Introduction

Currently, veterinary medicine is experiencing a severe shortage^1,2 of credentialed veterinary technicians (VTs) and veterinary assistants (VAs), forcing many hospitals, including emergency and advanced care facilities, to divert cases, thereby reducing access to care and affecting medical quality. The underlying cause of this shortage is likely multifactorial. Attrition from nondoctor roles in veterinary medicine is also multifactorial, but burnout, which VTs experience at high levels,^2–5 may contribute significantly.

Burnout is a syndrome that has been well-documented in caregiving professions.^6–8 It has 3 distinct characteristics: (1) emotional exhaustion, in which a caregiver is no longer able to give of themselves; (2) depersonalization, in which a caregiver has negative or cynical attitudes toward patients or recipients of care; and (3) a diminished sense of personal accomplishment, in which a caregiver has a negative self-view, especially in relation to job performance and patient care.⁹ One possible factor leading to such a high level of burnout among VTs is the repeated experience of moral distress associated with providing futile care to pets. Moral distress was first described by Andrew Jameton in 1984 and defined at that time as the painful feeling(s) and lack of mental peace resulting when nurses are unable to act on their ethical impulses due to institutional constraints.^10,11 Jameton initiated the study of and discussion about distress that results when an individual caregiver believes they know the right thing to do morally but are prevented from doing it. Since 1984, the concept has been widely explored and applied in human healthcare, particularly through the lens of nursing philosophy and the lived experiences of nurses in a wide variety of healthcare settings.^12,13

Recently, Kogan and Rishniw¹⁴ documented high levels of moral distress in veterinarians; however, the investigation of moral distress in veterinary professionals, specifically its relationship to medically futile treatment, is in its nascent stage. There has been initial empirical investigation into the effects of futile treatment in relation to veterinarians,^15,16 but no work has yet been done to evaluate the impact on other veterinary professionals (ie, VTs and VAs). It is probable that providing futile treatment is as impactful on VTs as it is on veterinarians since technicians are in direct contact with animal owners and patients receiving care; in addition, they are commonly the veterinary team member responsible for executing medical orders and administering treatments. Extrapolating from available evidence regarding veterinarian educational curricula and VT accreditation standards, credentialed VTs are unlikely to receive training in how to deal with the emotions or distress associated with providing futile treatments.^15,17,18 Currently, debate about what constitutes futility contributes to the difficulty in studying and discussing this phenomenon in both human and veterinary medicine.

To begin documenting the impact that the provision of medically futile treatments has on VTs, the authors undertook this descriptive study with 7 distinct aims: (1) to determine whether VTs encounter medical futility and, if so, how frequently; (2) to describe in which types of veterinary hospital setting(s) futile treatments occur; (3) to understand VTs’ opinions about providing futile treatments to patients; (4) to understand what types of procedures cause the most distress in the context of medical futility; (5) to document the moral implications that providing futile treatments have on VTs; (6) to describe possible links between participation in medical futility and attrition from the profession; and (7) to document how VTs conceptualize and define futility in an effort to continue moving closer to a common definition to facilitate future study and conversation.

Methods

A web-based survey consisting of 56 quantitative and qualitative questions was developed to explore the 7 aims described previously (Supplementary Material S1). Questions were adapted for use from a previously published survey¹⁶ of veterinary specialists, with additional questions included to evaluate intention to leave, moral concerns, and personal impact of witnessing or providing futile treatment. Question formats included demographic questions, yes/no questions, multiple-choice questions (allowing for multiple answers), Likert scale questions, ranking questions, and free-text answer questions. Skip logic was utilized in the survey, allowing participants to skip questions without terminating the survey. The survey was distributed through the National Association of Veterinary Technicians in America (NAVTA), the central professional organization for VTs in the Americas, with the use of an online survey service (SurveyMonkey Inc). A link to the survey was placed on the social media pages of NAVTA as well as appearing on the news section of the NAVTA website and in their newsletter. Respondents had to be at least 18 years of age. Consent was confirmed by respondents completing the survey after being informed that participation was anonymous, voluntary, and could be terminated at any time. The survey was open between January 20 and February 16, 2023.

Results

Discussion

To the authors’ knowledge, this study was the first to examine the question of medical futility as it relates to and is experienced by VTs. The authors (NP, LM, JWB) have previously identified the importance of seeking a working definition of veterinary medical futility and proposed the following: “Futile care occurs when the continuation of current treatment or institution of new treatment is not expected to alter the clinical course of the patient, even if such treatment confers some benefit to the owner(s).”¹⁶ This proposed definition was based on the results of a study¹⁶ that documented veterinary specialists’ experience with medical futility and was included on the list of suggested definitions that respondents to this study were asked to rank as most closely matching their conception of medical futility. The physiologic focus of this proposed definition reflects veterinarians’ inclination to define futility according to tangible clinical goals, possibly because their training and job duties emphasize correct diagnosis, accurate prognosis, and case management. In the current study, technicians preferred a more experiential definition based on concepts such as suffering and quality of life (“Continuing care when suffering is uncontrollable or when the prognosis is permanent suffering, pain, distress, or disability”), most likely due to their work in roles that emphasize task-oriented, hands-on, and patient-facing care. The difference in perspective between veterinarians and technicians may reflect underlying differences in the value structures between those who choose to pursue a career as a VT rather than a veterinarian or may be a result of lived experiences unique to the different roles. A feminist ethic recognizes the interdependence of people and connection to others while recognizing that moral knowledge derives from and is influence by moral experience.¹⁹ A feminist ethic of care is identified in human nursing literature as an important part of understanding nurses’ belief structures.^13,19–21 While much scholarly research has been conducted to clarify human nursing ethics, including ethics of care, as yet there has been minimal empirical exploration of ethics of care in relation to veterinary technology and veterinary nursing practice. Future studies are warranted to examine the value structures of VTs and determine whether they place more emphasis on ethics of care or feminist ethics, prioritizing the relational aspects of veterinary medicine as demonstrated by the human-animal bond and deeply rooted in caregiving.

This project suggests that differences exist between how veterinarians and technicians perceive and define veterinary medical futility. The ongoing importance of devising a working definition in veterinary medicine is reinforced by the similarity with which each group considers the impact that providing futile treatments has on pets and pet owners regardless of their preferred physiologic and experiential definitions. The fact that almost half of the VTs surveyed disagreed with the statement that “providing futile care is always wrong” while virtually two-thirds of respondents believed that the treatments they deemed futile did benefit pet owners in some way aligns with how veterinarians responded to the same questions in our previous work (69% and 76%, respectively),¹⁶ highlighting the need to more clearly define the profession’s moral and ethical obligations to patients and their owners in these circumstances. The alignment between respondents to this study and the prior work with veterinarians further highlights the ambivalence veterinary professionals feel about the role medically futile treatments play in veterinary practice, as both groups of professionals believe that provision of medically futile care is not always wrong, may benefit clients, or may be used as a mechanism to resolve conflicts between seemingly divergent obligations.

This study appears to confirm the previously reported ubiquity of medical futility in veterinary medicine, with over 99% of respondents believing that futile treatments occur in veterinary medicine and almost 98% experiencing it firsthand.¹⁶ In the current study, a large majority of VTs had been asked or directed to act against their conscience to provide futile treatment to terminally ill pets; troublingly, nearly all those who were asked had done so, causing them moderate to severe stress. The high proportion of VTs who followed through on requests to provide futile treatments despite their reservations suggests that VTs experience a constrained sense of agency and an inability to say no, possibly due to fear of repercussions including loss of clinician trust, altered team dynamics, potential disciplinary action, reputational damage, and job loss. Alternatively, the high participation in medically futile treatments despite individual reservations may speak to an inner conflict about what constitutes optimal patient care. In times of high case load and reduced staffing, the pressure a VT feels to suppress any reservations about clinician and client decisions to ensure patient care tasks are carried out may be intense. Correspondingly, in the absence of clear reassurance that the workplace is a psychologically safe space to raise concerns or objections, it is possible that VTs may not articulate the full scope of their reservations. The present study found that most technicians expressed their concerns to a veterinarian or peer, yet provided the treatments anyway. One possible explanation for this finding is that VTs may prioritize provision of care to patients over individual moral concerns. Alternatively, it may reflect on the previously discussed constrained sense of agency plus a possible lack of professional autonomy and fluctuating power dynamics within the technician-veterinarian relationship.

As a profession, veterinary medicine operates within complex and sometimes unacknowledged ethical frameworks in which providers have various responsibilities to the patient, the patient’s caregivers/owners, each other, and society at large (eg, within the context of public health).²² The alleviation of pain and anxiety is often cited by both clients and veterinary professionals as a central tenet, as is the commitment to a “good death.” The authors believe that the provision of high-quality, modern medical care on par with that provided to humans may also be becoming a societal expectation of pet owners. A client’s ability to pay for recommended treatments impacts clinical decision-making and likely factors into moral distress experienced by VTs. The burgeoning discussion surrounding spectrum of care in veterinary medicine emphasizes delivering the best care clients can afford. This conversation may increase decision-making transparency and provider empathy.

Moral distress within this ethical context can be defined as the negative emotional impact caregivers feel when either the best moral action is known and they are prevented from taking it, or the best course of action is not known. A 2018 study¹⁵ found medical futility to occur commonly and to be a potential contributor to both moral distress and poor well-being in veterinarians; at the same time, the study emphasized the poor training that clinicians are given to recognize and resolve issues of moral distress. In comparison to the average 4 to 6 years of postgraduate professional training that veterinarians receive in the US, credentialed VTs in the US receive an average of 2 to 4 years of formal clinical education and training. Given this compressed time frame, other skills and knowledge elements may be prioritized over educating technicians to recognize and cope with the ethical challenges associated with medically futile treatment requests, euthanasia, moral distress, and burnout.

Most VT respondents in the current study consulted a veterinarian about their concerns surrounding medically futile care, indicating trust and willingness to collaborate, and the authors suggest that veterinarians should reciprocate by emphasizing VT agency in futility settings. This could include inviting VTs into conversations with pet owners, as has been advocated in human medicine when nurses are centrally involved in family meetings to not only optimize transparency of decision-making but also improve bilateral communication and support for all parties.^23,24 Additional actions to consider include debriefing nondoctor personnel in detail about quality-of-life conversations with pet families, facilitating team conversations, or providing a low-risk pathway for VTs to be relieved of the responsibility to provide treatments based on conscientious objection.^25,26 The authors have previously suggested that VTs have a role to play in shared decision-making around end-of-life futility concerns.¹⁶ This idea is supported by the findings of Janke et al,²⁷ in which client involvement in decision-making increased when both veterinarians and VTs contributed to communication. In that study, client preferences were integrated to a greater degree than when veterinarians interacted with clients alone, leading the authors to conclude that “veterinary practices, clients, and patients are likely to benefit from utilizing credentialed VTs more, fostering shared decision-making with clients.”²⁷ One challenge the present study faced was determining the motivating factors behind owners’ requests for futile treatments. The survey instrument sought the perspective of VTs on what factors they believed motivated clients to make such requests. However, the study was not designed to, nor was capable of, determining clients’ actual motivation. If VTs’ perspectives are based on potentially harmful assumptions rather than firsthand observation or conversation with the client, the scene is set for misunderstanding(s) that could harm the relationship between VTs and clients and contribute to moral distress with the potential for collateral damage to DVM-VT relationships. It is possible that a difference between actual and perceived motivations exists and might provide a target for resolving conflict surrounding such treatment requests.

Veterinary technicians form the backbone upon which patient care and client services are built, and it is imperative that their physical and mental well-being are prioritized for retention and career satisfaction. The prevalence of adverse emotional responses identified in this study, including anger, depression, frustration, and loss of compassion, coupled with the prevalence of physical manifestations of stress, such as sleeplessness, loss of appetite, and fatigue, indicate that the current lack of an organized approach (including the lack of a widely accepted definition) to managing the problem of futility within the veterinary community is unsustainable. Perhaps a better indication of the acuity of the problem is the high number of VTs in this study who reported self-medicating with either drugs or alcohol, or the nearly 10% that indicated they had considered or attempted self-harm. High rates of suicide and suicidal ideation across roles are well-documented and continue to plague the veterinary profession²⁸; moral distress resulting from encounters with futility may be a contributing factor. The results of the current study confirm that conversations about futility are taking place in the clinic between veterinarians, technicians, assistants, and pet owners. Notably, administrators and supervisors appear to be less involved in these discussions, indicating a possible disconnect between the clinical team’s experience and that of the operational team. Fostering a better link may provide an opportunity to ensure that needed structural changes take place to properly support VTs and other care team members facing futility questions on the floor. For concerns about medical futility to be raised without fear of reprisal or misrepresentation, an emphasis on psychological safety through training on emotional intelligence, mutual respect, communication styles, and guided debriefing may be beneficial. The veterinary profession is at an inflection point. The turnover rate for veterinarians is currently 16%, twice that of physicians.²⁹ Large areas of the country are underserved, with over 250 regions listed by the USDA in 2024 as having rural veterinary service shortages.³⁰ Large veterinary care deserts exist in many urban locations, including Chicago³¹ and Atlanta.³² It has been estimated that to meet the anticipated growth in demand, an additional 55,000 veterinarians will be needed by 2030 to provide care for companion animals alone; when new graduates are included, a shortage of nearly 24,000 companion animal veterinarians is still anticipated.³³ These figures do not address gaps in other fields of veterinary practice like veterinary technology. Each new graduate veterinarian will require the support of multiple VTs and VAs to continue providing needed care to their communities. The findings in the current study that nearly half of surveyed VTs have considered leaving their position and over half reported firsthand knowledge of a VT who has left the profession suggest that if the profession cannot devise strategies for addressing moral distress and burnout attributed to medical futility, VT shortages will not only persist but may become more severe.

The current study had several limitations. First among them is that this cross-sectional study only evaluated respondent beliefs at a single moment in time and failed to capture evolving beliefs or the beliefs of VTs who have already left the profession. This limitation is coupled with the possibility of selection and volunteer bias. The estimated response rate of 22% may not allow for generalization to the entire VT community, since those who chose to respond may have had preexisting knowledge, interest in, and/or concerns about the topic. The selected distribution method aimed to maximize distribution to a wide range of VTs but only captured those with an affiliation to NAVTA and failed to account for others that may be doing the work of VTs or VAs without that affiliation. The authors also cannot rule out crossover of the survey instrument on social media outside the NAVTA membership. The relatively low response rate of 22% may reflect lack of interest in the survey topic or may have been due to members of NAVTA who do not routinely engage with the electronic distribution methods used for this study. The high attrition rate of responses during the survey may be a result of fatigue due to the length of the survey instrument. Alternatively, this attrition may be due to an emotional response to the subject matter or general disinterest. Finally, the survey instrument did not provide definitions for several terms, leaving them up to respondents to interpret on an individual basis (eg, the type of support sought by respondents). The survey also did not provide a definition for futility but rather relied on respondents to align their own conception of what futility means to preselected sample definitions, opening the possibility of misalignment between the authors’ definition of futility and that of the individual respondents.

The current study achieved its goal of documenting the way encounters with medical futility are experienced by VTs, the impact they have on individuals, and the potential impact on the profession. In addition to further work toward developing a working definition of medically futile treatment in veterinary medicine, there are several avenues for future work: (1) continuing an empirical exploration of the characteristics of futile treatment requests that are morally distressing, specifically enumerating the values that are in conflict within both veterinarians and VTs and how those values evolve over time; (2) exploring how cultural differences, religious beliefs, and socioeconomic circumstances impact the way members of the veterinary care team and the public experience and respond to requests for morally distressing treatment; (3) elucidating and defining common values in VTs’ self and professional identities; and (4) strengthening and reinforcing autonomy and respect for VTs as medical practitioners in their own right to allow for their important contributions to shared decision-making to be fully leveraged.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose.