This article was presented at the 2008 Ontario VMA Conference
February 1, 2008 9:15 AM-10:15 AM
The “HHHHHMM” Quality of Life Scale
by Dr. Alice Villalobos
Veterinarians are often asked to assess the various aspects that determine the overall quality of life in terminally ill pets. Most older companion animals have one or more concurrent disease conditions that worsen with time. One third of our pet population is overweight and or obese. When pets become burdened with illness or cancer and related treatment issues, their pre-existing conditions complicate the prognosis for survival or may limit options for effective treatment.
The attending doctor is frequently asked, “When is the right time to euthanize my beloved pet? How will I know?” You can respond with something like this, “ One day it will gel. You will know when it is the right time because your pet will tell you with a look or a gesture, a sign or a series of bad days.” A quality of life scale may help everyone, especially those who are in denial, to look at issues that are difficult to face. Caretakers can use the proposed Quality of Life Scale to ask themselves if they are able to provide enough help to maintain an ailing pet properly.
More and more clients are requesting in home health care help for their ailing pets. We must remaining sensitive to the caregiver’s wishes and provide end of life care such as pet hospice or “Pawspice.” More information on Pawspice care will be presented at the 2:30PM -3:30 PM session.
Animal patients have specific needs and desires that should be recognized and respected. Veterinarians must rise to accept the challenge of meeting these basic needs and desires for terminal patients. If we can create or restore a satisfactory level for our ailing companion animals, then we are justified in preserving the life of the ill pet during its steady decline toward death. The goal in setting up the Quality of Life Scale is to provide an easy guideline for assessment of the pet so that family members can maintain a rewarding relationship and nurture the human animal bond. This Quality of Life scale offers some objectivity while remaining sensitive to the caregiver’s wishes. It will relieve guilt feelings and engender the support of the veterinary team to actively help in the care and decision-making for end of life, Pawspice patients.
The basic needs and desires innate to quality of life for terminal geriatric cancer patients should not and cannot in good consciousness be ignored (McMillan 2005). It is up to the veterinary professionals and to the pet’s individual caretaker to design an end of life program. The program needs to address each factor that deals with quality of life openly and honestly. We can be very proactive in helping pets achieve an improved score on their evaluations. The scale for each factor runs from one to ten. 10 is the best and highest quality rating for each factor. There are 7 basic factors in this proposed scale. A score of 70 would therefore be perfect. (If the terminal geriatric cancer patient scores at least 5 on each issue, the quality of life is considered reasonably good.)
Use this proposed list of basic desires or factors. These factors are presumed to be essential for quality of life. There may be additional factors for individual cases which may impact the decision for the family. Each factor needs to be monitored by both the attending doctor and caretaker with careful attention. The proposed list can be named “HHHHHMM,” The 5 H’s and the 2 M’s are easy to remember. The list includes the problems that every Pawspice program should strive to satisfy: Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility and More good days than bad days. A score above 5 on most of these Quality of Life Issues is acceptable in maintaining a Pawspice program. Each pet’s situation needs to be customized, and each pet owner needs to be recognized as an individual who needs a kind, supportive coaching approach to come to terms with the decision to end a best friend’s life.
The HHHHHMM Quality of Life Scale
Hurt— Score 0-10 No hurt: adequate pain control is first and foremost on the scale. This includes the pet’s ability to breath properly. Most people do not realize that not being able to breath is ranked at the top of the pain scale in human medicine. So attention to the pet’s ability to breathe properly is a top priority. Cases with pulmonary effusion need thoracocentesis on an as needed basis. Pet owners need to be trained to monitor the pet’s respirations and comfort level and to identify labored breathing so they won’t wait too long to provide relief. Some families are willing to provide oxygen therapy at home for their ailing pets. The veterinarian can prescribe oxygen through a medical supply house. Pain control may include oral, transdermal and injectable medications and be given preemptively.
Hunger— Score 0-10 No hunger: if adequate nutrition is not being taken in by the pet willingly or by hand or coaxing or force feeding, then placement of a feeding tube needs to be considered. Cats do very well with esophageal feeding tubes. Malnutrition develops quickly in sick animals when the caretaker is not educated enough to know how much their pet needs to eat to maintain body weight. Instruct owners to use a blender or liquid diets to help their best friend maintain proper nutritional and caloric intake. Many pets will live much longer if offered wholesome, flavorful foods that are varied. My own Great Pyrenees, Alaska, went from a life of consuming only dry food to canned food to hamburger, fresh baked turkey, to chicken, to various types of sausages, to venison (thanks to Dr. Jack Stephens), pastrami, cheeses of all types and gourmet cut and marinated meats. She liked parmesan cheese, smoke flavor, Alfredo sauce and cheddar cheese soup mixed into her food along with lots of encouragement and coaxing and hand feeding. It takes patience and gentle concentrated coaxing to get some Pawspice pets to eat. It is hard not to be disappointed when such specially prepared food is rejected. Just come back with another offering with a different flavor a little later and that meal may be more appealing to the patient.
Hydration---Score 0-10 No hydration problems. Educate the pet owner about adequate fluid intake per pound (10 ml per pound per day) and to assess for hydration by the pinch method. Subcutaneous (SQ) fluids are a wonderful way to supplement the fluid intake of ailing pets. It may take a few demonstration sessions for a pet owner to learn how to administer SQ fluids. This helpful procedure saves the client a lot of money and keeps the pet on a much healthier status. Giving SQ fluids can make a huge difference in quality of life during pawspice.
Hygiene—Score 0-10 Good Hygiene is a must! Can the pet be kept brushed and cleaned? Is the coat matted? Is the pet situated properly so that it won’t have to lie in its own soil after eliminations? Pets, especially cats with oral cancer can’t keep themselves clean, so they get demoralized quickly. The odor associated with necrotic, oral tumors can be offensive and cause social rejection by family members. Instruct the pet owner to use antibiotics to help reduce foul smelling infections. Dampen a sponge with a much-diluted solution of lemon juice and hydrogen peroxide and gently stroke the face, paws and legs of the patient. This action is similar to a “mother tongue” and helps to clean the fur while soothing the unkempt cat. Dogs love this type of facial and paw grooming too!
Happiness--- Score 0-10 Happiness is important for both caregiver and receiver. Ask yourself if the patient has desires wants and needs (Comstock 2001). Are these being met? Is the pet able to experience any joy or mental stimulation? It is easy to see that our pets communicate with their eyes. They know what is going on via their senses and mental telepathy. Is the ailing pet willing to interact with the family and be responsive to things going on around him? Is the aging cat able to purr and enjoy being on the bed or in one’s lap? Is there a response to a bit of catnip? Can the cat bat at toys or look and follow a laser light? Can the ailing pet enjoy the upbeat greetings and petting of loving family members? Can the pet’s bed be moved close to the family’s activities and not left in an isolated or neglected area? Is the pet depressed, lonely, anxious, bored or afraid? Do you have a routine fun time that the pet looks forward to? Mobility--- Score 0-10.
Mobility is relative. Ask, is the pet able to get up and move around enough to satisfy normal desires? Does the pet feel like going out for a walk? Is the pet showing CNS signs, seizures or stumbling? Can the pet be taken outdoors or helped into the litter box to eliminate with assistance? Will a harness, a sling, or cart help? Is medication helping? The answer to the mobility question has viable and variable scenarios. The scale score for mobility is acceptable anywhere from 0-10. I have met some utilitarian pet owners who are way too rigid for their requirements in mobility of their pets. For instance, they are regretfully but willing to sacrifice their pet’s life rather than elect amputation of a limb. Some pet owners have the honest yet teleological feeling that amputation is mutilation and not fair to the pet. Instead, they allow the pet to bear a painful limb for months before euthanasia. Then there are cases like the 12 year-old, male, 90 pound, Golden Retriever, Krash Pancino of Orange County. Krash’s mobility was compromised when he entered our pawspice program with osteosarcoma of his left distal radius. His history precluded amputation because of severe degenerative joint and disk disease and degenerative myelitis. Krash had severe osteoarthritis of both his knees along with moderate to severe DJD from bilateral hip dysplasia. Krash’s cancer leg was splinted for visits to dog park and at playtime to offset a potential pathological fracture. His Pawspice was happy full of joy and love that lasted for 3 months.
Dr. Robin Downing wrote thoughtfully about the mobility issue for Murphy in her book, Pets Living With Cancer, A Pet Owner’s Resource. She wrote, “ Because Murphy is such a big dog---150 pounds and very tall---her ability to get up and down and to walk under her own power are very important benchmarks in my personal “bottom line.” She would be impossible to pick up and carry around. For the same reason---her size---her ability to control her urine and stool output is important.” In my opinion, the mobility scale can have a variable score from 0 to 10. The need for mobility seems dependent on the species and breed. Cats and small lap dogs can and do enjoy life with much less need for handling their own mobility than large and giant breed dogs. If the pet is compromised and is only able to lie in bed, is there a schedule to change the position of the pet and rotate the body at least as often as every two hours? Can the pet’s bed be moved around the house to keep the pet entertained and in the family’s company? Atelectasis and decubital ulcers must be avoided. The nursing care of large immobile dogs is very demanding. Is the bedding material soft enough? Can an egg crate mattress be used and set up properly to avoid decubital ulcers? Is there a role for a pet mobility cart or an Evans standing cart? These items really make a difference in the Quality of Life for the pet that has limited mobility yet is still alert and responsive.
More Good Days Than Bad Days--- Score 0-10 Ask if there are more good days than bad days. When there are too many bad days in a row, (or if the pet seems to be “turned off” to life), the quality of life is too compromised. Bad days are those filled with undesirable experiences such as: vomiting, nausea, diarrhea, frustration, falling down, seizures, etc. Bad days could be from a condition that worsens such as: cancer cachexia or the profound weakness from anemia, or from the discomfort caused by gradual tumor pressure or obstruction or a large, inoperable tumor in the abdomen This was the situation with my own dear 111?2 year -old Australian Shepard, Alfie. He had a huge, undifferentiated mass that rapidly expanded his liver. If the two-way exchange needed to communicate and maintain a healthy human-animal bond is just not there, the pet owner must reconcile or be gently told that the end may be near.
It is very difficult for families to make the final decision to end a beloved pet’s life by euthanasia. Coming to a decision about ending a pet’s life is especially avoided when euthanasia is against the pet owner’s gut feelings or if it against their religious beliefs. Sometimes they are not sure about the quality of life issues at the very end. It can be made more clear to them if a standard scale for Quality of Life is explained and measured ahead of time and re-evaluated every couple of weeks or every few days or hours as the situation requires. If the pet is slowly passing on with a peaceful tranquility, then that may be a satisfactory situation.
What many pet caregivers really want is for their pet to pass on naturally at home, in their arms or in their own bed. That is okay as long as the pet is just weakening steadily and not ‘suffering to death’. We as veterinarians need to accept the fact that it is a very personal and natural wish when our clients request us to help their pet to die naturally at home. We are the ones they turn to for help and we have an oath “to use our scientific knowledge and skills for the benefit of society through the protection of animal health and the relief of animal suffering.” We can help our client’s pet loss needs and at the same time guarantee that the pet has a pain free passage by using the most powerful preemptive pain medications during the last days and hours.
As part of a Quality of Life Program, or Pawspice program, we should suggest the option of home euthanasia and refer the family to a kindly house call veterinarian. Hopefully, using this conceptualized user-friendly “HHHHHMM” scale for quality of life will facilitate the heart wrenching decision that euthanasia truly is. Hopefully your professional guidance and kindness can help relieve the angst and regret about a beloved pet’s death that often haunts pet owners for the rest of their lives.