Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians.

BACKGROUND: Concerns about ethical conflicts, moral distress, and burnout in veterinary practice are steadily increasing. Root causes of these problems have not been rigorously identified. Little research has been done to evaluate the existence of moral distress in North American veterinarians or to explore its impact on career sustainability and poor well-being. HYPOTHESIS/
OBJECTIVES: Ethical conflict and resultant moral distress are common occurrences in contemporary veterinary practice and negatively impact daily practice life, but may not be identified or labeled by veterinarians as such. ANIMALS: No animals were used in this study.
METHODS: Mixed methods sequential explanatory design; confidential and anonymous on-line sampling of 889 veterinarians in North America.
RESULTS: A majority of respondents reported feeling conflict over what care is appropriate to provide. Over 70% of respondents felt that the obstacles they faced that prevented them from providing appropriate care caused them or their staff moderate to severe distress. Seventy-nine percent of participants report being asked to provide care that they consider futile. More than 70% of participants reported no training in conflict resolution or self-care. CONCLUSIONS AND CLINICAL IMPORTANCE: Veterinarians report widespread ethical conflict and moral distress across many practice types and demographics. Most veterinarians have little to no training on how to decrease the impact of these problems. Ethical conflict and resulting moral distress may be an important source of stress and poor well-being that is not widely recognized or well defined. Well-researched and effective tools used to decrease moral distress in human healthcare could be adapted to ameliorate this problem.

INTRODUCTION

The practice of veterinary medicine has a complex ethical structure that consists of professional obligations to the animal patient, the animal owner, other veterinary professionals and society at large.1 Ethical dilemmas, or situations where the right course of action is not clear, occur when these obligations conflict either with one another, with the veterinarians' own moral standards, or both.2 These types of conflicts are ethical in nature and can cause moral distress. Because of this complex ethical structure, veterinarians may consider moral distress an unavoidable part of veterinary practice. Although some small scale studies have documented ethical conflict in veterinary medicine, much of this work has been done outside of North America.3, 4, 5 Even less has been written about how veterinarians feel about and cope with these kinds of situations.

Moral distress as it pertains to healthcare professionals has been discussed for over 30 years.6, 7 Andrew Jameton originally defined moral distress among nurses in 1984 as “the experience of knowing the right thing to do while being in a situation in which it is nearly impossible to do it.”6 In contrast to the existing literature of the time, Jameton focused on the psychological impact of painful feelings, psychological disequilibrium, or both resulting from barriers to performing actions consistent with one's own moral compass.7 This distinguishes moral distress from other kinds of distress encountered in professional work. Since that time, a large body of research and literature has expanded the definition and application of the concept of moral distress in professional life far beyond the original application.6, 8, 9, 10 Although disagreement exists about the ethical underpinnings of healthcare provider moral distress and the scope of the definition, the literature supports broad agreement that moral distress has measurable impact on patient safety, compassion fatigue, mental health, and professional quality of life.11, 12 Several authors have suggested that a similar link exists in veterinary medicine.13, 14

The purpose of our study was to investigate the hypothesis that veterinarians frequently encounter ethical conflicts during the practice of medicine that cause moral distress, yet may rarely label or recognize these situations as ethical or moral in nature (ie, concerning actions that run contrary to what is considered morally right, in contrast to other kinds of distress). The implicit assumption is that veterinarians may not consider commonly felt distress as being triggered by a conflict between their actions and their personal morals. Instead, they may perceive the situation as “sad” or “upsetting” without acknowledging why. Our study was designed to document the existence of unlabeled ethical conflict in North American veterinary clinical medicine and assess whether it is a frequent and relevant problem for veterinarians. We sought to determine how much formal training veterinarians received at any point in their training about how to navigate these situations. Moreover, the frequency with which veterinarians disagree with requests by animal owners for certain kinds of treatment such as futile or non‐beneficial treatments was investigated. Finally, we inquired about the nature and extent of the distress that veterinarians feel in these situations and what coping methods they have used.

MATERIALS AND METHODS

Between June and September of 2017, a survey of veterinarians who are currently or were formerly practicing in North America was conducted. The participants were members of various professional veterinary associations who received an email invitation to participate directly from their organization or saw an invitation to participate in newsletters or online postings. The professional member organizations that solicited their members for participation were: the University of Pennsylvania School of Veterinary Medicine Alumni Association, The International Veterinary Academy of Pain Management, The Veterinary Emergency and Critical Care Society, The American College of Veterinary Dentistry, The Massachusetts Veterinary Medical Association, The Angell Animal Medical Center Alumni Association, and the DVM/VMD staff members at The ASPCA/Humane Alliance Shelter Veterinarians, The College of Veterinary Medicine at Michigan State University, Angell Animal Medical Center, and The Cummings School of Veterinary Medicine at Tufts University. A notice soliciting participation was posted on the message boards for the small animal internal medicine diplomates of the American College of Veterinary Internal Medicine and on the Equine Vet‐to‐Vet Facebook page.

In addition to these participants, a small number of individuals (30) who attended continuing education meetings at US veterinary conferences in 2016 and 2017 voluntarily provided their email addresses to the authors expressly for the purpose of taking the survey.

No attempt was made to structure which veterinarians were surveyed because the study was designed to use an opportunistic sampling configuration.15

Participants were invited to open the questionnaire in an email or online posting that explained the purpose of the survey and contained a URL link. Participation was entirely voluntary. Veterinarians who chose to participate clicked on a link within the email that brought them to an anonymous online 49 item questionnaire by SurveyMonkey survey software. Please see the Supporting Information for the entire set of questions posed. Although most questions had options for answers offered via a drop down menu, some questions asked for and allowed participants to provide free text answers. Results were tabulated by SurveyMonkey survey software. The study was approved by the Cambridge Health Alliance Institutional Review Board.

RESULTS

Participant characteristics, demographics, and relevant training

See Table 1 and supporting informaion for numerical data. Eight hundred and eighty‐nine individuals responded to our survey. Respondents were from all but 2 states in the United States, and 5% of respondents were from Canada. Nineteen percent of our respondents have been in practice for 1‐5 years, 23.6% for 5‐10 years, and 58% for 10 years or longer. Respondents were approximately equally split between generalist and specialist veterinarians and 93% were currently practicing veterinary medicine. A large variety of practice types was represented, including companion animal, equine, food animal, and exotic animal medicine. When asked about how many hours of instruction or training they received in their veterinary training about resolving differences of opinion about what is best care for patients, most (71%) reported they had received no conflict resolution training. When asked, “In your veterinary training, how many hours of instruction or training in self‐care did you receive?” 79% of respondents reported receiving no such training.

Table 1

Demographics of respondents

	Percent	N
Q1. How long have you been in veterinary practice?
1–5 years	18.79%	167
5–10 years	23.62%	210
Over 10 years	57.59%	512
	Answered	889
	Skipped	4
Q3. In your veterinary training, how many hours of instruction or training did you receive about resolving differences of opinion about what is best care for patients?
None	70.75%	629
1–5 hours	22.72%	202
More than 5 hours	6.52%	58
	Answered	889
	Skipped	4
Q4. In your veterinary training, how many hours of instruction or training in self‐care did you receive?
None	78.54%	699
1–5 hours	17.87%	159
More than 5	3.60%	32
	Answered	890
	Skipped	3
Q5. Do you have a specialty within vet medicine?
Yes	48.76%	434
No	51.24%	456
	Answered	890
	Skipped	3
Q7. Are you currently practicing clinical veterinary medicine or have you been in the past 3 years?
Yes, currently	92.92%	827
Yes, in the past 3 years	4.94%	44
No	2.13%	19
	Answered	890
	Skipped	3
Q9. Are you a solo practitioner?
Yes	11.15%	98
No	88.85%	781
	Answered	879
	Skipped	14

The causes of ethical conflict

See Table 2 for numerical results. When asked how often they had conflicts with pet owners about how to proceed with the care of their patients, 32% said “often” and 53% said “sometimes.” Most (68%) said they dealt with these situations by discussing them with colleagues and 15% said they did nothing when these scenarios occurred. Respondents were given the option of explaining in free text how they dealt with this conflict. Many participants expressed their belief, via free text answers, that ultimately, pet owners have the final say in care decisions although many reported taking action when they disagreed with an owner's decision. Participant responses included several comments such as “The situations of [sic] just part of veterinary practice” and “Honestly this doesn't bother me that much ‐ their pet is their property to do what they want/can do”. In contrast to those comments, many comments indicated that, in some situations, veterinarians expressed their disagreement to the client and that discussion may have included a refusal to provide continued care. Examples of these answers included “Resolved it to our mutual satisfaction; very rarely, have to respectfully fire the client” and “I try to find common ground with owners. An owner cannot compel me to perform treatments I consider inappropriate, just as I cannot compel them to elect euthanasia. Rarely I have had to recuse myself from caring for a pet.” Many veterinarians indicated, again via free text answers, that they spend a great deal of time grappling with this problem in lengthy discussions with clients and peers.

Table 2

Survey responses to questions about ethical conflict and moral distress

	Percent	n
Q12. How often have you had a conflict of opinion with pet owners about how they wish to proceed in the treatment of their pets?
Never	0.34%	3
Rarely	14.30%	126
Sometimes	52.89%	466
Often	31.56%	278
Always	0.91%	8
	Answered	881
	Skipped	12
Q13. What have you done in these situations, if anything?
Nothing	14.86%	130
Discussed with colleague	67.89%	594
Other (please specify)	41.60%	364
	Answered	875
	Skipped	18
Q14. How often have you been asked to do something in the course of your clinical practice that feels like the wrong thing to do?
Never	1.83%	16
Rarely	46.91%	410
Sometimes	45.31%	396
Often	5.61%	49
Always	0.34%	3
	Answered	874
	Skipped	19
Q15. How often have you complied with these requests?
Never	23.21%	198
Rarely	45.96%	392
Sometimes	23.56%	201
Often	7.03%	60
Always	0.23%	2
	Answered	853
	Skipped	40
Q16. Did you feel like you had the right to say no?
Yes	71.63%	611
No	28.37%	242
	Answered	853
	Skipped	40
Q17. How often have you had a case where you felt like you could not do the “right thing”?
Answer choices	Responses
Never	4.28%	37
Rarely	33.06%	286
Sometimes	49.25%	426
Often	13.29%	115
Always	0.12%	1
	Answered	865
	Skipped	28
Q18. What prevented you from doing the right thing?
Answered via free text	761
Skipped	132
Q19. When you have had cases like this, how much distress has it caused your staff, at its worst?
None	2.98%	24
Mild distress	24.07%	194
Moderate distress	54.34%	438
Severe distress	18.61%	150
	Answered	806
	Skipped	87
Q20. When you have had cases like this, how much distress has it caused you, at its worst?
None	1.00%	8
Mild distress	21.02%	169
Moderate distress	49.88%	401
Severe distress	28.11%	226
	Answered	804
	Skipped	89
Q21. What, if anything, have you done to cope in these situations?
Done nothing	17.15%	136
Talked with partner or friend	72.51%	575
Discussed with colleague	72.51%	575
Sought professional help	11.73%	93
Other	15.89%	126
	Answered	793
	Skipped	100
Q22. How often have you received what you consider to be inappropriate requests for euthanasia?
Never	6.95%	58
Rarely	63.67%	531
Sometimes	26.86%	224
Often	2.40%	20
Always	0.12%	1
	Answered	834
	Skipped	59
Q23. How often have you complied with these requests?
Never	39.74%	308
Rarely	37.68%	292
Sometimes	11.48%	89
Often	7.35%	57
Always	3.74%	29
	Answered	775
	Skipped	118
Q24. When you have had requests like this, how much distress has it caused you or your staff, at its worst?
None	3.89%	30
Mild distress	32.81%	253
Moderate distress	44.62%	344
Severe distress	18.68%	144
	Answered	771
	Skipped	122
Q25. How often have you managed cases where you feel that a pet owner is requesting treatment when you consider those efforts to be futile?
Answer choices	Responses
Never	0.96%	8
Rarely	20.38%	170
Sometimes	56.95%	475
Often	21.58%	180
Always	0.12%	1
	Answered	834
	Skipped	59
Q26. What strategies did you use to manage this situation?
Done nothing	16.93%	138
Discussed with colleague	70.92%	578
Other, if so what?	43.19%	352
	Answered	815
	Skipped	78
Q27. Have you ever refused to provide a treatment that you feel is futile?
Yes	50.73%	416
No	49.27%	404
	Answered	820
	Skipped	73
Q28. How often do you feel conflicted or upset because a pet owner refuses to do what you think is in the best interest of your patient?
Never	1.33%	11
Rarely	18.89%	156
Sometimes	54.96%	454
Often	23.49%	194
Always	1.33%	11
	Answered	826
	Skipped	67
Q29. How have you opted to cope with these feelings?
Done nothing	21.99%	179
Talked with partner or friend	72.48%	590
Discussed with colleague	76.29%	621
Sought professional help	9.58%	78
Other	15.36%	125
	Answered	814
	Skipped	79
Q30. How often do you recommend euthanasia to pet owners if they have not brought up the topic?
Never	2.68%	22
Rarely	12.18%	100
Sometimes	57.13%	469
Often	28.01%	230
	Answered	821
	Skipped	72
Q31. Do you recommend euthanasia to pet owners when they have already said they will not consider it?
Answer choices	Responses
Yes	85.00%	680
No	15.00%	120
	Answered	800
	Skipped	93
Q33. How often have pet owners' attitudes or beliefs about treatment made it difficult to provide the care you think is appropriate?
Never	0.49%	4
Rarely	25.67%	210
Sometimes	59.17%	484
Often	14.30%	117
Always	0.37%	3
	Answered	818
	Skipped	75
Q35. How much distress has this caused you, at its worst?
None	3.29%	26
Mild distress	27.56%	218
Moderate distress	50.57%	400
Severe distress	18.58%	147
	Answered	791
	Skipped	102
Q36. How often have you felt distressed or anxious about your work?
Never	1.00%	8
Rarely	12.23%	98
Sometimes	34.46%	276
Often	43.32%	347
Always	8.99%	72
	Answered	801
	Skipped	92
Q37. How often have you been asked to do things that are outside of your skill set for financial or other reasons?
Never	6.37%	51
Rarely	36.08%	289
Sometimes	44.07%	353
Often	12.11%	97
Always	1.37%	11
	Answered	801
	Skipped	92
Q38. How often do these requests cause conflict?
Never	4.03%	30
Rarely	40.94%	305
Sometimes	41.07%	306
Often	10.74%	80
Always	3.22%	24
	Answered	745
	Skipped	148
Q39. How often have you had disagreements with other veterinarians about how best to manage a case you share?
Never	4.64%	37
Rarely	46.80%	373
Sometimes	42.79%	341
Often	5.40%	43
Always	0.38%	3
	Answered	797
	Skipped	96
Q40. How have you resolved such situations?
Done nothing	18.47%	140
Discussed with colleague	87.20%	661
Other	20.84%	158
	Answered	758
	Skipped	135
Q41. How much distress have these disagreements caused you, at its worst?
None	5.28%	40
Mild distress	47.10%	357
Moderate distress	34.04%	258
Severe distress	13.59%	103
	Answered	758
	Skipped	135
Q42. Are disagreements with other veterinarians more or less distressing than when you disagree with a pet owner?
More distressing	38.63%	277
Less distressing	35.43%	254
About the same	25.94%	186
	Answered	717
	Skipped	176
Q43. How often have you had disagreements with other members of your staff (ie, non‐veterinarians) about how best to proceed with a clinical case?
Never	14.12%	111
Rarely	50.64%	398
Sometimes	32.32%	254
Often	2.80%	22
Always	0.13%	1
	Answered	786
	Skipped	107
Q44. Do you feel that your compassion or ability to empathize toward your patients has waned over the course of your practice?
Yes	26.14%	206
Sometimes	32.49%	256
No	41.37%	326
	Answered	788
	Skipped	105
Q45. Do you feel like you have lost compassion for pet owners over the course of your practice?
Yes	31.35%	247
Sometimes	43.15%	340
No	25.51%	201
	Answered	788
	Skipped	105
Q46. How often do you feel like you are just going through the motions?
Never	8.52%	67
Rarely	30.53%	240
Sometimes	41.48%	326
Often	17.68%	139
Always	1.78%	14
	Answered	786
	Skipped	107
Q47. Do you ever feel like you prioritize the needs of animal owners over your patients?
Yes	60.00%	471
No	40.00%	314
	Answered	785
	Skipped	108
Q49. Do you feel conflicted about this?
Never	2.60%	12
Rarely	19.09%	88
Sometimes	47.72%	220
Often	25.38%	117
Always	5.21%	24
	Answered	461
	Skipped	432

In response to our question, “How often have you been asked to do something in the course of your clinical practice that feels like the wrong thing to do?” 45.3% said “sometimes” and 5.6% said “often.” Although approximately 25% of respondents said they never complied with these requests, 45% of respondents said they complied rarely, 23.6% said they sometimes did so, 7% said they often did so and <1% said they always did so. Sixty‐two percent of respondents stated that sometimes or often they felt they could not “do the right thing.” Many respondents in free text answers cited financial constraints as the most common obstacle to doing what they felt was right, but some also cited external pressure from an employer or management policies.

With respect to euthanasia, 29.3% stated that they sometimes or often receive what they consider to be inappropriate requests for the procedure, and approximately 19% of respondents said they sometimes or often acceded to these requests. Almost 45% said it caused them or their staff a moderate amount of distress and 18.7% reported it caused them or their staff severe distress.

Seventy‐nine percent of respondents said that they sometimes or often have received requests to provide treatment that they considered futile. Approximately half of our respondents have refused such requests.

Moral distress levels and coping methods

Overall, 73% of respondents stated that not being able to do the right thing for a patient caused their staff moderate to severe stress and 78% replied that it caused them moderate to severe distress.

Sixty‐nine percent of respondents said they felt they had moderate to severe amounts of distress as a result of not being able to provide care they thought was appropriate. When asked “How often have you felt distressed or anxious about your work?” 35% of our respondents reported “sometimes” and 43% answered “often.” When asked how often they had been asked to do things that are outside of their skill set for financial or other reasons, over 50% of our respondents said that they sometimes or often were so asked.

Twenty‐six percent of respondents said their empathy for their patients had waned over time and 31% said that their empathy for pet owners had waned over time, and 60% of respondents said they feel like they have prioritized the needs of animal owners over their patients.

When asked about coping mechanisms when they felt they could not do the right thing, 11% said they had sought unspecified professional help. And when asked about how they coped when “a client refuses to do what you think is in the best interest of your patient”, 9% of respondents indicated that they sought professional help. In both of these situations, over 75% of participants indicated that they discussed the situation with a partner, friend, or colleague, whereas approximately 20% responded that they “did nothing.”

DISCUSSION

Our study was undertaken to document and explore elements of the problem of moral distress among North American veterinarians. After a number of well‐publicized suicides, the veterinary profession has acknowledged the importance of good mental health and wellness as a foundation of practice.16, 17 A Centers for Disease Control and Prevention survey of over 10 000 US veterinarians in 2014 determined that more than 1 in 6 veterinarians might have experienced suicidal ideation and nearly 1 in 10 may have serious psychological distress.18 Discussions of burnout, compassion fatigue and sustainability have become regular features of continuing education seminars and, more recently, veterinary school curricula. So far, little has been written about the causes of these serious problems, although a reassuring survey of veterinary students disputed the suspicion that veterinarians may be at higher risk than the general population for mental health problems because of adverse childhood experiences.14, 19, 20

Our study findings show that veterinarians regularly face conflict and ethical distress in the normal course of practice. The findings implicate moral distress in generating feelings of burnout and compassion fatigue, raising concern that moral distress may contribute to the development of mental health problems among veterinarians. We join other researchers in veterinary profession in urging that the roots of stress and poor well‐being in the veterinary community be fully explored and addressed by professional societies.

Although our findings document that moral distress is common among North American veterinarians, it differed from other related studies conducted outside of North America in focusing more on the impact and coping mechanisms in participant‐identified clinical situations of ethical dilemmas.4, 5 Additional differences from studies in other regions likely come from differences in veterinary business models, veterinary cultural practices, and societal norm differences. Our study also invited participants to contribute examples from their own experience, adding detail to the results.

Our findings show that many veterinarians are distressed and anxious about their work and are troubled by many of the requests that are made of them. Many feel like they are just “going through the motions” and although many are troubled, very few receive any professional help. The majority of respondents who do take action to cope with their distress talk with colleagues or others, presumably informally, instead of seeking professional help.

Even if our findings are not broadly representative, they still are highly concerning. They show that many veterinarians are not happy in aspects of their work, feel discomfort and distress about various elements of their work, and do not have many outlets for their distress. The results validate current concerns for the mental health and well‐being of veterinarians given that they suffer in the face of multiple conflicts at work and utilize very few outlets for support and help.

Our study has some important limitations. Self‐selection bias to participate (particularly if respondents already felt distress) and variable access to professional member organizations may have affected the representativeness of participant characteristics and results. Because of the structure of the survey questions, the results did not allow tracking of responses by practice type or demographic. Although the goal of documenting the frequency, severity, and common causes of moral distress in individuals was achieved, the nonrandom survey design precludes the ability to draw statistical, population‐based conclusions about prevalence.

Given how little training participants reported in resolving differences of opinion regarding veterinary care and in personal self‐care, the implications of the findings are clear. They offer a clarion call for increased awareness of moral distress and more instruction in ethical conflict and self‐care for veterinarians‐in‐training. A recent survey of the American Veterinary Medical Association Council of Education‐accredited US veterinary school curricula found that 18 of 30 provided dedicated courses in ethics.21 Because most respondents (>70%) did not report any training in navigating ethical dilemmas, either the training they received did not provide enough practical guidance or ethics in the curriculum is a relatively recent addition. Regardless of the explanation, training in recognizing, naming, and navigating ethical conflict as part of veterinary professional education could start to address the problem. Normalizing the need for self‐care and providing practical training in self‐care early in veterinary professional life could help decrease the impact of ethical conflict.

Perhaps even more concerning is the idea that although US veterinarians are well aware of the mental and physical toll of practice, there is little acknowledgment or understanding of the frequency and role that ethical conflict plays. We hypothesize, based on our study and experience in providing continuing education on navigating moral distress to veterinarians, that several important reasons for this problem exist. The relative deficiency, compared to other regions in the world, in the study and publication of research on veterinary ethical conflict and moral distress is notable. Although it is unclear whether this deficiency is cause, effect, or both, it may reflect both a lack of ethical literacy and that these distressing situations are not viewed through the lens of ethics. Many veterinarians wrote that they consider these conflicts an inevitable part of veterinary practice. They may accept ethical conflict as an inherent part of veterinary practice without recognizing that it might be cumulatively damaging or that they can mitigate its impact. One striking aspect of the comments is that many view providing care with which they disagree as an obligation because of animals' legal status as property although (at least in the case of companion animals) owners strongly identify their pets as family members rather than property, regardless of legal definitions.22 The perception that veterinarians are duty‐bound to provide requested, but non‐recommended, treatments suggests that this feeling of obligation may come from within the veterinary culture and professional ethics itself, perhaps reflecting a cultural conflict between pets as family members and as property. Physicians struggle with this feeling of obligation as well, even though they are not legally or professionally ethically bound to provide non‐beneficial care to patients. Profession‐wide discussions and exploration of the culture surrounding provision of non‐beneficial (ie, futile) care to veterinary patients will be important in helping veterinarians decrease their moral distress.

Recognizing, acknowledging, and labeling conflict and distress as ethical in nature are important first steps in combating moral distress. By means of lessons learned from research about nurses, we can work to improve moral agency (ie, the ability or freedom to make moral judgements and be held accountable), moral imagination (ie, viewing conflict and situations through a lens of ethics), and developing a morally supportive community to decrease moral distress in our profession.23 We plan, in future interview‐based research, to more fully explore the obstacles faced in both recognizing and alleviating moral distress. Our findings indicate the importance of considering moral distress in future evaluations of risk factors for poor mental health outcomes. We hope other investigators will undertake research to define and examine potential links between moral distress and mental health problems in veterinarians.

Addressing moral distress in veterinary medicine will require self‐assessment and adjustments in individual self‐care, but without changes in practice culture, business models, and other external factors that increase burnout and compassion fatigue, this problem will only be partially solved. For example, veterinarians spend large amounts of practice time discussing and negotiating non‐medical decisions with clients (eg, economic decisions, quality of life assessments). Sharing this duty with other trained professionals, such as social workers, might decrease the emotional burden of this kind of work. Additionally, the relative lack of standardized guidelines for care in veterinary medicine may improve moral agency among individual veterinarians, but it might also increase the burden of using personal judgment in deciding what care to offer. This may increase the ethical dilemmas perceived by individual veterinarians. Potential institutional solutions to moral distress include formation of ethics committees, discussion and support groups, and ethics consultation services, as exist in human hospitals and at 1 author's (Lisa Moses) clinical institution.

Veterinarians would benefit from training and support in managing the distress they inevitably will feel in their everyday work. Our findings indicate that, to date, such training and support have not yet happened. We hope our findings as well as future research will lead to supportive, positive changes that will make the practice of veterinary medicine sustainable, less damaging and, in the end, better for veterinarians, their patients, and staff.

CONFLICT OF INTEREST DECLARATION

Authors declare no conflict of interest.

Appendix S1: Supplementary Material.

Click here for additional data file.