offering humans the required availability. The role of caregiver is already not recognized, how can you take it into account when it comes to your animal...”

“That the employer recognizes the bereavement, 1 day of absence from work?”

### Financial Management:

Transparency on associated costs, such as cremation, is requested, as well as potential assistance for these expenses.

“Clear information on the duration of said care, its consequences, its costs.”

“Aid for cremation costs.”

### Pain Management:

Owners want to be assured that their pet’s pain is well managed and that they understand what their companion is feeling.

“Pain relief should be better taken into account.”

“Serious management of pain and empathy (especially towards animals) by my veterinarian.”

“Decision making is not focused enough on pain in animals.”

“Pain management.”

### Chi-square tests

The Chi-square test revealed a significant association between ‘What type of pet did you have?’ and ‘How did your experience go?’ ($\chi^2 = 4.52$, df = 1, p = 0.034) with higher percentages of bad experience for cat owners (Table 2). However, further Chi-square analyses showed no significant associations.

<table><caption>**Table 2** Contingency table built from the answers to question ‘What type of pet did you have?’ (rows) and “How did your experience go?” (columns).</caption><thead><tr><th></th><th>good</th><th>badly</th></tr></thead><tbody><tr><td>cat owners</td><td>60 (68.8 %)</td><td>57 (48.2 %)</td></tr><tr><td>dog owners</td><td>90 (81.2 %)</td><td>48 (56.8 %)</td></tr></tbody></table>

## Discussion

The results of this study reveal that most participants (56.6 %) reported that the death of their pet occurred relatively smoothly. Nevertheless, the end-of-life for pets in France remains a challenging period, with nearly 67.0 % of surveyed owners experiencing this as difficult, if not very difficult. EOL seems to be perceived more painful for owner than the pet. This type of discordance in perception has been studied between individuals at the end of life, family caregivers, and healthcare staff<sup>22</sup>. However, in the context of companion animals, there is a significant bias stemming from the owner’s point of view. A more in-depth investigation into the veterinarian’s perspective on this moment shared between the owner and the pet could provide valuable insights into understanding this discordance in perception. These findings also underscore the need for support at various levels. Three different groups of owners were identified regarding their needs: The first one includes owners with a high level of guilt and a higher need for support regarding the end-of-life of their animals (need for information and better training to assess the quality of life of their pets). The second group seems to be better informed with a lower need for support. These owners seem to be more independent but still need support from the vet and a leaflet seems quite appropriate for them. The last group included individuals with greater ability to evaluate pain, who had a higher degree of information. These individuals may require less support from the vet teams. These differences underlie the importance of individualised support for owners from the vet teams. However, we must be careful not to over-categorize individuals based on their lack of answers, as some may be better at hiding their emotions or not being able to communicate their true needs.

Based on the needs of owners, different essential pillars of support of owners arise from this study that could be the foundation of veterinarian- and nurse- specific training to support individual owners during the end-of-life period: Emotional support, Personalisation of the support, Information and training, Tools, Open-discussion (the EPITO system)

### E (emotion): emotional support – a period of guilt and higher risk of depression or anxiety

The sense of appropriate support, both medically and emotionally, seems rather limited, with only 30.2 % of respondents stating that they feel well-supported in both aspects. This observation highlights an increased need for support compared to what is currently provided. Furthermore, it is essential to recognize that owners’ guilt is a major concern.<sup>16,23</sup> Only 29.7 % of respondents feel fully legitimate and supported in their decisions regarding euthanasia or non-euthanasia, highlighting the sense of isolation experienced by owners in the face of these complex decisions. Several studies encourage veterinary staff to anticipate the needs of pet owners and support them in the grieving process, given their essential role in this delicate moment.<sup>24,25</sup> A recent publication suggested that guilt associated with the care of aging dogs may be a predictor for depression and anxiety which underlying the importance for the vet team to closely observe their clients to prevent potential mental health issues.<sup>26</sup> Positive interactions and high level of support from the veterinary team seem to help the owner to be better able to grieve and have a reduced trauma.<sup>10</sup> One publication also mentioned that 24 % of owners reported a negative interaction with their veterinarian and technician prior to their animal’s death. Some of them mentioned a lack of communication and compassion from the veterinarian.<sup>27</sup> The same study reported the importance of counsellors and veterinarians to help normalise the grief experience of the owner, especially given the negative impacts of disenfranchised grief.

### P (personalization): personalised support from the vet teams – owners should have individualised support

Over 40 % (43.4 %) of respondents prefer asking healthcare
questions after leaving the professional's presence, highlighting diverse information processing styles. Veterinarians should adapt to immediate or delayed question styles, allowing patients to seek clarifications later. Providing informative documents for post-announcement consultations is suggested. Proposals like an end-of-life support brochure, supported by 78.1 % of owners, can aid in communicating critical information, as immediate reactions often focus on primary messages, potentially sidelinig peripheral details. Recognizing individual processing differ- ences is crucial, ensuring effective communication in challenging situ- ations such as a pet's cancer diagnosis, where primary information may overshadow treatment options and recommendations. Different owner profiles regarding grief management have been identified in a recent publication, highlighting the need to adapt communication to the specificities of these profiles. Owners in the "distress" category experi- ence high levels of caregiver burden, elevated anticipatory grief, and lower quality of life. More resilient individuals compartimentalize their distress, showing high levels of grief and anticipatory grief but main- taining better quality of life. Owners in the "non-distressed" category exhibit low caregiver burden, while the final category includes owners with borderline caregiver burden and low levels of anticipatory grief. Each of these owner types requires tailored support and manage- ment.²⁸Effective communication during challenging announcements, like a cancer diagnosis for pets, is essential. Avoiding common pitfalls such as blocking, sermonizing, routine reliance, collusion, and prema- ture reassurance is crucial.²⁹ Employing fundamental skills like the "Ask-Tell-Ask" model aids in gradual information delivery, ensuring patient understanding and sensitivity to their emotional response, rec- ommended in human cancer medicine[29]. It's vital to avoid over- whelming with excessive information simultaneously.³⁰ The "Tell me more" principle and empathetic responses facilitate dialogue, aiding in sharing sensitive information between clients and the veterinary team.³¹ Cat owners may undergo a more intricate end-of-life period, reflecting a stronger perceived relationship with cats.³²

### I (information): training and technical support – how to understand the needs of my animal?

Pet owners, beyond grappling with guilt, express a strong need for more information, particularly to assess their animals' comfort and pain levels,³³ as 46.8 % feel inadequately competent in this area in the pre- sent study. Supporting families in understanding their pets' needs is imperative, along with detailed information on end-of-life stages. Notably, 31.8 % lack essential details about pet euthanasia, emphasizing the importance of thorough communication and professional support, which can alleviate family anxiety.³⁴ Principal component and cluster analyses identify three respondent groups, with Group 1 feeling poorly informed, while Groups 2 and 3 feel better informed, emphasizing the significance of tailored information dissemination. It is important to note that those who felt less informed also experienced the end of their pet's life with more difficulty. This result underscores once again the importance of providing adequate information to the owner. These findings confirm that the sensitivity of the veterinarians and their ability to assist owners in making conscious and informed decisions regarding euthanasia are key elements in managing the loss of an animal²⁵ and that veterinarians play a key role in providing information to the owner.³⁵ Although the internet is a major source of information for pet caregivers, they place more trust in their veterinarian than in other sources,³⁶ even for the after-death body care.³⁷ This trust should continue to be reinforced to prevent any medical misinformation. Finally, providing information about health status beforehand is crucial to enable pet owners to prepare under the right conditions.³⁸ The use of QOL scale such as the HHHHHMM scale,³⁹ or more recent resources developed by veterinary practitioners (such as “Lap of Love”⁴⁰) and based on AAHA/AAFP Pain Management Guidelines for Dogs and Cats⁴¹ seem to be easy-to understand tools for owners⁴² and bases for person- alised decisions regarding individualized end-of-life care for companion

animals.⁴³

### T (tools): a need for appropriate leaflets and tools to support the veterinary team

The creation of an informational brochure is recognized as a poten- tial solution to the information deficit among pet owners, with broad support from participants. Tailored educational materials could assist professionals in adapting communication to diverse owners, alleviating family anxiety when presented in a straightforward manner. These tools may serve not only as discussion support but also as a resource for future inquiries, addressing differences among owner groups observed in the survey. Respondents emphasize the brochure should cover technical aspects of euthanasia, awareness of animal suffering, post-euthanasia options, emotional and ethical support, ecological considerations (e.g. carbon footprint of a cremation...), and communication resources. While existing leaflets from the International Association for Animal Hospice and Palliative Care are available, to the knowledge of the au- thors, in France, none has been created after a study on the actual needs of owners, which underscores the importance of surveys that truly give caregivers a voice in expressing their needs. A brochure could serve as a tool to guide owners toward additional resources they identify as necessary, such as the clinic's website or support groups, which remain relatively uncommon in France.

### O (open discussion): open discussion regarding in-home euthanasia

Although our questionnaire did not directly address this issue, an important trend emerged from responses to open-ended questions: many owners express the desire to opt for the euthanasia of their pets at home. These observations align with the results of other studies.⁴⁴,⁴⁵ In-home euthanasia seems to be more and more common each year, which is still unexplored from an academic point of view, with possibly around one million of in-home euthanasia each year in US.⁴⁶ According to an American study, owners who chose in-home euthanasia were more likely to describe the end-of-life experience for their pets as positive.⁴⁵ Furthermore, a recent study focused on veterinarians revealed that home euthanasia was often associated with a "gentle death," with 59 % of surveyed veterinarians stating that they practised this method. The house as a site for euthanasia could increase comfort and intimacy, but also the potential for isolation, as it was suggested in a recent article.⁴⁶ In contrast, in France, our questionnaire estimates that only 26.8 % of euthanasia take place at home.

### A wider need: societal recognition of animal mourning

Society often deems mourning for pets as illegitimate, leading to negative psychological consequences and decreased quality of life for individuals. The lack of social support intensifies grief severity, impacting the owner's well-being.⁴⁷,⁴⁸ To address this, societal recog- nition of pet loss needs radical shifts, emphasizing the importance of animal companions and the emotional responses tied to their loss. The concept of "more-than-human" families highlights the unique social role of pets in families.⁴⁹ Policies, attitudes, and practices supporting pets can enhance social and community well-being, preventing trauma linked to pet loss and fostering healthier environments.

### Study limitations and future research

While we employed convenience sampling for data collection, which may lack proper randomization or systematic sampling, the results still revealed a diverse range of contrasting perceptions. Within the cluster analysis, a group of participants for whom the end-of-life period for their pets was not such a negative experience was observed, and these profiles of owners considered themselves sufficiently informed. This result re- inforces the confidence in the representativeness of the present sample.
The survey was not exclusively to individuals who had negative experiences during the end of their pet's life, nor to those who felt abandoned by their veterinary team.

It is important to question the reality of the information perceived by those who believe they are sufficiently informed. Is this truly the case, or do they simply feel that way while possibly overlooking essential questions that have never crossed their minds?

The formulation of the question "Where are you from?" may have induced some confusion as it could be interpreted in two ways: either as a question about the country of origin or about the current place of residence. This ambiguity potentially introduced a slight distortion in our results, especially considering that our study was primarily focused on the experience in France. It is important to note that during the first distribution of the questionnaire via LinkedIn, approximately 1,200 contacts were reached, with nearly 1,000 of them residing in France.

It is important to highlight that in the questionnaire, we included the following mention: "If you have lost several animals, you have the option to base your answers on a single experience or to fill out the questionnaire multiple times to reflect different experiences." Therefore, it is conceivable that a respondent participated multiple times, but in accordance with GDPR regulations regarding data protection, we are not able to determine how many times an individual responded. However, the duplication rate may be presumably low.

Future research should explore caregiver personality impacts, as seen in horse owners with neurotic tendencies affecting euthanasia decisions.⁵⁰ However, ethical constraints prevented implementing a validated personality questionnaire online. As the implementation of a personality questionnaire often leads to a return of results to participants, the sending of personal data would fall under French regulations, resulting in a more complex process.

Finally, it should be noted that this study focused on the needs of pet owners regarding end-of-life support. The impact of euthanasia and empathy cost for the vet team should not be underestimated. A perceived resilience at 12 months is influenced by the frequency of animal euthanasia and the level of emotional empathy.⁵¹ A future study will investigate the approach and comprehension of vet teams in France with the objective to match approaches between the needs of the caregivers and the emotional/communication possibilities of the vet teams to create appropriate resources to fill the gap. The difference between cat owners and dog owners should also be investigated in a more in-depth study to personalize the veterinarian's support.

## Conclusion

The study reveals varying owner experiences during their pets' end-of-life (EOL). Three distinct owner profiles emerge, highlighting the necessity for tailored support. The findings emphasize the importance of educating veterinary teams to provide positive and personalized support in palliative care and euthanasia, focusing on Emotional support, Personalization of the support, Information and training, Tools, Open-discussion. The following steps can help tailor the procedure to meet owners' needs effectively:

1. Identify the owner's profile: Determine which of the three categories the owner belongs to. This assessment helps in understanding their needs in terms of emotional support.

2. Provide tailored emotional support for at-risk individuals: For owners identified as emotionally vulnerable, consider offering specific support. Veterinary teams can undergo training to better support sensitive owners or refer them to a specialist when needed.

3. Determine the type of support needed: Identify what type of resources the owner might require (e.g., leaflet, website). Open-ended questions can encourage owners to express their needs freely, facilitating better communication.

4. Address key concerns: Identify the owner's critical questions to provide appropriate support and information, such as pain management, assessing quality of life, and handling the pet's remains.

5. Discuss home care and euthanasia: Topics such as home care or euthanasia must be addressed, as some owners may find these difficult to bring up but have numerous questions regarding them.

## Declaration of generative AI in scientific writing

During the preparation of this work authors used chatgpt 3.5 to analyse data as mentioned in the material and methods and improvement of the language. After using this tool, authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

## CRediT authorship contribution statement

Sara Hoummady: Writing – original draft, Formal analysis. Laure-line Chaise: Writing – original draft, Formal analysis. Marion Guillot: Writing – original draft. Nancy Rebout: Writing – original draft, Methodology, Formal analysis, Conceptualization.

## Declaration of competing interest

N.R., L.C., and S.H. launched the questionnaire as part of their research and as co-founders of the French Association for Animal Geriatrics and Palliative Care.

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