Can Quality of Life be Measured with a Number?
Many pet owners are told, “you’ll know when it’s time,” but this often isn’t true. For many pets, there is a gradual decline from health to debilitation with ups and downs along the way; where we draw a line to stop this progression is not exact. With many illnesses, it’s impossible to know what each day will bring. While every euthanasia decision is incredibly sad, sometimes there are conflicting inputs that make the decision especially difficult. Are any of the following situations familiar?
Your pet may have a mixture of truly good days and truly bad days
Your pet may have a mixture of good and bad symptoms; for example, poor mobility with an excellent appetite and spirit
Your pet’s decline in health or mobility have been very gradual over time, so it’s hard to pick a day to end the progression
Your pet isn’t feeling great, but he or she isn’t suffering either. How bad do things have to get?
Some family members feel that the pet is suffering, but others feel that the pet is ok
Pet owners who are conflicted about a euthanasia decision may turn to a Quality of Life (QOL) scoring scale for guidance. Benefits of these scales include:
An objective means to weigh all the pet’s symptoms and provide insight or clarity.
A platform for a reasoned discussion with family members. Talking about illness and dying can be very difficult; bringing structure to the conversation can be a big help.
When the score is low, such a system can provide comfort. The pet owner knows that they are not making this decision arbitrarily, but they have good medical reasoning supporting them.
These scales work best for long-term, slowly progressing diseases that affect the whole body, for example (most cases of) kidney disease and lymphoma.
The best known QOL scale for pets is the “Five H Two M” Scale created by Dr. Alice Villilobos and it is at the bottom of this page. Other QOL measuring systems exist. While such scoring systems can be helpful, they are by no means the only means for deciding when it’s time to consider euthanasia. Here are some things to think about if you look at a QOL score:
A QOL score should not be used for pets that are suffering. This is very, very important. For example, if a pet has very labored breathing, or has severe pain, it does not matter what the total point score is.
Non-negotiables (also known as “deal breakers” or “lines in the sand”) Some concerns may outweigh an overall score. For example, if a pet cannot walk any more, this would be unacceptable for most pets.
Accuracy. The items on the list are scored subjectively - different observers will give different scores. If you use a QOL scale, do the best you can, but realize that there is an emotional component to scoring. In particular, gradually worsening symptoms will become perceived as the “new normal” over time. This can lead to owners giving higher scores than they would have given if the pet had become ill more suddenly.
Rate of decline. If there is a noticeable deterioration each day, it may be best to be proactive to prevent suffering.
Possibility of a tragic event. If there is a risk for an emergency (such as internal bleeding or fluid in the lungs), or other traumatic event (such as getting stuck and panicked while the family is not home), it may be best to act in advance to prevent suffering.
Logistical considerations. Things like the number of stairs in the home, or the number of hours the pet is alone each day have a tremendous impact on the care and comfort a pet can receive. Are other pets in the home adding to the stress of illness or immobility?
Individual considerations. Pets are like people: some are much more tolerant of treatments, discomfort and immobility than others. The ultimate assessment of any pet’s joy in life is one that comes from the hearts of the people who know him or her best.
In general, QOL scales are less helpful for pets who have severe orthopedic disease, cognitive decline, or illnesses that cause pain, difficulty breathing, or internal bleeding. Do not lose sight of the big picture as you focus on the details of your pet’s well being. Also, please remember that every pet’s medical and emotional situation is unique, as is every family and home situation. QOL scales are not always good at taking such unique differences into account.
Often, there really is no such thing as a precise Right Time to euthanize. Most importantly, the timing of euthanasia is almost never a purely medical decision - it’s an emotional one, too. Whatever your pet’s medical problem is, no QOL scale can tell you if your pet is happy or not: you are the best expert on your pet’s well-being. A QOL score may help guide you, but the ultimate decision lies within your heart, telling you what is best for your beloved friend.
Quality of Life Scale (The HHHHHMM Scale)
Score the pet on each item below using a scale of 0 to 10 (10 being healthy).
See the above caveats when interpreting the result.
HURT - Adequate pain control & breathing ability is of top concern. Trouble breathing outweighs all concerns. Is the pet's pain well managed? Can the pet breathe properly? Is oxygen supplementation necessary?
HUNGER - Is the pet eating enough? Does hand feeding help?
HYDRATION - Is the pet dehydrated? For patients not drinking enough water, subcutaneous fluids daily or can supplement fluid intake.
HYGIENE - The pet should be brushed and cleaned, particularly after eliminations. Avoid pressure sores with soft bedding and keep all wounds clean.
HAPPINESS - Does the pet express joy and interest? Is the pet responsive to family, toys, etc.? Is the pet depressed, lonely, anxious, bored or afraid? Can the pet's bed be moved to be close to family activities?
MOBILITY - Can the pet get up without assistance? Does the pet need human or mechanical help? Does the pet feel like going for a walk? Is the pet having seizures or stumbling?
MORE GOOD DAYS THAN BAD - When bad days outnumber good days, quality of life might be too compromised. When a healthy human-animal bond is no longer possible, the caregiver must be made aware that the end is near. The decision for euthanasia needs to be made if the pet is suffering. If death comes peacefully and painlessly at home, that is okay.
*TOTAL SCORE (0 - 70)* A total over 35 points represents acceptable life quality to continue with pet hospice.
Original concept, Oncology Outlook, by Dr. Alice Villalobos, Quality of Life Scale Helps Make Final Call, VPN, 09/2004; Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond, Blackwell Publishing, 2007. Revised for the International Veterinary Association of Pain Management (IVAPM) 2011 Palliative Care and Hospice Guidelines.
Available for download at www.pawspice.com.