Written by Shannon Fujimoto Nakaya, DVM
If we choose to provide care which keeps an animal alive, we have an obligation to uphold a quality of life for that pet. Otherwise, it becomes an act of selfishness rather than a gift.
Some people simply know when an animal's quality of life has dropped beneath an acceptable threshold. Sometimes the pet's condition is so clearly deteriorated that it's hard not to see that it is no longer fair to the animal to embark on further life-saving or life-preserving protocols. There are also many situations which are less certain. There are situations where emotional attachments can cloud objectivity. In these cases, a Quality of Life worksheet or checklist can be helpful in more methodically assessing a pet's situation and making more thoughtful choices on it's behalf.
Some people argue that Quality of Life charts don't really work. Do they really assess quality of life? Is the patient really living and enjoying life? Or are we just insuring that the patient is not suffering from neglect during its convalescence. Maybe. There are a lot of shades of grey in these decisions. Nevertheless, it is essential to have some minimum standard if we are to keep convalescing patients alive. And quality of life evaluations help us keep our eye on that minimum standard.
Veterinarian Alice Villalobos, who is truly a kindred spirit, created a HHHHHMM (that's 5 "H"s and 2 "M"s) Quality of Life scale for pets that she has posted on her Pawspice website, www.pawspice.com. The 5 "H"s represent Hurt, Hunger, Hydration, Hygiene, and Happiness. The 2 "M"s represent Mobility and More good days than bad days. For each objective, the pet is scored on a scale of 0 to 10, zero being the worst possible condition and ten being the best. Total scores of > 35 suggest that there is reasonable quality of life. Dr. Villalobos' worksheet is a tool to help people determine whether their pet has enough quality of life to justify ongoing hospice care.
My own list of objectives to consider is very similar to Dr. Villalobos:
- Physical pain
- Emotional pain / stress / anxiety
- Positive energy balance (food)
- Enjoyment of life and Interest in living.
- Ability and commitment of care givers to support the convalescing patient.
I do not numerically score patients because I think all these objectives need to be considered and might be weighted differently in different situations. For example, even if a patient's quality of life is deemed acceptable by all other objectives, if a patient is laboring to breathe, it's bottom line quality of life is unacceptable. In such a case, alleviating respiratory distress needs to be addressed or nothing else matters. Another example: Managing a 15 pound patient that is non-ambulatory is very different from managing a 120 pound patient that is non-ambulatory and lives on the third floor without an elevator.
I do include the ability and willingness of the care givers in my Quality of Life evaluations because the reality for pets is that there is no Medicare or Medicaid or pet nursing homes to attend to them during their convalescence, PRE-hospice, or hospice. It's up to the human who brought them home and has been caring for them. Not everyone can take a leave of absence from their job to care for a convalescing pet. Not everyone can physically lift a 50 pound invalid. Not everyone is comfortable being a nurse for an animal. And it may just be that pet's reality that without that level of care, it's quality of life will be unacceptable.
A Quality of Life worksheet or checklist is a tool to aid in decision-making on behalf of an animal companion. Like all tools, Quality of Life worksheets or checklists will be more accurate and useful in some situations than others. Understanding the intent of the worksheet will allow the user to tailor its weight in their actual decision.
- Quality of life evaluations are intended to be applied to patients who have been diagnosed with a serious and/or probably fatal disease.
- Quality of life evaluations are intended to remind us where we might improve things for our convalescing animal companion. Once we recognize that one or several of the objectives that allow our pet to live are deficient, it follows that we need to step up our care and compensate for what our animal companion's body can no longer do on its own. This is part of comfort care and it is morally and ethically essential if we are to challenge our animal companions to carry on.
- Example: I once adopted a handicapped peahen. A birth defect and subsequent back injury left her essentially non-ambulatory. I made a walker for her, which kept her body off the ground and allowed her some independent mobility. But she still couldn't be left outside unsupervised, couldn't be "thrown in" with the other peafowl, needed to be taken out of her walker and "tucked in" her soft bed at night. It made me realize that in challenging Henny Penny to adapt to life as a bird in a walker, I also created an obligation to make that life fulfilling for her. Sitting around in a walker all day is not Living. She deserved opportunities to engage in the foraging, grooming, and social activities of her species. Doing a Quality of Life evaluation led me to think about what else I needed to do improve and maintain a quality of life for Henny Penny.
- Quality of life evaluations are intended to make us step back and take stock of where we are in the grand scheme of things, particularly with long term convalescent care. While providing appropriate comfort care is essential if we choose to keep our pets alive at this stage, providing this level of care does not in and of itself equate to a good life. Whether or not life is good and appreciated by our animal companion depends on the individual pet, the person, and their relationship. If your pet has been diagnosed with a terminal illness and given a poor prognosis, and you have chosen to engage in palliative or comfort care, you should be asking yourself daily if you are doing right by your animal companion. If your answer is "yes," then you are justified in carrying on. If your answer is repeatedly "I don't know" or "no," then it it time to re-evaluate your choices. Re-evaluating your choices doesn't necessarily mean that you made the wrong choice. Your pet's condition may have changed. Or maybe your pet did not respond to your choices as you were hoping. Either way, it is time to reassess and reconsider your options.
- Quality of life evaluations are intended to provide guidelines to help decide whether or not it is fair to our animal companion to continue active life-preserving care.
For some people, strong emotional attachments can cloud their ability to see a situation clearly, or at least make them worry about being blinded by love and devotion. I have observed that people deeply attached to an animal companion and determined to care for them until their natural passing, are often the most concerned that they may be missing some distress signal and ignoring some quality of life objective. They seek my opinion about whether their animal companion is truly doing okay, or is actually suffering and hanging on for their sake.
Sometimes there is conflict between family members about whether or not a pet is suffering and whether or not it is reasonable to continue offering PRE-hospice and hospice care. In these cases a list of objectives that contribute to quality of life and sometimes a scale to quantify each objective and overall quality of life can guide the discussion between family members.
- Quality of Life evaluations are intended to make certain that decisions to end life have been carefully considered because it is an act that cannot be reversed once it it done.