Sara Waltz, right, a veterinary student at Virginia Tech, steadies Tank while Mark Freeman, an assistant professor, checks Tank's eye during an exam. (Norm Shafer/For The Washington Post)

Sara Waltz never wandered far without her bull terrier, Marti Gra, padding by her side. They went on long hikes, on romps around the family farm, and at night they shared the same bed.

When the brindle-and-white dog suffered a debilitating infection in 2008, Waltz was unable to watch her companion in pain and decided to euthanize her. When Marti Gra took her last breath in Waltz’s arms, anguished tears welled in Waltz’s eyes. The veterinarian, meanwhile, approached the procedure with a disconcerting nonchalance; his clinical lack of empathy and apparent disregard for her grief left Waltz reeling.

“For me, I vowed at that point that I didn’t want to be a vet like that,” Waltz said.

Now a fourth-year veterinary student at Virginia Tech, Waltz, 29, is among a class of future doctors learning that saying goodbye to patients they often come to love like their own — and understanding what their human owners are going through — can be the hardest part of the job.

Euthanasia is one of the most common procedures veterinarians perform, and some individual doctors put more than 100 of their patients to death each year. Experts say that can exact an indelible psychological toll. And now college programs training future veterinarians are paying special attention to the emotional aspects of death.

Mark Freeman shows vet student Lucy Lee how to do acupuncture on Charlie, who was at the school's animal clinic recovering from spinal surgery. (Norm Shafer/For The Washington Post)

College professors now realize that veterinarians face unique stressors compared with any other career, even within the medical field. It’s considered the only medical profession in which killing your patient is not only acceptable, but also occasionally encouraged as the best possible resolution to alleviate suffering. The term euthanasia is derived from the Greek words “eu,” meaning good, and “thanatos,” meaning death.

“A good death is tantamount to the humane termination of an animal’s life,” according to a 102-page report published by the American Veterinary Medical Association on guidelines for euthanasia.

As difficult as euthanasia can be for pet owners, the sense of loss can be magnified for veterinarians who grow attached to patients that they watch grow from puppies to old dogs with snow-flecked snouts.

“It takes something out of you,” Virginia Tech professor Harold C. McKenzie III said. “It weighs on me. It’s a cumulative toll. It weighs more heavily on me now than it did 20 years ago.”

A recent report from the Centers for Disease Control and Prevention revealed that veterinarians experience suicidal thoughts at a significantly higher rate than the average population.

The CDC study found that among 10,000 veterinarians who took part in a 2014 survey, 14 percent of men and 19 percent of women had considered suicide since leaving school, which is three times the national average.

In response, veterinary schools across the country are changing how euthanasia is taught in classrooms by emphasizing ways to cope emotionally, including grieving alongside clients in their anguish.

Vet student Sara Waltz gives discharge instructions to Ayesha Overstreet, who was bringing her cat, Buster, home after a stay at the Virginia Tech Community Practice Clinic. (Norm Shafer/For The Washington Post)

“Classically, in the old tradition, we ignored this very human side of the profession,” said Jennifer Hodgson, associate dean for professional programs at Virginia Tech. “We used to teach just the science and didn’t talk about how you think and how you feel. We can’t train the next generation of students like that.”

At Colorado State University, the veterinary school offers a course called the healer’s art, which explores “the mystery and awe in life,” during which a medical professional and students discuss the emotions that accompany euthanasia, said associate dean Melinda Frye.

At Iowa State University, professor Dawn Sweet teaches a course for veterinary students on communication in tense moments and “how important it is to build and cultivate a relationship with your client so you can foster trust.” Jim Clark, a professor at the University of California at Davis, said that, schoolwide, “there’s a growing focus on recognizing the importance of mental well-being among veterinary students.”

Veterinary students at Virginia Tech are exposed to the realities of euthanasia beginning in their first year of classes. Throughout their four years, students take part in lectures and seminars on the ethics of euthanasia and discuss how to break bad news to clients.

“I see it as a gift of veterinary medicine to make it so that our animals don’t have to suffer at the end of their lives,” said Army Col. Bess Pierce, a Virginia Tech veterinary professor. “I have gotten more thank-you cards from euthanasias that were done compassionately than anything else. It makes such an impression on owners who needed it the most.”

Pet owner Michael Brodie of Coral Springs, Fla., said that veterinarians and their staff can bring comfort in subtle ways before, during and after a euthanasia procedure. Brodie recently had to euthanize his family’s poodle mix, Milton, who had suffered heart problems.

“I knew that the next time I was going to the vet that it was going to be his final time,” he said.

When he and his wife arrived with Milton, the office staff members guided them to a private waiting room and arranged for Brodie to pay for the procedure ahead of time, knowing that he would be dealing with the emotions of the euthanasia afterward. The veterinarian ensured that Milton was wrapped in a blanket and that Brodie and his wife held the dog as a fatal dose of drugs was administered. Afterward, the vet offered words of sympathy and let Brodie and his wife sit with Milton to grieve for as long as they wanted. Brodie said that the office receptionist cried with them.

“They wanted to make sure it was the most comfortable way that we wanted,” Brodie said. “It was calm and quiet. Very dignified.”

Virginia Tech students learn to sit side by side with a pet owner, rather than directly across, as they discuss end-of-life options and how to listen to client concerns without judgment. Admissions director Jacquelyn Pelzer said that professors bring in actors to simulate situations with clients and record video of how the students react.

“It doesn’t come natural to a lot of students,” she said.

But students relish the opportunity in the simulations to learn to best address clients in such fragile moments.

“Even as young students, we’re so unequipped to deal with people’s emotions because it’s not something you are taught in school,” Waltz said.

Pierce said that she trains her veterinary students to sit with pet owners and talk through the procedure to help reassure pet owners who choose to witness the euthanasia. For dogs, the first step is to administer a sedative, often injected through an intravenous catheter inserted into the animal’s cephalic vein, located near the top of their front leg. Once the dog is quiet and calm, the veterinarian will inject what is essentially an overdose of an anesthesia drug known as pentobarbital to stop the animal’s heart. The procedure can be completed in less than 15 minutes.

Virginia Tech professor Kevin Pelzer said that he remembers clearly his first euthanasia case: a 35-pound gray poodle with tartar-crusted teeth and waxy ears.

“I can still smell its breath,” he said. “Feeling that dog just relax in my arms. It’s just like yesterday.”

It was 1974.

Kevin Pelzer said that on his worst day, he had to euthanize a flock of 60 sheep that had been infected by a parasite. The farm owner used a backhoe to bury the bodies.

“It looked like a mass grave,” he said.

Trent Davis, a counselor who serves the vet school, said that euthanasia can be especially taxing for veterinarians who run out of options to heal a patient and yet don’t want to accept defeat.

“You may have to euthanize your own failure,” Davis said.

Talking about mental health in class, particularly when the subject is euthanasia, is part of the broader effort at vet schools to help students cope with the strenuous nature of the field. Professors reiterate to students that the best way to face euthanasia is with compassion. Oncology specialist Shawna Klahn said that too often veterinarians compartmentalize their feelings in order to endure what can seem like day-in, day-out death.

“You do question the value of getting involved and of caring, because it hurts,” Klahn said. “It paralyzes you as a doctor. Who does it help if I care? You go through these moments where you get distanced. But you can’t help it. If at some point I don’t care, then I no longer belong in this profession.”

Waltz said that she decided to focus on euthanasia as a veterinarian after her own traumatic experience with Marti Gra during her senior year in college. When she arrived at the clinic that day in 2008, Waltz saw that her 10-year-old dog was in pain.

The veterinarian told Waltz that Marti Gra was suffering from a severe infection, was septic and was experiencing kidney failure. She said that the veterinarian did little to comfort Waltz once she made the decision to put down Marti Gra. Peace came to her, Waltz said, when she walked in to see Marti Gra.

“I came in, and she wagged her tail,” Waltz said, brightening at the remembrance. “That’s how I knew it was time. She made me feel like it was okay to say goodbye.”