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Research issues w/ QOL

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Research issues w/ QOL
MAXIMIZING
QUALITY OF LIFE
IN ILL ANIMALS
Franklin D. McMillan, DVM, DACVIM (SAIM)
Best Friends Animal Society
Kanab, Utah
“I promise to
give you
the best
possible
quality of
life.”
“Everyone knows what quality of life is”
 When you ask a pet owner what she feels her dog’s quality
of life is, you don’t have to explain to her what you mean.
She knows. And you know she knows. The mutual
understanding is a given.
 Quality of life is so well understood that the term itself
communicates a massive amount of information
 Imagine after examining a very ill elderly dog you explain to the
pet owner the options: a battery of tests, X-rays, which may lead
to the need for a major abdominal surgery, and…
 She interrupts you, “Doctor, it’s a quality of life issue now.”
 You nod in understanding of what she means. The mere
utterance of the term stops the conversation by summoning a
mutual understanding.
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
The Smith brothers got together one day to walk their dogs
Ben and his dog live in a busy part of the
city. His dog is neutered, wears a collar
with ID tags as well as having a tattoo
and microchip. The dog receives three
walks a day and for safety’s sake is never
allowed outside without a leash. Ben
feeds his dog two measured meals a day
of a low-fat dog food. He is fastidious
about bathing and grooming his dog
regularly. His dog is trained to obey
commands. When Ben is at work his dog
lounges in his house – “a dog’s life” in
Ben’s words.
Jerry lives in a rural area at the outskirts
of town. His dog is allowed to roam free
and has never worn a collar in his life.
Jerry feeds his dog generously but
sporadically. The dog is rarely bathed and
usually has burrs in his coat from his
frequent exploratory ventures into the
woods surrounding their property.
Jerry’s dog is not neutered and has
plentiful opportunities to “intimately
interact” with the numerous female dogs
in the neighborhood.
Fraser et al. 1997. Anim Welf 6:187-205
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
Ben and his
city dog
Jerry and his
country dog
I FEEL SORRY FOR
YOUR DOG
I FEEL SORRY FOR
YOUR DOG
Ben and his dog live in a busy part of the
Jerry lives in a rural area at the outskirts
city. His dog is neutered, wears a collar
of town. His dog is allowed to roam free
with ID tags as well as having a tattoo
and has never worn a collar in his life.
and microchip. The dog receives three
Jerry feeds his dog generously but
walks a day Each
and for safety’s
is never quality
sporadically.
The from
dog is rarely
bathed and
man,sake
judging
of life
very
allowed outside without a leash. Ben
usually has burrs in his coat from his
viewpoints…
feeds his dog
If quality
two measured
ofdifferent
meals
life has
a day any
frequent
meaning
exploratory
at all,
ventures
then
into the
of a low-fat
dog food.one
He is of
fastidious
woods
surrounding
property.
clearly
these dogs
must
have their
a higher
about bathing and grooming his dog
Jerry’s dog is not neutered and has
QOL
than
the
other…
regularly. His dog is trained to obey
plentiful
opportunities to “intimately
commands. When Ben is at work his dog
interact” with the numerous female dogs
lounges in his house – “a dog’s life” in
in the neighborhood.
Ben’s words.
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
Ben and his
city dog
Jerry and his
country dog
If quality of life has any meaning at all, then
clearly one of these dogs must have a higher
QOL than the other…
Which one is it?
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
MORE OF THE IMAGINARY SCENARIO:
Ben’s city dog
Both of these brothers
are clients of yours.
Your busy day at your
vet hospital ends and
your receptionist has left
you a phone message
from “Mr. Smith” – with
no first name or pet’s
name…
Jerry’s country dog
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
MORE OF THE IMAGINARY SCENARIO:
Ben’s city dog
.
Jerry’s country dog
You have all night to
ponder what your advice
will be before calling him
the next morning.
“Everybody knows what
quality of life is,” you’re
thinking, so this should
be a no-brainer…
What are you going to tell him?
“Everyone knows what quality of life is” – Part 2
The scene: Your clinic. A drug rep, obviously excited, scurries in.
“We just received FDA approval for a new drug
that you’re going to love! It’s the closest thing to a
true ‘wonder drug’ that’s ever been developed!”
“What’s it do?”
“It’s incredible! It’s the first drug that increases a
dog’s quality of life! And here’s the amazing part: it
achieves an increase no matter what the dog’s
current quality of life is.”
“You’ve got a dog, don’t you Doctor? Just try
it on your own dog. You’ll see for yourself.”
Hmmm
Everyone knows what quality of life is – Part 2, Part 2
What
are youtogoing
for
You decide
give to
it alook
try…
to tell if the drug is working?
Does Bill Gates have a good QOL?
What about the
immaculately
groomed silver
Persian cat laying in
the Queen of
England’s lap eating
caviar out of a crystal
goblet?
The indoor cat is allowed outside
Question:
I move from Los Angeles to
a remote town in Utah. In
Los Angeles my cat could
never go outside because
of street traffic. My house
in Utah has a huge fenced
in backyard. I decide my
indoor cat can now go
outside, so I open the door
and allow her free access.
What happens to her QOL?
Mental disabilities and QOL
Mentally disabled
children
 Does making
them “like us” raise
their QOL?
 Why do we
assume they would
want this?
Mental disabilities and QOL
Do you assume
that dogs with
cognitive
dysfunction
syndrome have
decreased QOL
and our job is to
increase it?
WHAT DO WE MEAN BY QUALITY OF LIFE?
THE ANSWER GETS HARDER AND
MORE COMPLEX
 Happiness in humans exists in two forms: short-term current feeling happiness (“I feel
great!”) and long-term mood happiness (“I’m happy with the way my life is going”)
 Do animals have both forms?
 If QOL is made up solely by the feelings the animal is experiencing at that moment,
then his QOL would go up and down frequently, possibly every few minutes
 Imagine you are asking a client on the phone what she feels her dog’s QOL is. You
expect a certain type of answer—a reflection of what kind of life her dog is
experiencing overall over the past few weeks or so. You don’t expect an answer like:
“His QOL? Well, when he woke up this morning it was okay, I guess, but then it went way
down when the garbage truck came by and scared him with its loud noise, then it
went way up when I played fetch with his favorite ball, but then it went way down
when his knee-cap popped out of place and made him limp something terrible…”
 This answer FEELS WRONG. Why? The expectation you had for the client’s answer
implied the existence of a long-term mood state; you weren’t inquiring about the
dog’s current feelings. It seems, then, that QOL must be made up of more than simply
current feelings
 HOW long does a period of feeling good (or bad) have to last to be QOL as opposed to
a current mood state?
CONFUSION…
Quality of life is one of many similar or synonymous
concepts regarding the experience of life












Well-being
General well-being
Psychological well-being
Mental well-being
Emotional well-being
Subjective well-being
Quality of life
Welfare
Happiness
Life satisfaction
Contentment
‘Feeling good’
QUESTIONS
What IS quality of life?
Is it something you FEEL?
Or is it something
you THINK?
WHAT IS QUALITY OF LIFE?
TWO KEY QUESTIONS
1.
2.
WHAT FACTORS
INFLUENCE QUALITY
OF LIFE?
HOW MUCH DO THESE
FACTORS INFLUENCE
QUALITY OF LIFE?
Has an effect
on QOL
1.
2.
3.
4.
5.
6.
7.
8.
osteoarthritis
lots of playtime
abuse
tasty treats
always alone
nausea from CKD
new ‘bully’ dog
pulmonary edema
Does NOT have
an effect on QOL
1.
2.
3.
4.
5.
painted toenails
Neuticals
expensive collar
small lipoma
no Starbucks
nearby
6. toe amputation
7. food looks like bacon
8. male w/ female
name
do we OF
THEWhy
FEELINGS
have feelings?
QUALITY
OF LIFE
Why do we have feelings?
 Feelings have evolved to ASSIGN VALUE to
the nearly infinite internal and external stimuli
constantly inundating the nervous system
► sounds, smells, sights, internal and external
physical sensations, cognitions, knowledge
 The brain/body is constantly evaluating this
vast array of stimuli and DELIVERING ITS
ASSESSMENT OF IMPORTANCE to the
individual IN THE FORM OF FEELINGS
If something does not elicit a feeling
—pleasant or unpleasant—
then it has no value…
it does not MATTER to the animal
Hence, there appears to be no way
that it can affect QOL
FEELINGS
Pleasant
Physical
Emotional
Unpleasant
Taste, physical
Hypoxia, pain, thirst,
contact with others, hunger, illness, nausea, full
sexual activity
urinary bladder,
constipation, pruritus,
bright lights, temp
extremes, etc
Joy, social
companionship,
mental stimulation
Fear, anxiety, loneliness,
boredom, frustration,
anger, depression, grief,
helplessness
By definition, pleasant feelings
give life a pleasant quality,
and unpleasant feelings give
life an unpleasant quality
“Beeper studies” in people:
Overall pleasantness of life
relates to time spent experiencing
pleasant and unpleasant feelings
Positive (good) QOL coincides with
a preponderance of pleasant feelings, and
negative (poor) QOL coincides with
a preponderance of unpleasant feelings.
The Affect Balance Model
of Quality of Life
Quality of life is represented by a
balance of the pleasant and
unpleasant feelings of life over time
PLEASANT
FEELINGS
● Joy
● Play
● Social
companionship
● Mental
stimulation
● Physical contact
● Taste
● Nurturing young
(mammals)
● Sexual activity
● Control
UNPLEASANT
FEELINGS
● Fear
● Anxiety
● Boredom
● Loneliness
● Separation
distress
● Grief
● Depression
● Pain
● Hypoxia
● Full bladder
● Nausea
● Pruritus
The Affect Balance Model of Quality of Life
High QOL
PLEASANT
FEELINGS
UNPLEASANT
FEELINGS
Low QOL
PLEASANT
FEELINGS
UNPLEASANT
FEELINGS
WHAT IS QUALITY OF LIFE?
TWO KEY QUESTIONS
1.
WHAT FACTORS
INFLUENCE QUALITY
OF LIFE?
Anything which tips the QOL scales—in
either direction—plays a role in the
animal’s QOL. Those things that do not tip
the scales do not affect the animal’s QOL
WHAT IS QUALITY OF LIFE?
TWO KEY QUESTIONS
1.
2.
WHAT FACTORS
INFLUENCE QUALITY
OF LIFE?
On the QOL scales
intensity
of the feelings
HOWthe
MUCH
DO THESE
dictates the degree to which the scales are
FACTORS
INFLUENCE
tipped, and hence defines the magnitude of
influence thatQUALITY
factor hasOF
onLIFE?
QOL
Has an effect
on QOL
1. osteoarthritis
2. lots of playtime
Do
NOT tip
3. abuse
tasty treats
the4. QOL
scales
5. always alone
6. nausea from CKD
7. new ‘bully’ dog
8. pulmonary edema
Does NOT have
an effect on QOL
1. painted toenails
2. Neuticals
3. expensive
collar
Tip the
4. small lipoma
QOL
scales
5.
no Starbucks
nearby
6. bacon look to food
7. male w/ female
name
8. toe amputation
Balance Model of Quality of Life
This model of QOL explains the reason for the
intuitive feeling that an animal’s QOL is compromised
when:
 animal is in pain – unpleasant feeling tips the
scales negatively
 animal is abused or neglected – unpleasant
feelings of fear, pain, loneliness, hunger, etc,
strongly tip the scales
 animal is paralyzed – the decreased
opportunities to experience enjoyable activities
lessens the weight of pleasant feelings, tipping the
scales toward the unpleasant feelings
Affect Balance Model of Quality of
Life
BUT NOT ALL FEELINGS
WEIGH THE SAME
 FEELINGS 
PLEASANT vs UNPLEASANT
 Because of the importance of unpleasant
feelings in protecting life, it appears that they
are constructed to command more attention
than pleasant feelings
 They do this by inflicting feelings that HURT,
so that the animal cannot ignore them
 Because of this, unpleasant feelings appear
to carry more weight in one’s QOL
WHY DOES PAIN HURT SO MUCH?
THE PRIORITY OF UNPLEASANT FEELINGS
Nature intended discomfort (and suffering) to
command more attention, priority, and urgency
than the pleasant feelings of life
Pleasant emotions – attraction to beneficial things
Single malfunction has minimal consequences
Threats and dangers in nature – which the
unpleasant feelings protect the animal from –
much more critical to survival than the pleasant
experiences – often a matter of life and death
PLEASANT FEELINGS
Single malfunction equals
loss of a tasty meal
UNPLEASANT FEELINGS
Single malfunction equals
loss of life
PAY
ATTENTION
TO ME!
Unpleasant
feelings
I CAN
MAKE
YOU
FEEL GOOD
Pleasant
feelings
ALL
UNPLEASANT
FEELINGS
ARE NOT EQUAL
Situations most urgently threatening to life have
evolved to have the most intensely unpleasant
feelings (sufferings)
SITUATION
FEELING
Impaired oxygen intake
Hypoxia, terror, panic
Tissue damage
Pain
Threat to life
Fear
When You Can’t Breathe,
Nothing Else Matters
American Lung Association
PHYSICAL vs EMOTIONAL PAIN –
WHICH IS WORSE?
Study: electrified
grid placed
between puppies
and sociallyattached human.
Puppies endured
the pain of crossing
the grid to
reestablish contact
with the person
Photo by Clay Myers
PHYSICAL VERSUS EMOTIONAL PAIN:
WHICH IS WORSE? Scarlett’s answer
Scarlett
October 2008
THE MAJOR CONTRIBUTING FACTORS
TO QUALITY OF LIFE
ALL EFFECTS ARE THROUGH FEELINGS
Social relationships—Social bonds are promoted and enforced by pleasant and
unpleasant emotions. Positive social affiliations and companionship elicit
pleasant feelings, and separation and isolation elicit unpleasant feelings
Mental stimulation—Monotonous, unchanging environments elicit signs of
boredom. Conversely, pleasant feelings are elicited by stimulation,
challenges, and mental engagement
Control—The perception that one has the ability to influence the events in his
own life, especially the unpleasant events, provides a peace of mind and
sense of security that permits living in confidence rather than in insecurity,
fear, and hopelessness
Health—Compromised health involves myriad unpleasant feelings. Physical
disabilities limit one’s opportunities for experiencing pleasurable feeling
states
“Stress”—As a contributing factor to QOL, stress refers to specific unpleasant
emotions such as fear, anxiety, pain, loneliness, boredom, and anger. Its
influence on QOL is through the feelings associated with these emotions
MEASUREMENT OF QUALITY OF LIFE IN ANIMALS
We all agree that knowing an animal’s
quality of life is important. But what’s the
big deal? Why not rely on what we’ve
always relied on—our intuitive judgment?
WHY DO WE NEED FANCY TOOLS
TO MEASURE SOMETHING SO OBVIOUS?
MANY HUMAN DOCTORS
ASK THE SAME QUESTION
For dogs with spinal cord injury, quality of life
scores for dogs able to walk were significantly
higher than scores for dogs unable to walk
Quality of life scores for healthy dogs
were significantly higher than scores for
dogs with spinal cord injuries
What’s wrong with just using our intuition
to assess an animal’s quality of life?
KEY QUESTIONS
 How reliable are our gut-level, intuitive assessments of a pet’s
QOL?
 If you judged your own pet’s quality of life, how willing would
you be to accept the findings from a questionnaire that said
you were wrong?
HOW MUCH IMPORTANCE DO WE GIVE GUT-LEVEL,
INTUITIVE ASSESSMENTS OF QOL?
 Using it for the biggest decision we make for animals: the lifeand-death decision of euthanasia
 Best example: Owner asks veterinarian how they’ll know when
it is “time” for euthanasia. “You’ll just know.” Intuitively.
Human intuition and animal feelings
How good is our intuition in judging QOL?
 Study: Feeding low-palatability
rations reduced or eliminated intra- and
intercage aggressiveness, allowing
dogs to be housed in groups and
participate together in activities such
as social play and exercise. Other
studies showed the same thing in a
different way: switching group-housed
dogs from low quality food to meat,
instant and often ferocious fighting
ensued.
 The low palatability food likely
decreases QOL, while social
companionship increases it.
 What does your intuition tell you will
result in the highest QOL: an
unenjoyable food with more pleasant
social interaction, or a very tasty food
but more antagonistic encounters with
cagemates?
How good is our intuition
in judging QOL?
STUDY: A DRUG TO TREAT COGNITIVE DYSFUNCTION SYNDROME
 More than 600 elderly dogs and their owners were enlisted in a field
study of a drug that improves neurotransmitter function
 Owners assessed their dog’s behavior at the beginning of the study, then
at 30 and 60 days of treatment
 Unexpected finding  a number of dog owners who
had assessed their dog as “normal” at the start of the
trial reported improvement at 30 days
 Implications for assessing QOL: The very gradual
progression of loss of mental function occurred too
slowly for owners to see the changes. Animals can be
rated as “normal” by their owner when they are not.
How good is our intuition in judging QOL?
OTHER EXAMPLES
Dental
work
NSAID
treatment
trials
Hypothyroid
treatment
How good is our intuition in judging QOL?
MORE PROBLEMS
Study in dogs showed that the bond
between a person and dog influences
the person’s reports about the dog’s health
MEASUREMENT OF QUALITY OF LIFE IN ANIMALS
 In people, the gold standard method of measuring QOL is
the self-report, using a structured questionnaire
instrument that is subjected to formal assessment
 Measuring even a single component of QOL, such as
pain, is very difficult; thus the much more complex
totality of QOL is exceptionally difficult to assess
 Specific criteria proposed for measuring animal QOL
include:
Behavior, stress hormone levels, health status,
physical functioning (disability), immune function,
brain imaging
 Barriers: language, also differences in species, sex,
breed, age, and individuals regarding needs, preferences,
values, and sources of discomfort and pleasure
PROXY MEASUREMENT
 Many people cannot report their own QOL –
neonates, infants, mentally disabled, and
severely ill
 Need to use alternative sources, such as
parents, spouses, partners, caregivers,
siblings, and health care providers – “proxy”
informants
 Reliance on proxies for QOL assessment in
animals is an obvious necessity
How accurate are proxy measurements of QOL?
 Studied extensively in adolescent humans by
comparing data from proxy informants with data from
pediatric patients themselves.
 Well-documented finding: Poor agreement between
children and parents on measures of private
experiences, such as emotions and subjective states,
regardless of whether the child is healthy or sick.
 The importance for animal care is that if parent-child
proxy QOL assessment is inaccurate, then personanimal assessment is likely to be even more so.
Without a QOL thermometer…
This makes QOL assessment at the present time a
very inexact science, and wide open to influences
such as personal bias
Examples
 A pet owner who wants to please the
veterinarian may give an exaggerated report of
improved QOL after treatment has begun
 An owner who cannot “let go” may falsely
assess a pet’s QOL as higher than it actually is,
in order to avoid the decision on euthanasia
If allonly
That
seems
simple
enough
it were…
The puzzling aspects of
quality of life
…what’s going on?
People who suffer injury and become paralyzed from the waist
down. Most will rate their QOL as good or excellent 1 year later.
● Imagine now: One of the paralyzed individuals who rated their
QOL as excellent then regains the ability to walk.
● What happens to this person’s QOL?
Scientists at the University of Florida scientists recently
reported that delivering a specific gene through an eggshell would
give sight to a type of chicken normally born blind.
● Now, consider that people born blind often rate their QOL as
excellent in their adult life.
● And now… if (when) this fetal gene therapy is developed for
humans, causing those destined to be born blind to be born with
normal sight, and one of these people later rated her adult life QOL
as excellent – the same as she would have if she had been born
blind – wouldn’t this suggest that having sight is irrelevant to QOL?
…what’s going on?
Many people report satisfaction in situations
that the majority of the population believe
that they would find unbearable
Cancer
 Birnbacher (1999) writes of cancer patients
who successfully adapt to a health situation
they had thought intolerable at the time of
onset of their disease.
Spinal cord injury
 DeLisa (2002): multiple researchers have
found that “the assumptions of those of us
who are able-bodied bear little relationship to
the realities of life for the people with SCI”
…a paradox
Numerous studies have shown:
Across a wide range of health conditions,
people with illness or disability typically
report greater happiness and QOL than do
healthy people envisioning themselves in
those very circumstances
The Disability Paradox
THE DISABILITY PARADOX
IN ANIMAL QUALITY OF LIFE
 If the disability paradox shows that we do not see
our own future QOL clearly, predicting an animal’s
future QOL would be no more successful
 The Disability Paradox in animals
 In a survey of 50 blind dogs, over 50 percent (28 of 50) of
the dogs’ owners had encountered people who had
suggested it was unkind to keep a blind dog. In this study,
many hold the view that appears to be based on a
presumption that blindness would so negatively affect QOL
that keeping such a dog alive would be wrong
 In a study of pet owner responses to amputation for their
animal, 100 percent (7 of 7) of those whose main objection
to the amputation was a prediction of a decreased QOL later
stated that their concern was unfounded
WHAT CAN EXPLAIN
THE DISABILITY PARADOX?
1. The focusing illusion
2. Underestimation of adaptation
3. Scale recalibration
Focusing Illusion
When people experience or anticipate
an unpleasant change in life there is a
strong psychological tendency to
FOCUS ON THE NEGATIVE and all
bad things this change will bring
But after time passes, the other parts
of their lives regain their importance
Focusing Illusion
The focusing illusion is very powerful
force and EXTREMELY DIFFICULT
TO DISREGARD when looking at
one’s own future situation
 Even when the person predicting a
QOL (including one’s own) is aware
of focusing illusion, still very difficult
to incorporate it into predictions of
well-being
 Degree of person’s knowledge and
familiarity with the animal won’t
eliminate focusing illusion’s effects
WHAT CAN EXPLAIN
THE DISABILITY PARADOX?
1. The focusing illusion
2. Underestimation of adaptation
3. Scale recalibration
Adaptation
 As the individual comes to terms with the conditions of
long-term illness, disability, or emotional trauma,
psychological changes occur that tend to preserve one's
personal well-being
 Studies in humans: Unusual for any single event—good or
bad—to create a lasting alteration of the individual's sense
of well-being, even for the greatest extremes of tragedy
and triumph
 Death of spouse or close companion
 Severely disabling and permanent injuries and illnesses such
as paralysis, loss of vision, or the diagnosis of a progressive
fatal disease
 Winning the lottery, major promotion, coveted award
 ADAPTATION is ADAPTIVE
 Emotional recovery helps ensure the individual is able to
EFFECTIVELY RESPOND TO THE NEXT CHALLENGE he or she
encounters in life
Adaptation in Animals
Evidence suggests adaptation works similarly in animals and humans
 A study of dogs that had become paralyzed in their hind legs showed
that their mental attitudes, as judged by their owners, was as good
three months after as before the paralysis in 85 percent of the
animals
 In a survey of dog and cat owners whose pet had undergone a limb
amputation, all respondents (17 of 17) said that after their pet
adjusted it was as active and happy as it had been before the
amputation
 In another study of animals having had amputations performed, 100
percent (74 of 74) pet owners reported that their pets led normal
lives after healing from the surgery
 Anecdotal: Pet animals – signs of clinical depression when a new pet
or human infant added to the home or when the pet loses an animal
or human companion
Recovery to their original emotional well-being appears to be
roughly the same as seen in humans recovering from similar
emotional troubles
WHAT CAN EXPLAIN
THE DISABILITY PARADOX?
1. The focusing illusion
2. Underestimation of adaptation
3. Scale recalibration
Scale Recalibration
 Appears to be a SHIFT IN THE
INTERNAL STANDARD, which
results in a changed expectation of
QOL MORE IN FITTING WITH
THE INDIVIDUAL’S CURRENT
SITUATION IN LIFE
 The QOL scale shifts, so “90” for
the elderly man means something
different than a “90” for the young
man
Scale Recalibration in
Animal QOL Assessment
 Routinely applied to animals
 Example
 Typical comment from owner of an elderly dog:
“He’s doing pretty well, considering his age.”
 Key phrase: “considering his age”
 This qualifying comment is a scale recalibration It signals
that the owner is applying a different standard to this dog than
she would to a young dog
 “Pretty well” does not necessarily mean same thing
for a 17-year old Cocker Spaniel as for one that is
2 years old
Quality of Life in Health Care
Why is quality of life important
in health care?
 Because QOL is a view of one’s life from within – by that individual
and not an outsider – it forces us to look at the health effects from the
animal’s POV rather than by a blood test or Xray.
 It tells us what we need to change and how much change is needed.
 It guides decision-making about an animal’s care. When there is a
choice of care options, it tells us which is (or should be) the best one.
 It tells us whether what we’re doing for an animal is benefitting or
harming them.
 Without QOL, all of these things above are guesses (which, right
now, many are).
QOL in the
ill animal
Quality of Life
Early illness
Quality of Life
Progressing illness
Quality of Life
Late illness
Maximizing QOL
can be summarized by a single principle:
Tip the QOL scales as far toward
the pleasant side as possible
THIS MAY BE ACHIEVED BY:
 minimizing unpleasant feelings
 increasing pleasant feelings
 both
Maximizing QOL in Ill Animals
 For animals with an illness or injury the
main effort is to restore a diminished QOL
by alleviating the unpleasant feelings
associated with the health disorder
 The ideal: restore health
 When health cannot be restored
 Use all means possible to decrease the
unpleasant feelings
 Drugs, surgery, human contact
Maximizing QOL in Ill Animals
PROMOTING PLEASANT FEELINGS
 Humans – social support, fun activities,
humor
 Pleasurable feelings in ill animals
 Social interaction and companionship
 Human contact
 Mentally stimulating and engaging activities
 Games, chase and pounce, outings, interactive
toys, digging up buried treasures
 Taste pleasures – delicious foods and snacks
Maximizing QOL in
dogs with disabilities
 Neuromuscular disease
 Degenerative myelopathy
 Paralysis
 Loss of vision
 Loss of hearing
Maximizing QOL in Clinical Practice
All therapeutic decisions
should be decided in favor of
that choice which tips the
QOL scales THE MOST
toward pleasant feelings
HOWEVER…
IS QUALITY OF LIFE
“EVERYTHING”?
IS IT THE ONLY THING THAT
MATTERS?
IS ANYTHING ELSE
IMPORTANT?
IS QUALITY OF LIFE “EVERYTHING”?
IS IT THE ONLY THING THAT MATTERS?
IS ANYTHING ELSE MORE IMPORTANT?
 Is the highest quality of life what we want for our
animals?
 Is it what we want for ourselves?
 Is there anything more important than quality of
life?
 What if you could “buy” a longer life – more
QUANTITY of life – by giving up some of your
QUALITY of life?
 What if you could “buy” a higher QUALITY of life
by giving up some of your QUANTITY of life?
IS QUALITY OF LIFE “EVERYTHING”?
IS IT THE ONLY THING THAT MATTERS?
IS ANYTHING ELSE MORE IMPORTANT?
In clinical practice
 I weigh in quantity of life in many if not most of my decisions
and recommendations to the pets’ owners
 Recommendation: that an owner of a cat with kidney disease
to feed a less tasty food that will slow the progress of the
renal failure and allow the cat to live longer  sacrifices
quality of life for quantity
 Recommendation: surgical, radiation, or chemotherapy
treatments for a dog with a malignant cancer  places
quantity (to at least some degree) over quality
A MATH WE DON’T UNDERSTAND AT ALL –
AND AT STAKE IS AN ANIMAL’S LIFE
 VETERINARIANS ARE SOMEHOW – APPARENTLY
BASED SOLELY ON INTUITIVE FEEL – DOING THIS
MENTAL MATH EVERY DAY
 ANY decrease in QUALITY OF LIFE requires us to determine if the
animal would accept a longer life in trade for the decrease in
QUALITY OF LIFE (or, more simply, “Can he live with this?”)
 Even the simplest things like telling owners to bring their scared
animals to the clinic for immunizations against disease involves a
decision as to how the animal would trade QUALITY for QUANTITY
 For minor decreases in QUALITY this decision is not difficult, even
for minor gains in QUANTITY. But as the decrease in QUALITY
grows larger and the increase in QUANTITY grows smaller, at some
point the trade-off is not worth it. So… How is QUALITY of life
weighed against QUANTITY of life?
QUESTIONS
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