When our companion animals near the end of their life or when they are seriously ill, we want to do the very best we can to keep them from suffering. Quality of life assessments are emerging as an important tool in end-of-life care for our companion animals. QOL assessments are crucial to provision of good palliative and hospice care, and are also often the fulcrum for decision-making about euthanasia. The purpose of the QOL assessment is to determine how much an animal is suffering and in what ways, with an eye toward seeing what we can do to make them more comfortable. It is important, then, that they be as thorough and careful as we can possibly make them.
As useful as they are, QOL assessments for animals are still in an early stage of development, and are not yet broadly used by veterinarians or pet owners in the care of ailing animals. Nor is there a “gold standard” QOL assessment tool. This is partly because the concept of QOL has only been recently been applied to animals, and partly because these assessments are very complex and hard to measure. Animals cannot tell us directly how they are feeling , with the common human currency of words, so we have to do our best to “read” their behavior and observe physical changes. It seems there is no single, best way to assess an animal’s quality of life, but rather a number of different tools that we can use, in combination. I outline here what I consider to be four important tools in our QOL toolbox.
1. Establish a Baseline
One useful tool in making QOL assessments is a baseline by which to compare changes over time. What we are looking for, in QOL assessments, is a trend. Not a snapshot in time, but the trend over time: up or down or level (with bumps)? Sadly, for many ill or elderly animals, the trend will be downward. But how steep is the downward trend? Has a rather gentle decline all of a sudden turned sharply downward? One bad day, in the midst of mostly good days, is tolerable. But we might notice a trend toward more bad days. And when the good days disappear, or when they become very infrequent, or peppered in with really, really awful days, then QOL might be considered poor.
The ideal baseline would be “normal”: what is your animal like in when excellent health? (If you are reading this, maybe you should think about writing down a baseline assessment for your pet or pets, even if they seem perfectly healthy.) Often, an animal is already sick or injured when we start worrying about QOL, so the baseline starts at the beginning of the illness.
What should a baseline measure? It would be useful to have a baseline for physical health: weight, activity level, blood pressure, a full blood panel, dental health, and so forth. We might note how much our animal eats, to what degree they are “food-oriented,” and what they like most. And we should pay attention to elimination patterns: how often do they poop and pee? Also behavioral characteristics: what does the animal love to do? What are her favorite activities? What makes him upset or stressed out?
A baseline is really useful because it is hard to recognize gradual changes, and it is also hard to remember “how Rufus used to be”—memory is notoriously tricky.
2. Keep a daily log
A daily QOL log can include things like how happy your animal seems; whether she seems to be uncomfortable or restless; activities you engaged in together (e.g. “took a 2 mile walk… she enjoyed smelling the roses but seemed to get very tired. Was stiff the next day.” Or some such.). And yes: pay attention to body fluids! Check to see whether your animal has a bowel movement and whether it was normal for them. Do they have diarrhea? Are they constipated? How much are they eating? Are their eating behaviors changing? Changes in activity level, stiffness, and eating or elimination patterns can be really important information for your veterinarian. Often these changes—even subtle ones, like walking a little more slowly—can be a sign of pain or discomfort. Our pets can’t ask directly that we take them to the vet, and the daily log reminds us to pay careful attention to what they tell us through their behavior.
3. Fill out a QOL scale
There are a few pain scales and QOL scales developed for use in animals. Some of these scales are called monoparametric: they measure one parameter, such as pain. You are probably familiar with a simple monoparametric scale used by human doctors: on a scale of 1-10, how much does it hurt?
Other scales—the more useful ones, are multiparametric. They measure a range of parameters, including physical pain, behavioral changes, and emotional states.One of the most popular multiparametric scales is what’s known as the Pawspice scale. Developed by veterinary oncologist Alice Villalobos, this scale asks you to make a numerical rating of your animal, on a scale of 0-10 (with 10 being good) in 7 categories: Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility, and More Good Days than Bad. The Pawspice scale is simple, straightforward, and relatively objective. But it has limitations (as will any QOL scale): it places an equal numerical scoring on things that don’t really seem equally important (e.g., hygiene is rated the same as pain and labored breathing); it doesn’t work all that well within the context of hospice care because certain things that might be associated with the natural dying process—such as weight loss and inappetance—are counted as reasons to euthanize. The Pawspice scale, though, is a good example of the kinds of questions we need to ask.
Some of the factors that can impact quality of life for animals include pain, nausea, inappetance, breathlessness, loss of mobility, incontinence, dehydration, boredom, anxiety, and inability to engage in meaningful activities. (This list obviously could go on and on, and extent to which each of these factors would impact a particular animal’s QOL is highly individual.)
One important piece of information that is hard to capture with any kind of QOL scale is an individual animal’s “will to live.” “Is this animal suffering?” and “Does this animal still want to live?” are two distinct questions we need to ask.
How often do you need to measure quality of life? Ideally, it is an on-going process, which you engage in continually. In terms of actually filling out an assessment or scale, it depends on the condition of your animal. An animal whose health is deteriorating gradually may need less frequent monitoring than an animal who is suffering from a more severe or quickly advancing disease process. At least once a day is a good ballpark figure.
4. Collaborate and communicate
QOL assessments involve a collaborative effort between pet owner and veterinarian. Pet owners know their animals best, and are in the best position to answer the question “what is important to this animal in his or her life?” Pet owners are also the ones who monitor the animal from day to day, and keep track of changes. The information gathered by pet owners is indispensable to the veterinarian. (Incidentally, if an animal has several human caregivers, it can be very helpful for these individuals to make separate assessments of their animal’s QOL. Often there can be surprising disparities in how different members of the family assess the animal’s QOL and open dialogue can bring insight to everyone.)
Likewise, veterinarians are in the best position to assess the medical condition of an animal. Pet owners often don’t know exactly what to look for, nor do are we necessarily familiar with all of the subtle ways in which pain can manifest in behavioral changes. A vet can usually pick up on things that an owner has missed.
Another really important thing the vet can offer is perspective: it is often hard for pet owners to see their animal declining, and our “vision” or perception of our animal’s health can get clouded by our own anxiety, denial, fear, or grief.
If you have provided end-of-life care for an animal, what tools have you used to assess quality of life?