1. Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah MAXIMIZING QUALITY OF LIFE IN ILL ANIMALS MAXIMIZING QUALITY OF LIFE IN ILL ANIMALS

2. “I promise to give you the best possible quality of life.”

3. “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.

8. 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. HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE? Fraser et al. 1997. Anim Welf 6:187-205

9. Jerry and his country dog Ben and his city dog 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. 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. I FEEL SORRY FOR YOUR DOG I FEEL SORRY FOR YOUR DOG If quality of life has any meaning at all, then clearly one of these dogs must have a higher QOL than the other… Each man, judging quality of life from very different viewpoints… HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

10. Jerry and his country dog Ben and his city dog If quality of life has any meaning at all, then clearly one of these dogs must have a higher QOL than the other… HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE? Which one is it?

11. 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… Ben’s city dogJerry’s country dog MORE OF THE IMAGINARY SCENARIO: PHONE MESSAGE Mr. Smith called – he said “My brother has convinced me that his dog has a really good quality of life and mine doesn’t. So I need your advice on how I can give my dog as good of a quality of life as his dog has. Please call me.” HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

12. Ben’s city dogJerry’s country dog MORE OF THE IMAGINARY SCENARIO: PHONE MESSAGE Mr. Smith called – he said “My brother has convinced me that his dog has a really good quality of life and mine doesn’t. So I need your advice on how I can give my dog as good of a quality of life as his dog has. Please call me.” HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE? 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?

13. “Everyone knows what quality of life is” – Part 2 “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.” The scene: Your clinic. A drug rep, obviously excited, scurries in. Hmmm

14. What are you going to look for to tell if the drug is working? What are you going to look for to tell if the drug is working? You decide to give it a try… Everyone knows what quality of life is – Part 2, Part 2

15. 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?

16. 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? The indoor cat is allowed outside

17. Mental disabilities and QOL Mentally disabled children  Does making them “like us” raise their QOL?  Why do we assume they would want this?

18. Mental disabilities and QOL Do you assume that dogs with cognitive dysfunction syndrome have decreased QOL and our job is to increase it?

19. 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?

20. 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’ CONFUSION…

21. QUESTIONS What IS quality of life? Is it something you FEEL? Or is it something you THINK?

22. TWO KEY QUESTIONS WHAT FACTORS INFLUENCE QUALITY OF LIFE? 1. 2. HOW MUCH DO THESE FACTORS INFLUENCE QUALITY OF LIFE? WHAT IS QUALITY OF LIFE?

23. Does NOT have an effect on QOL Has an effect on QOL 1. painted toenails 2. Neuticals 3. expensive collar 4. small lipoma 5. no Starbucks nearby 6. toe amputation 7. food looks like bacon 8. male w/ female name 1. osteoarthritis 2. lots of playtime 3. abuse 4. tasty treats 5. always alone 6. nausea from CKD 7. new ‘bully’ dog 8. pulmonary edema MATTERS to the animal Does NOT matter to the animal ELICITS FEELINGS ELICITS NO FEELINGS

24. THE FEELINGS OF QUALITY OF LIFE Why do we have feelings?

25.  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 Why do we have feelings?

26. 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

27. Taste, physical contact with others, sexual activity Hypoxia, pain, thirst, hunger, illness, nausea, full urinary bladder, constipation, pruritus, bright lights, temp extremes, etc Joy, social companionship, mental stimulation Fear, anxiety, loneliness, boredom, frustration, anger, depression, grief, helplessness Physical Emotional Pleasant Unpleasant FEELINGS

28. By definition, pleasant feelings give life a pleasant quality, and unpleasant feelings give life an unpleasant quality

29. “Beeper studies” in people: Overall pleasantness of life relates to time spent experiencing pleasant and unpleasant feelings

30. Positive (good) QOL coincides with a preponderance of pleasant feelings, and a preponderance of pleasant feelings, and negative (poor) QOL coincides with a preponderance of unpleasant feelings. a preponderance of unpleasant feelings.

31. Quality of life is represented by a balance of the pleasant and unpleasant feelings of life over time The Affect Balance Model of Quality of Life The Affect Balance Model of Quality of Life

32. The Affect Balance Model of Quality of Life UNPLEASANT FEELINGS PLEASANT FEELINGS ● Joy ● Play ● Social companionship ● Mental stimulation ● Physical contact ● Taste ● Nurturing young (mammals) ● Sexual activity ● Control ● Fear ● Anxiety ● Boredom ● Loneliness ● Separation distress ● Grief ● Depression ● Pain ● Hypoxia ● Full bladder ● Nausea ● Pruritus

33. PLEASANT FEELINGS UNPLEASANT FEELINGS High QOL

34. UNPLEASANT FEELINGS PLEASANT FEELINGS Low QOL

35. TWO KEY QUESTIONS WHAT FACTORS INFLUENCE QUALITY OF LIFE? 1. WHAT IS 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

36. TWO KEY QUESTIONS WHAT FACTORS INFLUENCE QUALITY OF LIFE? 1. 2. HOW MUCH DO THESE FACTORS INFLUENCE QUALITY OF LIFE? WHAT IS QUALITY OF LIFE? On the QOL scales the intensity of the feelings dictates the degree to which the scales are tipped, and hence defines the magnitude of influence that factor has on QOL

37. Does NOT have an effect on QOL Has an effect on QOL 1. painted toenails 2. Neuticals 3. expensive collar 4. small lipoma 5. no Starbucks nearby 6. bacon look to food 7. male w/ female name 8. toe amputation 1. osteoarthritis 2. lots of playtime 3. abuse 4. tasty treats 5. always alone 6. nausea from CKD 7. new ‘bully’ dog 8. pulmonary edema Do NOT tip the QOL scales Tip the QOL scales

38. 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

39. Affect Balance Model of Quality of Life BUT NOT ALL FEELINGS WEIGH THE SAME

40.  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

41. 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

42. PLEASANT FEELINGS Single malfunction equals loss of a tasty meal UNPLEASANT FEELINGS Single malfunction equals loss of life

43. Unpleasant feelings Pleasant feelings PAY ATTENTION TO ME ! I CAN MAKE YOU FEEL GOOD

44. ALL UNPLEASANT FEELINGS ARE NOT EQUAL SITUATION FEELING Impaired oxygen intakeHypoxia, terror, panic Tissue damage Pain Threat to lifeFear Situations most urgently threatening to life have evolved to have the most intensely unpleasant feelings (sufferings)

45. When You Can’t Breathe, Nothing Else Matters American Lung Association

46. Study: electrified grid placed between puppies and socially- attached human. Puppies endured the pain of crossing the grid to reestablish contact with the person PHYSICAL vs EMOTIONAL PAIN – WHICH IS WORSE? Photo by Clay Myers

47. PHYSICAL VERSUS EMOTIONAL PAIN: WHICH IS WORSE? Scarlett’s answer Scarlett Scarlett Saves Her Family Brooklyn, New York: mother cat was nursing a litter of 4-week-old kittens in an abandoned building that caught fire. The mother cat re-entered the blazing building five times to rescue each of her five kittens one at a time. In the process, she suffered severe burns to her face and head, so damaging that her eyes were swollen tightly shut, her whiskers and facial hair were burned off, and her face was badly disfigured from the burned skin.

48. October 2008

50. THE MAJOR CONTRIBUTING FACTORS TO QUALITY OF LIFE 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 ALL EFFECTS ARE THROUGH FEELINGS

51. MEASUREMENT OF QUALITY OF LIFE IN ANIMALS

52. MANY HUMAN DOCTORS ASK THE SAME QUESTION 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?

53. 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

54. 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 life- and-death decision of euthanasia  Best example: Owner asks veterinarian how they’ll know when it is “time” for euthanasia. “You’ll just know.” Intuitively.

55. Human intuition and animal feelings

56. 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?

57. 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?

58. OTHER EXAMPLES Dental work NSAID treatment trials Hypo- thyroid treatment

59. Study in dogs showed that the bond between a person and dog influences the person’s reports about the dog’s health How good is our intuition in judging QOL? MORE PROBLEMS

60. A Quality of Life Thermometer

61. 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 MEASUREMENT OF QUALITY OF LIFE IN ANIMALS

62. 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

63. 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 person- animal assessment is likely to be even more so. How accurate are proxy measurements of QOL?

64. 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

65. That all seems simple enough If only it were…

66. The puzzling aspects of quality of life

67. …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?

68. 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 ” …what’s going on?

69. … a paradox The Disability 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

70.  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 THE DISABILITY PARADOX IN ANIMAL QUALITY OF LIFE

71. WHAT CAN EXPLAIN THE DISABILITY PARADOX? 1.The focusing illusion 2.Underestimation of adaptation 3.Scale recalibration

72. 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

73. 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

74. WHAT CAN EXPLAIN THE DISABILITY PARADOX? 1.The focusing illusion 2.Underestimation of adaptation 3.Scale recalibration

75. 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

76. 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

77. WHAT CAN EXPLAIN THE DISABILITY PARADOX? 1.The focusing illusion 2.Underestimation of adaptation 3.Scale recalibration

78. 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

79. 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

80. Quality of Life in Health Care

81. 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). Why is quality of life important in health care?

82. QOL in the ill animal

83. Quality of Life Early illness

84. Quality of Life Progressing illness

85. Quality of Life Late illness

86. can be summarized by a single principle: Tip the QOL scales as far toward the pleasant side as possible Maximizing QOL

87. minimizing unpleasant feelings increasing pleasant feelings both THIS MAY BE ACHIEVED BY:

88. 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

89. 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 Ill Animals

90.  Neuromuscular disease  Degenerative myelopathy  Paralysis  Loss of vision  Loss of hearing Maximizing QOL in dogs with disabilities

91. 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…

92. IS QUALITY OF LIFE “EVERYTHING”? IS IT THE ONLY THING THAT MATTERS? IS ANYTHING ELSE IMPORTANT?

93. 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?

94. 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 IS QUALITY OF LIFE “EVERYTHING”? IS IT THE ONLY THING THAT MATTERS? IS ANYTHING ELSE MORE IMPORTANT?

95. 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?

97. QUESTIONS