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Managing Patients with High Fear, Anxiety, and Stress: A Guide to Effective Handling

A four-part “from the trenches” series, written by a Fear Free veterinarian for Fear Free veterinary professionals.This is Part One of a four-part series on helping Fear Free Certified Veterinary Professionals handle patients with high levels of FAS and communicate with their owners.

By Julie Liu, DVM

At least once a day, I see a high FAS patient. While I don’t always know their detailed backstory, the alerts on their patient files are like a roadmap to how they got there, as a “wiggly” puppy transforms into an adolescent that “may urinate” to a 3-year-old who’s a “CAUTION, WILL BITE!!!” Some days it seems like every pet has an FAS score of 4 or 5, and for Fear Free Certified Professionals, those days can be both emotionally and physically exhausting. It’s even more disheartening when we encounter ethical quandaries such as a pet parent who’s not on board with our Fear Free plan for their highly stressed pet. These situations are common, and according to psychotherapist and compassion fatigue expert Dr. Elizabeth Strand, moral stress is the number-one contributor to compassion fatigue in vet med1.

So what do we do with these high FAS patients? How do we care for their emotional and physical wellness, while also caring for our own wellbeing and balancing the needs of the pet parent? Flexibility, communication, and supporting the Fear Free team culture are key to approaching these challenging cases.

After becoming Fear Free certified, I started realizing that a patient would be a lot less stressed if I approached the interaction like jazz–with a general sense of where it might go, but incorporating improvisation and responding to what the pet was communicating at that moment. This may mean giving the pet a brief break during handling to allow de-escalation, or even backing off completely on what I was originally trying to accomplish. Fear Free handling is a dialogue, not a monologue. When handling a patient with high FAS, a few other guiding principles can help:

  • Location, location, location. When handling any pet, try to choose the area where the pet prefers to be and is most comfortable. There are multiple places where a pet can be handled other than an exam table, such as the floor, on a lap, on the bench, or in the bottom of their cat carrier. In general, many pets with high FAS also do better with the owner present.
  • Give every pet a sense of choice and control where possible. Encourage voluntary movement by calling the pet using a happy voice, asking the owner to call them over, or luring them to move of their own free will with a treat or toy. Many dogs also know cues for sit and down, so instead of pushing a dog’s rear end down and pulling their legs out to get them sternal, ask or lure the dog to a sit and down. Respect the cat’s choice to stay in the carrier and access them by removing the top of the carrier and covering them with a towel to facilitate hiding. When restraining a pet, especially a high FAS pet, allowing them to stay in the position they prefer goes miles toward keeping them calm, whether it’s allowing a dog to stand instead of sit for a jugular draw or allowing a cat’s front end to remain sternal instead of forcing them into full lateral to reach the medial saphenous.
  • Less is more. Use the minimum number of people needed and the least amount of restraint needed while staying safe. The more hands on a pet and the more people crowded around them, the more likely they are to become stressed.
  • Prevent and treat for pain. Pain contributes to FAS and vice versa, and as mentioned in a 2022 Fear Free roundtable3, pain and fear are “two sides of the same coin.” Dull needles also hurt more, so try to make it common practice during sample collection to not reuse needles. During unsuccessful blood draws, I often see people pulling the needle out of a pet’s skin, re-palpating the vein, and then pushing that same, microscopically shredded needle back into that pet’s skin for a second or third attempt as the pet gets more and more stressed.
  • Sedate early, not as a last resort. With many high FAS pets, you will often reach a limit for what PVPs can accomplish. Injectable sedation may be the best way to help minimize FAS. Sedating earlier when the patient is calmer will be safer for the pet and likely allow you to use lower doses of anesthetic drugs. Familiarizing yourself with Fear Free in-clinic sedation protocols, lowering the charge for sedation to get client buy-in ($70 is more palatable than $140), and getting staff members comfortable with sedation/monitoring will also prove invaluable. Another way to approach stressful procedures for high FAS pets is to tack them onto an already-scheduled procedure involving general anesthesia. Depending on the patient’s needs, these could include shaving a matted cat, microchipping, trimming or dremeling nails, performing a cystocentesis, aspirating a growth in a sensitive location, expressing anal glands, or performing an orthopedic exam/radiographs. For more info on Fear Free in-clinic sedation, check out Fear Free Level 1 module 7b8, Fear Free Level 3 module 19, and these other Fear Free resources10, 11, 12, 13.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Julie Liu is a veterinarian and freelance writer based in Austin, Texas. In addition to advocating for fear free handling, she is passionate about felines and senior pet care. Learn more about Dr. Liu and her work at www.drjulieliu.com.

Continue learning about managing patients with high FAS through Part Two, Part Three & Part Four of this series.

 Want to learn more about Fear Free? Sign up for our newsletter to stay in the loop on upcoming events, specials, courses, and more by clicking here.

Resources

  1. Moral stress the top trigger in veterinarians’ compassion fatigue | American Veterinary Medical Association
  2. https://journals.sagepub.com/doi/full/10.1177/1098612X221128760
  3. https://fearfreepets.com/pain-and-fear-two-sides-of-the-same-coin/
  4. https://icatcare.org/our-campaigns/pledge-to-go-scruff-free/
  5. https://fearfreepets.com/treat-ladder/
  6. https://fearfreepets.com/top-10-treats/
  7. https://fearfreepets.com/wp-content/uploads/delightful-downloads/2019/01/Keep-Calm-and-Muzzle-On-1.pdf
  8. https://fearfreepets.com/courses/fear-free-certification-program/
  9. https://fearfreepets.com/courses/fear-free-certification-level-3/
  10. https://fearfreepets.com/fas-spectrum/
  11. https://fearfreepets.com/wp-content/uploads/delightful-downloads/2020/08/Dog-Sedation-Pain-Algorithm-2020.pdf
  12. https://fearfreepets.com/wp-content/uploads/delightful-downloads/2020/08/Cat-Sedation-Pain-Algorithm-2020.pdf
  13. https://fearfreepets.com/calming-pet-owners-concerns-sedation/
  14. https://www.felinegrimacescale.com/
  15. https://fearfreepets.com/courses/fear-free-level-2/
  16. https://www.avma.org/resources-tools/practice-management/communicating-clients-using-right-language-improve-care
  17. https://fearfreepets.com/resources/fear-free-store/fear-anxiety-and-stress-spectrum-cat/
  18. https://fearfreepets.com/resources/fear-free-store/fear-anxiety-and-stress-spectrum-dog/
  19. Moses L, Malowney MJ, Wesley Boyd J. Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Intern Med. 2018 Nov;32(6):2115-2122.
  20. https://www.youtube.com/watch?v=ExaL-pp9Kok&t=1531s

Improve Wound Healing and Patient Recovery

By Dr. Natalie Marks, DVM, CVJ, Elite FFCPAs a practicing veterinarian and previous practice owner for more than two decades, I’ve witnessed quite a bit of evolution within our industry. There continue to be advances in diagnostic technologies, telemedicine, novel therapeutics for dermatology and osteoarthritis, and a dramatic shift from independent practice ownership to corporatization. However, one of the most important discoveries and initiatives has been the concept of Fear Free, the initiative dedicated to the physical and emotional health of our patients and clients through the reduction of fear, anxiety, and stress.

However, Fear Free is, and can be, more. It is a lifestyle and guide on how to practice and manage and educate. Client trust and compliance is key to a successful veterinary-client-patient relationship, and that’s difficult to achieve when fear, anxiety, and stress surround exam room interactions and associated communications. This is never more evident than when trying to manage wound care. The aftercare associated with an incision, a laceration repair, a skin lesion, or a superficial burn can be extensive and complicated, often with multiple medications, bandage care, an Elizabethan collar, and an incredibly stressed patient and pet parent. This negatively affects patient care and the veterinary team as frustrated pet parents call and email frequently, taking veterinary professionals away from patient care in hospital.

There’s now a single solution for improved wound healing for patients, reduction of the home care burden for pet parents, and preservation of emotional health for patient, pet parent, and the veterinary health care team. KeraVet® Gel is a first-of-its-kind wound care product.  As a scientist, safety and efficacy of any new product is top of mind.  I’ve been impressed with the initial studies with this product, which has a keratin-based patent-protected technology to promote a moist wound environment and barrier to the environment as well as a bitterant to deter licking behavior, enabling us to send a patient home without that collar that so often leads to increased stress for both the patient and our client. That said, it is important to note that there can be a risk to the human-animal bond when we frequently apply something to our pets that tastes unpleasant, and for some pets that can be more stressful than protective clothing, bandages, or an Elizabethan collar. Each animal is an individual and their needs should be taken into account when deciding on the best solution for wound healing.

In the right circumstances, though, this product can be a game changer. One of the tenets I lived by as a practice owner was “best medicine leads to best business.” Our clients want to see the value in the care they are investing in, that it’s convenient and safe, and that it addresses their family member’s physical and emotional health. When we choose to use KeraVet® gel, we give our clients a single effective solution addressing both of their needs, thus building trust and compliance, and strengthening the human-animal bond. These are the clients who return and refer and stay lifelong members of our hospitals.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Natalie Marks is a veterinarian, consultant, educator, media expert, an advisor for KeraVet Bio, on the Executive Committee of VANE (Veterinary Angel Network), and an Elite Fear Free Certified Professional. She is passionate about working with colleagues and mentees and moving the needle forward with innovation with companies like KeraVet Bio. Learn more about Dr. Marks at marksdvmconsulting.com and KeraVet Bio at https://keravetbio.com/

Want to learn more about Fear Free? Sign up for our newsletter to stay in the loop on upcoming events, specials, courses, and more by clicking here.

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CEVA Practical Pheromone Use: The Road to a Calmer Pet Experience

CEVA Practical Pheromone Use: The Road to a Calmer Pet Experience

Did you know the smells in an environment can affect the stress and anxiety levels of pets? Join Dr. Natalie Marks as she discusses the prevalence of fear, anxiety, and stress (FAS) in pets, how these can create unwanted behaviors, and methods to alleviate this stress for a calmer experience. FAS leads to a stressful experience in the clinic, grooming, or boarding and daycare environments, as well as in a pet and pet parent’s day-to-day lives. Pheromones are a successful tool to help alleviate stress and anxiety in pets. By combining the use of pheromones with the calm clinic approach, you can help create a calmer experience for pets and pet parents.

Brought to you by our friends at Ceva.

Improving the Emotional Experience via Science of the Senses: Smell

Improving the Emotional Experience via Science of the Senses: Smell

This program will focus on the olfactory experience of canine and feline patients during the veterinary visit and the important role that it plays in the pet’s emotional health and physical health when under veterinary care. Join Jacqui Neilson, DVM, DACVB as she discusses the importance of protection against respiratory pathogens using Fear Free vaccination strategies.

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Como Implementar un Programa Fear Free en la Clínica Diaria Felina (Spanish webinar)

Conoceremos en que consiste el programa Fear Free, sus pilares fundamentales. Revisaremos las características de la especie felina, como percibe el mundo, sus necesidades y como se comunica permanentemente. El comprender y reconocer estos puntos será clave para desarrollar una practica Fear Free. Determinar si nuestros pacientes presentan miedo, ansiedad y estrés será un punto clave para trabajar de una manera acorde, pero fundamentalmente prevenirlas. Nuestras clínicas y hospitales, pueden beneficiarse ampliamente incorporando estas prácticas, sin tener que realizar grandes inversiones ni cambios edilicios.

Happier Cats and Happier Clients: Diagnosing and Treating Feline OA

Course Overview

Michael Petty, DVM, CVPP, CVMA, CCRT, CAAPM, covers how fear, anxiety, and stress can impact pain and vice versa, along with a team- and case-based approach to diagnosing and treating feline OA. A new treatment option, recently approved for controlling the pain associated with feline OA, is also discussed.

This course is approved for one hour of RACE CE. In order to obtain the CE and certificate, you must enroll in and complete the course quiz with a score of 80% or better.

Brought to you by our friends at Zoetis

Seeing Chronic Pain Through Cats’ Eyes

Cats are masters at hiding pain, and pet owners are not aware that changes in behavior can be indicative of pain. This podcast will focus on the specific behaviors that cats with osteoarthritis exhibit, how pain impacts the entire body, and what veterinary professionals can do to manage their feline patients’ OA pain, as well as how cat owners can provide history videos that will aid in the diagnosis.

Brought to you by our friends at Zoetis.

He’s Not Painful: Talking to Owners About Osteoarthritis and Gaining Compliance

Join Amy Newfield, MS, CVT, VTS (ECC), and Alison Gottlieb, BS, CVT, VTS (ECC), as they talk about the importance of osteoarthritis screening with pet owners, creating a checklist, taking videos to show vets during the exam, pain teaching tools (canine/feline), and how to connect with pet owners about osteoarthritis and gain compliance.

Brought to you by Zoetis Petcare.

Osteoarthritis Pain in Dogs: The Art & Value of OA Screening Using Fear Free Principles

Osteoarthritis insidiously, quietly, and progressively robs dogs of their quality of life. Think about it: People with OA don’t go to their doctor complaining of “lameness” – they complain that they’re in pain. Worst of all, the Labrador lifespan study found OA was the most common cause of death when it prompted an end of life decision. In this podcast, Ross H. Palmer, DVM, MS, DACVS, explains that early diagnosis and an exam that “tells you where it hurts” are the keys to successful treatment.

Brought to you by Zoetis Petcare.

Brought to you by Zoetis Petcare.

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