The Hard Conversations No One Trained Us For

High-risk, poor-prognosis, "it may not work": how to deliver hard news and help families decide with clarity and compassion.

Dr. Ernie Ward, Chief Veterinary Officer, VerticalVet

It's 8:40 on a Tuesday morning, and a twelve-year-old Labrador Retriever named Gus has blindsided you. An hour ago, he was "a little slow." Now his gums are white, his abdomen is sloshing with blood, and an ultrasound shows a splenic mass. You reenter the exam room, and his owner already knows something is terribly wrong. What you say in the next ninety seconds sets the tone for everything that follows.

The instinct is to lead with the medicine: hemoabdomen, splenic hemangiosarcoma, anesthetic risk, a guarded prognosis. But by then, the owner may have stopped listening, somewhere around "bleeding.

We were trained to examine, diagnose, and operate. Almost none of us were trained to do this: deliver devastating news, and help a frightened pet owner make a difficult decision, all for a patient who can't speak for himself, when there are no great options.

A skill you can learn

Doing this well can feel like a gift some are born with. It isn't. It's a clinical skill, and like any skill, it can be learned. Physicians have spent decades developing tools for these conversations, like the SPIKES protocol for breaking bad news, and applying that framework in the ER. Veterinarians have adapted that work in our own exam rooms.

Without preparation, we tend to make one common mistake: meeting fear with facts. When someone is flooded with emotion, in an emergency or after sudden bad news, the brain shifts into survival mode. Thinking narrows, memory falters, and it's hard to take in anything new, so piling on detail only buries the message rather than making it clearer. There's a better way.

A roadmap for the conversation

Set the stage. It starts before you walk into the room. Settle on your core message: one or two plain sentences that name what's happening with Gus and the decision the family is facing. Then bring them into a private, quiet room where you won't be interrupted, make sure the people who'll decide are there, and sit down before you say a word.

1. Prepare them, then ask; don't tell. Start with a gentle signal that serious news is coming: "I'm afraid I have serious news about Gus." This gives the client a moment to orient before details arrive. Then ask before you explain: "What is your understanding of what's happening with Gus?" Never put words in their mouth. Try "What are you thinking as we look at the options?" rather than prematurely asking, "Are you thinking about euthanasia?"
   
   
2. Lead with the core message. Use one or two plain sentences: what is happening, and what decision comes next. "Gus has a mass on his spleen that is bleeding into his belly. Our best chance at stopping the bleeding is emergency surgery, and I have to be honest with you: this is serious, and even with surgery, his odds aren't good." Then stop. Give them time to take it in before you add more.
   
   
3. Meet the emotion before the medicine. Tears, anger, silence, or disbelief may come, and your instinct may be to answer with more information. Resist it. Name what you see without judging it: "I can see how shocking this is." Normalize the reaction without minimizing it: "Anyone who loves Gus would need a moment with news like this." Then listen. Empathy is not a detour around the real conversation. It is what makes the real conversation possible.
   
   
4. Map the road; don't recite the risks. A list of disconnected risks just sounds like a wall of bad. Borrowing from surgeon Dr. Gretchen Schwarze's "Best Case/Worst Case" framework, lay out both real paths and paint three honest pictures of each.
   
   If we operate:
   • The best case: Gus gets through surgery, the bleeding stops, and the mass is benign.
   • The worst case: he doesn't survive surgery, or we find a disease that surgery can't meaningfully help.
   • The most likely: "Honestly, somewhere in between. He recovers, but if this is the cancer we're worried about, we can slow it, not cure it, and we add, at most, months, not years."
   
   If we focus on comfort instead:
   • The best case: he stays out of pain, and you get a little time, maybe a few quiet days, and a calm goodbye on your terms.
   • The worst case: he bleeds again suddenly, and the end is frightening instead of gentle.
   • The most likely: "A short, gentle stretch, maybe a few days, and then a clear sign that it's time, and a goodbye you plan rather than fear."
   
   You've hidden no hard truth, but now they can see what each path really means for Gus.
   
   When it helps, give risk as a plain, honest number: "about 9 in 10 come through the surgery itself, and that's only the first hurdle," rather than a vague "about 90% safe." And if you reach for a metaphor, keep it honest, so a comforting image doesn't oversell the odds.
   
   
5. Find the goal, then decide together. Ask what they hope for now: cure the condition, buy good-quality time, or keep Gus comfortable. Name what could go wrong, not just the surgical risks. What would recovery look like? What would a good day look like? What would make them feel that Gus is suffering?
   
   When the hoped-for outcome is no longer realistic, use language that is honest and still caring: "I wish I could tell you this surgery would fix this." "I worry it won't give him the time you're hoping for." "I wonder if our goal should shift to keeping him comfortable."
   
   Do not undercut hope with "but." Use "and" when both things are true: "I can see how much you want to give Gus every chance, and I'm worried surgery may not give him the kind of time you're hoping for."
   
   When the question becomes "Is it time?" a quality-of-life scale, such as Villalobos's HHHHHMM scale, gives families something concrete to hold onto. Hurt, hunger, hydration, hygiene, happiness, mobility, and more good days than bad can help turn guilt into a clearer, kinder decision.
   
   Then make a recommendation based on what they have told you matters most for Gus, not on what you would personally do. Talk about cost without shame. Cost is part of medical decision-making, not a moral failure. And when euthanasia fits Gus's suffering and the family's goals, name it as a compassionate option, not a failure.
   
   Before you leave the room, make sure the plan is clear in their words, not just yours. Ask, "When you're ready to talk with your family, what feels most important for them to understand about Gus and the plan?"
   
   
6. Don't stop at the decision. People in shock often remember less than they think they will, so send the plan home in writing. Include what you know, what remains uncertain, what signs would change the plan, and who to call. Check in the next day when you can.
   
   Acknowledge their grief, too. It often begins on the day of diagnosis, long before the goodbye. And because the world can dismiss pet loss as "just a pet," families may need real support, not just sympathy. Keep grief resources and support numbers where your team can easily offer them.

Words are Medicine

Underneath all six actions runs one truth: your words don't just describe the situation - they change it. Research on the nocebo effect shows language changes how people feel and cope with difficult situations, and a frightened owner sends that fear right down the leash.

And when needed, swap "That's all we can do" for "We've shifted from trying to cure Gus's cancer to keeping him comfortable, and there's a great deal we can do for that."

Drop the false reassurances, and retire the war-on-cancer framing. A peaceful goodbye isn't a war we lost; it's the last, kindest stretch of the road we walked with this family.

You won't do this perfectly, and you don't have to. Pick one action to practice this week. Our patients can't speak for themselves. Let's make our words count.

Here's to braver, kinder conversations,

Dr. Ernie Ward
Chief Veterinary Officer, VerticalVet

PS - Questions or suggestions for "The Altitude"? Email me at This email address is being protected from spambots. You need JavaScript enabled to view it..

Resources for the Hard Cases

Quality-of-life guidance to share with families

• AAHA: How to Assess Your Senior Pet's Quality of Life - built around tools like Dr. Alice Villalobos's HHHHHMM scale.
• To support grieving clients (worth keeping at the front desk)
• Cornell University Pet Loss Support Hotline: 607-218-7457
• Tufts Pet Loss Support Helpline: 508-839-7966
• Association for Pet Loss and Bereavement (APLB): a nonprofit offering moderated chat and video support groups
• 988 Suicide & Crisis Lifeline: call or text 988 if a client may be in crisis

For your team

• 2016 AAHA/IAAHPC End-of-Life Care Guidelines (PDF) - the profession's standard reference for hospice, palliative, and euthanasia care.

Suggested Reading

• Being Mortal: Medicine and What Matters in the End - Atul Gawande
  https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/0805095152
  If you haven't read this one, I'd encourage you to try it out. A surgeon confronts some of medicine's most challenging territories: aging, dying, and the limits of what we can "fix," and shows how real conversations about what matters most lead to better decisions than reflexive treatment. Every chapter will feel familiar to anyone who has stood in an exam room weighing "everything we can do" against "what's right for this patient."
• The Lost Art of Healing: Practicing Compassion in Medicine - Bernard Lown
  https://www.amazon.com/Lost-Art-Healing-Practicing-Compassion/dp/0345425979
  One of my favorites. A legendary cardiologist's reflection on the doctor-patient relationship and the healing and wounding power of words. It's the source of this month's quote and a moving reminder that listening and language are clinical tools every bit as real as those in your surgery pack.
• Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference - Stephen Trzeciak & Anthony Mazzarelli
  https://www.amazon.com/Compassionomics-Revolutionary-Scientific-Evidence-Difference/dp/1622181069
  Another good one. Two physician-scientists marshal decades of hard data to prove what we sense in our bones: that compassion isn't a soft extra but a measurable force that improves outcomes, adherence, and even the well-being of the caregiver. Consider it the evidence base behind everything in this issue.

Quote I’m Contemplating

"Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal." - Bernard Lown, MD, cardiologist (1921-2021)

This quote is from the physician who developed the DC (direct-current) defibrillator and pioneered cardioversion, and who co-founded International Physicians for the Prevention of Nuclear War, which was awarded the 1985 Nobel Peace Prize.

Lown spent a lifetime at the leading edge of cardiac medicine. Yet he concluded that the most powerful instrument he ever wielded wasn't a defibrillator or a drug. It was language.

We feel that truth in vet med every single day. The same diagnosis, delivered in two different ways, can leave one client reassured and ready to decide, while another is paralyzed by fear. We can't always change the facts or the situation. We can always choose how we carry and wield them in the exam room.

That's both a massive responsibility and a genuine comfort. On the days when the medicine runs out, when there's no surgery left to offer and no cure left to chase, our words are still a tool we can use to heal. Not the patient, perhaps. But the person holding the leash will carry that conversation with them for the rest of their life.