Visiting a veterinary hospital can be a stressful and frightening experience for many pets (Figure 11.1). They may feel overwhelmed by the new environment, unfamiliar smells, and the possibility of undergoing medical procedures. This stress is often heightened if the pet is already ill or in pain (Lloyd 2017). Caregivers are sensitive to their pets’ distress, which can negatively impact the perceived welfare of the animals during veterinary care (Mariti et al. 2016, 2017). In fact, the stress associated with veterinary visits is a substantial barrier to care, causing caregivers instead to turn first to the internet or friends for advice and information (Partners for Healthy Pets 2014). Moreover, fearful and anxious pets present potential safety concerns for veterinary staff (Campbell 1985; Reimer 2020). Research has shown that nearly 33% of dogs display aggressive behaviors, and up to 10% of these dogs exhibit severe aggression (Edwards et al. 2019; Stellato et al. 2021). Animal‐related injuries like bites and scratches not only cause physical harm but also pose the risk of transmitting zoonotic diseases (Campagna et al. 2023). In some cases, these injuries can be fatal (Epp and Waldner 2012). Dog bites alone constitute approximately 60–90% of animal bites leading to emergency room visits, and cat bites account for another 5–20% (Maniscalco and Edens 2022). Such incidents are more prevalent among less experienced veterinary staff, indicating the need for thorough education in understanding animal body language and proper handling techniques (Voss et al. 2023). Given this, it is important to develop and implement strategies to mitigate fear and anxiety in pets during their visits to veterinary hospitals (Reimer 2020). Recognizing the signs of fear and anxiety, addressing them early, and implementing techniques and protocols designed to create a more comfortable environment can improve the overall wellbeing of patients and enhance the veterinary experience for both pets and their caregivers (Figure 11.2) (Haywood et al. 2021; Reimer 2020). Recognizing the signs of fear, anxiety, and frustration in pets is the first step in addressing these emotions effectively. Both dogs and cats exhibit a range of behaviors when distressed, including panting, pacing, trembling, vocalizing, hiding, showing aggression, scratching, and biting. Observant caregivers can learn how to identify these signs at home and share their observations with the veterinary team. Early recognition allows for proactive measures to be taken to alleviate fear, anxiety, and frustration before they escalate. Figure 11.1 This dog is fearful, as is evident from her whale eye (prominent whites of her eyes), ears back, tight mouth, looking away, and stiff body. Source: rocketclips/Adobe Stock Photos. Figure 11.2 This cat is fearful, as evident from the dilated pupils, wide eyes, tight face, and flattened ears. Source: Андрей Журавлев/Adobe Stock Photos. The stress for pets often begins at home, before they even reach the veterinary hospital. A significant number of pet caregivers notice signs of stress in their animals, particularly cats, before leaving home (Karn‐Buehler and Kuhne 2022). Over 50% of cat caregivers report observing stress indicators in their cats while still in their house (Mariti et al. 2016). Factors such as the sight of the carrier, the car journey, and the anticipation of an unknown experience contribute to this stress. Caregivers can help reduce this arousal by implementing training and counterconditioning and desensitization techniques at home (Yin 2009). By lessening the anxiety associated with travel, pets can arrive at the clinic in a more relaxed state, which not only benefits the pets but also makes caregivers less anxious and more likely to return for regular wellness and sick visits (Nibblett et al. 2015; Partners for Healthy Pets 2014). Animals unfamiliar with their carriers or anxious about car travel tend to show increased signs of fear, anxiety, and stress at the clinic (Pratsch et al. 2018; Tateo et al. 2021). Therefore, cats and small dogs should become accustomed to their carriers well in advance of a veterinary visit. The carrier should be seen as a safe space where the pet can willingly enter and remain relaxed, from the moment they enter it, throughout the veterinary appointment, and until they arrive back home. There are various styles of carrier available, and veterinary teams can provide guidance to clients on choosing the most suitable one for their pet. The carrier should be appropriately sized, especially for older or arthritic animals who need extra space for comfort. The design should allow for quiet and easy disassembly, enabling veterinary staff to access the pet while they remain comfortable inside (Figures 11.3 and 11.4) (Taylor 2020). For pets that may require sedation injections at the hospital, softer, mesh carriers are advantageous, as they allow for the injections to be administered through the carrier material. Figure 11.3 A carrier with a shoulder strap can provide stability. Source: JackF/Adobe Stock Photos. Figure 11.4 Ideally carriers should be able to be easily disassembled for opportunities to conduct examinations where the cat feels safe. Source: phoenix021/Adobe Stock Photos. Caregivers can help their pets get comfortable with a carrier by using appealing incentives such as food or toys. Start by placing the pet’s meals near the carrier, gradually moving the food bowl further inside to encourage exploration. Scattering treats within the carrier can also entice the pet to explore it at their own pace. For cats, who are naturally curious about enclosed spaces, simply placing the carrier in a common area may prompt them to enter on their own. When they do, rewarding them with food reinforces this behavior. Pets that are more motivated by play than by food might respond well to lure toys or flirt poles, which can be used to engage them in and around the carrier. If a pet is initially apprehensive, use a stepwise approach to introduce the carrier. Start with only the bottom half of the carrier, and gradually add the top and door later. Place a soft blanket or towel inside and use calming pheromone sprays such as Feliway® for cats or Adaptil® for dogs (both CEVA Animal Health Ltd, Wooburn Green, UK) (Doonan 2018) to further enhance the carrier’s appeal and comfort. Studies have shown that carrier training effectively reduces stress in pets during car rides and veterinary visits (Pratsch et al. 2018). The main goal of carrier training is to develop a positive emotional association between the pet and the carrier, sometimes for extended periods (Table 11.1). Such behavior can be encouraged and reinforced through cues like “kennel up” or “crate.” Pets should never be forced into carriers; instead, using cues like “kennel up” or “crate” can encourage pets to enter the carrier on their own, reinforcing a positive experience. When transporting pets in their carriers, they need to feel comfortable with the movement involved, such as walking, lifting the carrier, and placing it in the car. Once pets voluntarily enter the carrier and remain relaxed inside with the door closed, caregivers can begin practicing moving the carrier with the animal inside. This process should be gradual to keep the pet’s anxiety level low and avoid stress. If the pet shows signs of increased arousal, the caregiver should slow down and return to the previous step where the pet was comfortable. To avoid swaying and bumping, the bottom of the carrier should be supported with both arms for steady and smooth transport, rather than relying on a handle or shoulder strap that allows the carrier to swing (Figure 11.5). For animals not being transported in a carrier, they should be properly conditioned to a collar or harness. Avoid using restraint devices that could cause fear, anxiety, stress, or pain such as pinch, prong, choke, or shock collars. Collars or harnesses should be properly fitted for comfort and should not impair movement. Avoid retractable leashes or collars that are too loose, as these could allow pets to escape. A front clip harness with a standard 4–6 ft leash is ideal (Figure 11.6). Table 11.1 Carrier training steps. Figure 11.5 Support is needed when carrying a carrier to increase security and stability. Source: EdNurg/Adobe Stock Photos. Figure 11.6 A front clip harness is ideal to use for a dog to reduce pulling and provide maximum safety. Source: Christine Calder (book author). Transport can be a source of stress for many animals (Padalino 2015; Van Haaften et al. 2017). Similar to carrier acclimation, helping pets form a positive conditioned emotional response to travel has numerous benefits. Begin the acclimation process below the pet’s emotional threshold, breaking the experience down into its simplest components. Start with activities outside the car while the engine is off, gradually encouraging the pet to enter the car on their own. Use ramps or stairs for pets unable to jump. Make the car comfortable with soft bedding, and use pheromone sprays to create a welcoming environment. Food and toy lures can also make the car more inviting. When riding in the car, pets should be secured in a safe location (Figures 11.7 and 11.8). For cats, the ideal spot is on the floor behind the passenger seat while dogs should be in an impact‐resistant crate secured to the floor, not on a seat. Playing music, such as “Through a Dog’s Ear” or “Music for Cats,” can help create a calm and relaxing environment (https://icalmpet.com). Once the pet is settled and relaxed in the car with the engine turned off, the caregiver can turn the engine on and offer rewards like food or toys to help the pet adjust to the sounds and vibrations of the engine. Start with short drives, gradually increasing the duration until it matches the time required to reach the clinic. During these rides pets can be given treats in long‐lasting toys, such as Kongs® stuffed with frozen, canned food, peanut butter, or cheese. A remote treat dispenser can also used for this purpose. Figure 11.7 The safest location for cats to ride is in a carrier, on the floor behind the passenger seat. Source: Bunny Approved LLC / http://bunnyapproved.com/road‐trip‐transporting‐rabbits‐in‐a‐car (accessed February 5, 2024). Figure 11.8 For dogs the safest location to ride is in the back in an impact‐resistant crate. Source: lifewithkleekai.com / https://lifewithkleekai.com/impact‐collapsible‐vs‐stationary‐dog‐crates (accessed February 5, 2024). All aspects of an animal’s journey during the car ride can affect their behavior and need to be considered. For example, some animals may experience nausea during transport due to the car’s movement or the sights and sounds passing by. Administering maropitant citrate at least two hours before travel, along with practicing smooth and safe driving techniques to minimize bumps and rapid turns can help reduce the chance of motion sickness. Pets may also react to external sights through the car windows, such as other dogs on walks. To address this, accessories like ThunderCaps® or Doggles® can be used to help limit their view, and window clings an be installed to obscure the pet’s view from inside the vehicle. For dogs sensitive to the noise of the car, sound‐damping ear muffs can be a helpful solution (Figure 11.9). Figure 11.9 Sound‐dampening ear protectors can reduce noise sensitivity when riding in the car. Source: Christine Calder (book author). Despite thorough preparation at home and during the car ride to the veterinary hospital, some animals may still experience fear, anxiety, or stress during veterinary visits. Pre‐visit pharmaceuticals can help reduce their arousal levels, making the journey and the veterinary experience significantly less stressful. Entering the veterinary clinic is a significant stressor for many animals. One study indicated that less than 50% of healthy dogs presented to a hospital are able to enter without fear (Doring et al. 2009). Similarly, another study found that only about 25% of cats remain relaxed in the waiting room (Mariti et al. 2016). When animals are fearful, subsequent veterinary visits can exacerbate negative welfare states for both the patient and the client (Reimer 2020; Simpson 1997). Animals learn to associate these negative emotions with the veterinary clinic, leading them to anticipate negative experiences in similar contexts in the future (Overall 2013; Reimer 2020). To promote positive behavioral and emotional health in patients, veterinary clinics must take proactive steps to create a more welcoming and less intimidating environment. Veterinary professionals need to prioritize preventing negative experiences for both clients and patients (Edwards et al. 2019; Tateo et al. 2021). This approach requires consistent integration and utilization of these methods throughout the veterinary hospital, from the moment the pet enters, continuing for their entire stay. The entryway and waiting room are among the most stressful areas of the hospital, so creating a low‐stress environment should start with the design of these spaces. (Mariti et al. 2015, 2016). Studies indicate that dogs are significantly less stressed when waiting outside rather than inside the waiting room (Lind et al. 2017; Perego et al. 2014). To minimize stress, patients and clients should be directed to go directly to an exam room upon entering the hospital (Engler et al. 2017), bypassing the waiting room whenever possible. Separate waiting areas for dogs and cats help minimize stress and prevent accidental encounters (Figure 11.10) (Taylor et al. 2022). In the veterinary hospital, dogs should be on a short, nonretractable leash and cat carriers should be placed on elevated surfaces such as a shelf or chair when in the waiting room (Taylor 2020). Covering the carrier with a pheromone‐infused towel can block visual stimuli, mute auditory stimuli, and help the cat feel safer and more relaxed (Herron and Shreyer 2014). Plug‐in species‐specific pheromone diffusers in the waiting areas can also contribute to a more relaxed atmosphere (Doonan 2018; Engler et al. 2017; Mills et al. 2006). Playing cat and dog‐specific music and keeping ambient noise levels to a minimum further reduce stress (Engler et al. 2017; Furgala et al. 2022; Kogan et al. 2012). Efforts should be made to maintain a space free of harsh or unpleasant odors to further reduce stress. At the veterinary hospital, the scale often causes significant stress for many patients, sometimes even more than the rest of the waiting room (Hernander 2008). When weighing a patient, they should never be forced onto the scale. Placing a nonslip mat on the scale helps reduce slippage (Doring et al. 2009). Additionally, placing a shelf with food near the scale allows clients to reward their dogs for stepping onto the scale. Teaching dogs to nose target, step up, and station are also effective methods to minimize stress and encourage voluntary cooperation. Figure 11.10 Separate cat waiting rooms are ideal, and cats should remain in their carrier and elevated off the floor while waiting. Source: beavera/Adobe Stock Photos. Placing the scale in an area where animals can walk directly onto and off it without having to enter a confined space or step onto an elevated surface can reduce fear and anxiety associated with the scale. Ideally scales should be recessed into the floor. Use food lures, treat trails, or lickable mats can help encourage an animal to walk onto and stay on the scale until their weight can be accurately measured. Establishing a relaxed atmosphere within the clinic significantly lowers stress levels in both pets and their caregivers. A calm and welcoming environment encourages clients to routine wellness checks or seek help earlier during an illness, rather than delaying until the pet’s condition becomes critical (Volk et al. 2011). Prioritizing the comfort and wellbeing of both pets and their caregivers, can greatly enhance the overall experience at the veterinary hospital. In addition to the waiting room, the exam room is often a significant source of fear and anxiety for patients. Studies reveal that only about 20% of cats remain relaxed upon entering the exam room, and this number drops to only 15% when they are placed on the exam table (Mariti et al. 2016). Therefore, veterinary professionals must prioritize minimizing patient fear, anxiety, and stress in their patients to promote positive welfare states and conduct accurate physical exam assessments (Bragg et al. 2015; Frank 2014). There are numerous strategies that veterinary clinic staff can utilize to make the exam room more comfortable for both clients and patients. Providing a sense of choice, control, and comfort is essential in reducing fear and stress in animals (Mellor 2016). Allowing the patient to explore the exam room during the history‐taking and visual exam can help them acclimate and become more at ease. For those in carriers, letting them exit on their own is preferable, and if this is not possible, disassembling the carrier is a better option than forcing them out. If the pet seems to favor a particular area of the exam room such as under the table or near the sink, staff should attempt to examine them in that area if possible. Allowing cats to be “hidden” during the exam is critical to their wellbeing; this can be accomplished by using their carrier, baskets, or loosely wrapped towels (Heath 2020; Taylor 2020). Consider the exam room from the perspective of the patient’s five senses (Taylor et al. 2022). Use species‐specific exam rooms and clean thoroughly between each appointment to maintain a welcoming environment. Playing species‐specific music can further enhance relaxation and has been shown to reduce stress in both clients and patients during their clinic visits (Engler et al. 2017; Hampton et al. 2020; King et al. 2022). Using pheromones and warmed, pheromone‐infused towels can help to make animals feel less anxious and aid in handling (Mills et al. 2006; Pereira et al. 2016). Additionally, nonslip mats should provide secure footing, and offering a variety of treats caters to the patient’s preferences for flavor and texture. Research indicates that over 75% of dogs display fear and stress‐related behaviors during veterinary exams (Doring et al. 2009; Travain et al. 2015). Similarly, at least 85% of cats exhibit fear‐based and stress‐related behaviors during exams (Tateo et al. 2021). Therefore, the physical exam in a veterinary clinic should be conducted in a manner that significantly reduces fear, anxiety, and stress for the animal. Allowing caregivers to stay with their pets during the examination can help minimize stress in patients. They can offer distractions (e.g., food, toys, grooming), to alleviate stress and improve the overall experience (Csoltova et al. 2017). Avoid taking temperatures in healthy animals, and adjust the order of physical examinations from least aversive to most aversive based on the animal’s body language. Fecal samples can be collected at home, and caregivers can safely obtain ear swabs and lift lips to assess teeth when needed. Always use minimal handling, and encourage staff to participate in professional development opportunities that focus on animal welfare (Riemer et al. 2021; Scherk 2022; Taylor 2020). Pursuing handling certifications such as Low Stress Handling® Silver Certification (LSHS‐C; www.cattledogpublishing.com), Fear Free™ certification (FFCP; https://fearfreepets.com), and Cat Friendly Practice® certification (CFP; https://catvets.com/cfp/veterinary‐professionals) equips veterinary professionals with the skills and knowledge necessary to handle animals in a way that minimizes stress and promotes a positive experience for both the animal and their caregiver (Table 11.2) (Scherk 2022). Table 11.2 Most common certifications for veterinary professionals. Kennel wards in veterinary hospitals, often characterized as crowded, loud, and high‐traffic areas, can be significant stressors for animals undergoing prolonged stays (Fullagar et al. 2015). However, veterinary staff can employ various strategies to maximize comfort in these environments. Appealing to an animal’s five senses is a key strategy in promoting positive welfare. Separating dogs and cats into different wards and using species‐specific pheromone products can help create a more comforting atmosphere (Siracusa et al. 2010). Visual and auditory stimuli can be minimized by hanging towels in front of cages or using opaque plexiglass shields, which allow staff to monitor the animals (Rodan and Heath 2016; Stoneburner et al. 2021). Providing hiding spaces, like boxes or carriers, is especially important for cats (Buckley and Arrandale 2017). All cages should face the same direction to prevent direct visual contact between animals. The same is true with kennels and runs. Barriers may be needed. Minimizing noise and disturbances helps maintain a predictable environment, which is beneficial for the animals. Particularly noisy animals might be housed in separate locations to further reduce stress for other patients (Stella et al. 2014; Taylor et al. 2022). Playing classical or species‐specific music can create a calming environment and drown out other hospital noises (Furgala et al. 2022; Hampton et al. 2020; McDonald and Zaki 2020). Separate food/water, elimination areas, and sleeping areas. Providing soft bedding, especially items with familiar scents from home, can significantly increase patient sense of comfort (Behnke et al. 2021; Ellis et al. 2013; Heath 2020; Taylor et al. 2022). Familiar scents can be further maintained by spot cleaning cages, leaving clean, unsoiled bedding in the cage (Ellis et al. 2013; Rodan and Heath 2016). Posting pain assessment scales on each patient’s cage and recording results regularly on the treatment sheet can help staff monitor and address pain effectively. Many dogs and cats hide pain well. Training staff how to interpret animal body language and assess pain enables them to better recognize subtle signs of pain (Brondani et al. 2013; Reid et al. 2007; Seksel 2013). Interventions should be made promptly for painful pets, sometimes before examinations or other procedures. Understanding the difference between urgent and elective procedures helps determine if oral medications or sedation is needed for the patient’s comfort and safety (Table 11.3). While some medical procedures are essential for a pet’s health, it is equally important to consider and prioritize the pet’s comfort level and overall wellbeing. This balancing act requires veterinarians to maintain clear and open communication with pet caregivers about the necessity of specific procedures and the available options. This approach helps to improve the pet’s welfare both immediately and long term. Table 11.3 Needs versus wants.
11
Prevention and the Veterinary Hospital
Early Recognition of Fear and Anxiety
Fear, Anxiety, Frustration, and Stress Start at Home
Carriers
Selecting a Carrier
Acclimation to the Carrier
Fear of the Carrier
Carrier Training
Transportation
Collars and Harnesses
Carrier training for cats: basic training steps
Description and tips
Understanding the basics
Training sessions should be short, lasting only a minute or two, due to cats’ quick satiation with treats. The carrier should be a familiar item in the cat’s environment before training begins.
Choosing rewards
Use high‐value treats, such as cream cheese, tuna, or fish paste. Some cats prefer treats delivered on a spoon to avoid direct touch.
Breaking down the process
Start with the bottom half of a hard carrier if possible. Gradually coax the cat to walk into and stay in the carrier, rewarding each small step of progress.
Step‐by‐step approach
Begin by rewarding the cat for approaching the carrier. Progressively reward for stepping in with one foot, then both front feet, all feet, and eventually for staying inside.
Adding the carrier top
Once comfortable with the bottom half, add the top (without the door) and repeat the reward process for entering and staying.
Introducing the door
Add the door, keeping it open initially. Reward the cat for being inside with the door moved, then closed, and finally for staying inside with the door closed.
Lifting and moving the carrier
Start by lifting the carrier with the cat inside, then putting it down and treating. Gradually increase time and start walking a few steps while carrying.
Add in car ride
Once the cat is comfortable, it is time to add in a car ride. Take frequent short trips to help the cat feel more comfortable in the carrier and with the movement of the car.
Adapting the method
If using a different type of carrier, adapt the method to reward approach and entry. Use any additional openings for treat delivery. Ensure safety with top‐opening carriers.
Duration of training
The amount of time it takes for a cat to feel comfortable varies. Kittens may learn quickly, within days, while adults with negative associations may take months.
Routine training sessions
Two short training sessions per day, about a minute each, are ideal. Incorporate training into daily routines like feeding or playtime.
Long‐term benefits
This training eases vet visits and is useful for emergency situations, ensuring quick and safe evacuation if needed. 
Car Rides
Practice Car Rides
Motion Sickness and Reactivity
Preparing the Veterinary Clinic Environment
Design
Waiting Rooms
Scales
Location of the Scale
Relaxed Atmosphere
Reducing Fear in the Exam Room
Exam Room Strategies
Patient’s Perspective
The Exam
Handling and Restraint
Approach
Description
Key features
Website
Low Stress Handling®
A method to reduce fear and anxiety in pets during veterinary visits through gentle handling. Created by Dr. Sophia Yin.
Focus on gentle and welfare friendly handling.
Positive reinforcement.
Minimal use of restraint.
Understanding each pet’s unique needs.
Use of medications when necessary.
Provides practical solutions and options beyond just distractions and sedation.
www.cattledogpublishing.com
Fear Free®
Professionals trained to identify and alleviate fear, anxiety, and stress in pets.
Comprehensive approach including calming techniques.
Environmental modifications.
Use of medications when necessary.
www.fearfreepets.com
Cat Friendly Practice®
Provides guidelines for a cat‐friendly environment within veterinary clinics.
Separate waiting areas for cats.
Feline‐specific handling techniques.
Enrichment items and hiding spots in exam rooms.
www.catfriendly.com
Low‐Stress Hospital Stays
Wards and Runs
Auditory and Olfactory Concerns
Assessing Pain
Needs versus Wants
Urgent veterinary procedures (need)
Nonurgent veterinary procedures (want)
Emergency surgery (e.g., for trauma, internal bleeding, or obstruction)
Routine spaying/neutering
Critical care for life‐threatening conditions (e.g., severe trauma, acute poisoning)
Dental cleaning and nonurgent dental care
Stabilization of acute severe illnesses (e.g., acute kidney failure, diabetic ketoacidosis)
Routine vaccinations
Treatment for severe respiratory distress
Routine wellness exams
Immediate care for severe allergic reactions
Nail trimming or grooming
Management of acute severe pain (e.g., due to injury or postsurgical pain)
Heartworm testing and preventive care
Stabilizing and treating severe dehydration and electrolyte imbalances
Nonurgent skin and ear infections
Urgent blood transfusions (e.g., in cases of severe anemia or blood loss)
Behavioral consultations
Emergency cesarean section (C‐section)
Follow‐up visits for chronic conditions (unless there is a sudden worsening)
Immediate intervention for uncontrolled seizures
Elective surgeries (e.g., cosmetic procedures)
At‐Home Medications and Sedation
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