Improving Pet Owner Assessments of Quality of Life
Expanding our toolbox for providing good care to animal patients.
Posted Oct 15, 2018
How Ethology Can Help Improve End of Life Care for Animal Patients:
Part 3 in a 3 Part Series
Part 2, Emotional Well-Being in Animal Patients, can be found here.
Veterinary end of life care relies heavily on owner assessments of how an animal is doing. One of the most common tools for owner assessment is the Quality of Life (QOL) scale. This could be and should be one of the most important elements of caring for ill or aged animals nearing the end of life. At its best, a QOL assessment would provide a relatively objective measure of how an animal patient is feeling, and how illness, age-related changes, and treatment protocols are affecting the life-experience and well-being of the animal patient, from the patient’s own point of view. The purpose of such an assessment would be, then, to fine tune pain protocols, look for improvements to an animal’s physical environment, reduce sources of stress and fear where possible, and identify and fill gaps in meeting an animal’s emotional and social needs.
Many QOL tools, such as the ubiquitous Pawspice Scale, are available online to pet owners, and veterinarians often recommend the use of such tools for clients. Yet although these simplified tools can sometimes help owners see gaps in care, more often they function as decision trees for euthanasia, and not rigorous ones at that. Pawspice and other pet-owner scales are rarely statistically validated and often lack the nuance required to carefully assess subjective states of an animal. They instruct people to look for certain behaviors, such as incontinence, but give no guidance about how such behaviors might reflect an animal’s internal state, nor do they give any hint at just how complex “reading” an animal’s behavior can be. They do not account for the individuality of animal patients, nor do they pay attention to the complex interplay of affect, illness, and behavior. QOL tools tend to focus on what the caregiver him or herself thinks is important—which may not track well onto what the animal wants or is experiencing.
Acknowledging our own limitations
One of the most important things we could do to improve these QOL assessments is to recognize our own limitations in understanding our animals, including lack of observational skills and behavioral training and the potential for human emotional “contamination” of behavioral observations.
Studies repeatedly show owners missing important behavioral cues. Although pet owners can usually recognize sudden changes in behavior, they are not skilled at recognizing subtle behaviors related to pain or the presence of disease, or at identifying gradual changes in behavior over time.[i] For example, in a large survey of dog owners by Mariti et al., only half of respondents were able to correctly identify what “stress” is (a short or long-term alteration of homeostasis that can lead to illness).[ii] Although many owners were able to recognize overt behavioral indicators of stress such as trembling, whining, and panting, few could identify more subtle stress behaviors such as an averted gaze, nose licking, or yawning. Packer et al. found that 58 percent of owners of dogs showing clinical signs of brachycephalic obstructive airway condition did not believe their dog had any breathing problem.[iii] Brown et al. found that owners had difficulty remembering the time their dog was in pain, and pain scales conducted by owners didn’t correlate with vertical force produced by arthritic dogs, suggesting that dog owners may not be good at detecting when their pet is in pain.[iv]
These and other similar studies highlight the critical need for caregiver education. Given that the purpose of the QOL assessment is to measure the subjective state of an animal, more attention paid to how to observe, record, and interpret canine or feline behavior surely would be beneficial. Ideally, the education of pet owners into Ethology 101 would begin before an animal is even brought into the home and would continue throughout the animal’s lifetime. (A recent U.K study found that fully a quarter of all people acquiring a pet knew nothing about the type of animal they chose to buy and had done no prior research.[v]) It goes well beyond the ethical obligations of veterinarians to provide this education for pet owners, but as long as there are such enormous gaps in pet owners’ understanding of animal behavior, veterinarians will need to do what they can to plug the holes.
No matter how good our QOL assessment tools, they only capture part of what is important to an animal. In addition to a larger and better set of QOL assessment options, then, hospice and palliative medicine could make use of a broader behavioral assessment toolbox. Pain scales are one important adjunct to QOL assessments (despite their limitations). An additional tool that might further augment end-of-life care (and, indeed, care throughout the lifespan of an animal) is the ethograms.
Briefly, an ethogram is an inventory or catalogue of species-specific and, for our purposes, individual-specific behaviors. The ethogram is one of the basic tools used by ethologists to observe and record an animal’s behavior. Marc Bekoff and I argue in our forthcoming book, Unleashing Your Dog, that simple ethograms could be used by pet owners to enhance their knowledge and understanding of their individual animal and thereby improve the quality of the human-canine or human-feline (or human-other) bond.[vi] The ethogram approach focuses on the full range of behaviors, not just those behaviors that have been identified (by caregiver or veterinarian) as problematic, negative, or illness-related. Creating ethograms can help pet owners establish a baseline of normal behavior and can encourage them to revel in and get to know the individual quirks of their animal.
The use of ethograms by pet owners with ill or very aged animals could augment care in important ways, by encouraging close observation, curiosity about behavioral patterns, and attention to change. Unlike QOL assessments, which focus heavily on negative experiences and involve highly subjective judgments by pet owners (e.g., “Did your animal have a good day or bad day?”), ethograms are descriptive and focus simply on what an animal is doing.
Quality of Life and Caregivers
Optimizing end of life care and quality of life for animals is an extraordinarily complex endeavor and, as we have seen, relies on an extremely nuanced appreciation of how pain and behavior intersect. As if gaining access to how an animal is feeling weren’t hard enough, there are layers of additional complexity arising from the patient’s relationship to his or her human caregiver(s). The knowledge, attitudes, and attentiveness of pet owners will influence how well they read their animal, and how responsive they are. Their own emotional state can influence what they “see” in their pet. For instance, hospice and palliative care veterinarians often report that owners seem blind to their animal’s suffering, because the owners themselves are so caught up in anticipatory grieving or denial.
How closely bonded a human is with his or her animal can influence both how well the human is able to read and interpret behaviors and what level of care an ill or dying animal receives. For example, the type of relationship a dog and owner have can influence the behavior of a dog during a clinical examination with a veterinarian[vii]—information that is useful for clinicians and caregivers alike, when trying to understand “normal” behavior patterns for a given animal. Csoltova et al. showed that veterinary encounters produce an acute stress response in dogs, with dogs showing significant increases in lip-licking, heart rate, and maximal ocular surface temperatures. An owner’s touching and talking to her dog during the exam had an attenuating effect on the dog’s stress level.[viii]
Another key area for further work is on the interconnections between what Mary Beth Spitznagel calls “caregiver burden” and the quality of an animal’s care.[ix] When caregivers are so stressed that they suffer from reduced psychosocial functioning, their ability to provide good care—including, presumably, their ability to make and report objective and accurate behavioral observations of their animal—may be compromised.
Although attention to the patient him or herself is always the priority, effective care cannot occur in isolation from the animal’s family.
[i] Reaney, S, Zulch H, Mills, D., Gardner, S, Collins, L. Emotional affect and the occurrence of owner reported health problems in the domestic dog. Applied Animal Behaviour Science 2017; 196: 76-83.
[ii] Mariti, C, Gazzano A., Lansdown Moore J., Chelli L., Sighieri C. Perception of dogs’ stress by their owners. Journal of Veterinary Behavior: Clinical Applications and Research. 2012; 7, 213-219.
[iii] Packer, RMA, Hendricks, A, Burn, CC. Do dog owners perceive the clinical signs related to conformational inherited disorders as 'normal' for the breed? A potential constraint to improving canine welfare. Animal Welfare 2012; 21: 81-93.
[iv] Brown DC, Boston RC, Farrar JT. Comparison of force plate gait analysis and owner assessment of pain using the canine brief inventory scale in dogs with osteoarthritis. Journal of Veterinary Internal Medicine 2013; 27, 22-30.
[v] People’s Dispensary for Sick Animals. PAWS Report 2017. https://www.pdsa.org.uk/media/4371/paw-2018-full-web-ready.pdf.
[vi] Bekoff M and Pierce J. Unleashing Your Dog: A Field Guide to Freedom. Novato, CA: New World Library; (forthcoming in 2019).
[vii] Lind, AK, Hydbring-Sandberg, E, Forkman, B, Keeling, LJ. Assessing stress in dogs during a visit to the veterinary clinic: Correlations between dog behavior in standardized tests and assessments by veterinary staff and owners. Journal of Veterinary Behavior: Clinical Applications and Research. 2017; 17, 24-31.
[viii] Csoltova E., Martineau M., Boissy A, Gilbert C. Behavioral and physiological reactions in dogs to a veterinary examination: Owner-dog interactions improve canine well-being. Physiology & Behavior 2017; 177, 270-281.
[ix] Spitznagel MB, Jacobson DM, Cox MD, Carlson M. Caregiver burden in owners of a sick companion animal: a cross-sectional observational study. Veterinary Record 2017. DOI: 10.1136/vr.104295.