Thank you very much. And, good evening to everyone. It's actually afternoon here, 1 o'clock in the 1:30, I guess by now.
And thank you all for being here. I wanted to just give you a quick, Visual, for some reason, there we go. So this is me.
And, in my, my typical role, my, friends make fun of me when they see this picture. Like, you're always lecturing everybody, even your dogs. So this is me, lecturing my dog, Bella, who is the black dog there, in the left hand picture and my grand dog, Poppy.
And then on the right there is my My beloved dog Maya, who sadly passed away over the summer. So this is my, my canine family. So, Why talk about quality of life?
Veterinary care seeks to provide animal patients, and particularly those of advanced age or with life-limiting illness, a course of treatment that allows them to enjoy their remaining life to the fullest, while still not prolonging life simply for the sake of more time. A fine balancing act is often required to manage symptoms and keep pain at bay while striving to keep an animal happy and to maximise positive experiences. Effective tools to interpret and track animals' quality of life can help veterinarians and family caregivers achieve this delicate balance, and one of these tools is the quality of life assessment.
So what I wanna do in this webinar just to give you a preview is, first of all, I'm gonna talk a little bit generally about what a quality of life assessment is and why they can be important in end of life care. I'll talk a little bit about some specific assessment tools that have been developed and their strengths and weaknesses. And then, broaden out a little bit just to talk about what would be the qualities of an ideal quality of life assessment tool.
What is it that ideally, we could accomplish with, a tool or a set of tools in our toolbox of this sort. And then, finally, some specific ways in which quality of life assessments can improve care for animal patients and also some of the, the, some cautionary words about how they, they may not always do exactly what we hope or intend for them to do. So, Let's dig into this first question.
What is a quality of life assessment? So the concept of quality of life has been in use in human medicine since at least the early 1970s and was developed as a measure of how much an illness or disability affected an individual patient's overall well-being and their ability to adapt to physical changes from illness or advanced age. And the impetus behind the development of quality of life, of the, the quality of life construct really was to represent the patient's interests in decisions made about healthcare.
And, you know, at the, at the time was a reflection of a growing interest among healthcare professionals and ethicists in patient autonomy and. Self-determination in medical decision making. So, what exactly health-related quality of life is and how to measure it, and even whether you can measure it has been, for what, 50 years now, and still is the subject of considerable debate.
And there are thousands of articles on quality of life, in human healthcare. Over about the past decade, the language of quality of life and quality of life assessment has become more common in veterinary medicine as well. As in the human realm, the conceptualization and measurement of quality of life in animals has been contentious.
And a wide variety of approaches and methods are still being explored, and there's no single gold standard for assessing quality of life in animal patients. The continued development of a wide variety of assessment tools is essential to the future of the field and particularly the future of hospice and palliative care, but not limited to that. We might define quality of life in animals in much the same way as in humans.
How an individual animal patient's physical, emotional, and social well-being is affected by disease, disability, or changes related to advanced age. To accomplish the objective of patient-centered care, and making decisions that respect patients' wants, needs and preferences, quality of life assessments are used to elicit elicit the patient's own experiences before, during, and after treatment. This is the goal in the animal realm as much as it as it is in the human realm.
Quality of life assessments focus as much as possible on how the animal is doing from the animal's own point of view. In its simplest form, assessing quality of life involves tracking the balance between negative emotional states and positive emotional states experienced by the animal patient. And some of the factors, and this is not an exhaustive list, even though it's a very long list, I'm sure.
That each of you can think of things that we could add to each of these categories. But some of the factors that can negatively impact an animal's quality of life include pain, nausea, inhabitence, respiratory distress, loss of mobility, incontinence, dehydration, confinement, social isolation, confusion. Agitation, boredom, frustration, the list is very long, anxiety, fear, depression, and the inability to engage in meaningful and enjoyable activities.
In assessing unpleasant feelings, we can consider that some factors, noticeably on this particular list, maybe respiratory distress and severe pain, may weigh more heavily than others, such as perhaps incontinence or inapetence. Some of the factors that can positively impact an animal's quality of life, including and again, you can, can add a lot more to this category, but tactile and other sensory stimulation, mental stimulation, companionship. Good food, comfortable bedding, play, pleasure, and a sense of control over oneself and one's environment.
And this is the, the one place where I have a poll question, not exactly how this works out, there we go. There we go, folks. So all you need to do is simply just click on the answer that you think best suits the question.
Do you use or recommend quality of life assessment tools in your practise? The answers are from 1 being not really, don't do it through to 5, extremely useful. Simply click on the answer that best suits yours.
As I said to you at the beginning of the programme. This is anonymous. There is no harm in, in just answering and giving Jessica some feedback on on who she's talking to and guidance so that she knows what she's going to be stressing as we go forward.
Yeah, yeah, thank you. Yeah, I, I feel like I swim in this material and then, and thinking about quality of life assessments and tools. So, my perspective may be, not at all reflective of the experience of actual practitioners, so that's why I wanted to see what they've given you.
There are your results. Can you see those? I can.
So interesting. OK. That, that's sort of, what I was expecting.
So, the majority of people don't, if I'm reading this correctly or answer asked a question that was useful, people don't find them all that helpful. OK, well, thank you so much for answering that. That's, that's very interesting, and kind of in line with my own thinking.
So, let's move on to talking about some specific approaches to assessing quality of life, some specific tools. So, as I suggested a minute ago, The quality of life assessment really, and this is true in human and animal realms both, that the attempt is to address the three primary Modes or factors that, that influence one's, one's quality of life, the physical, the psychological, and the social. And obviously, these are really overlapping and integrated categories, but for the sake of conversation, they're typically separated.
Physical factors would include An animal's ability to perform what in what in human terms are often called activities of daily living, including, you know, locomotion, being able to relieve themselves. Appetite, sleep, psychological factors would include the level of consciousness, you know, cognitive decline or challenges, a sense of well-being, and then social factors would include things like owner animal interactions, the quality of the bond. Social relationships with other pets and other animals, both inside the home and also outside the home, and social integration within a family, whether it's a multi-species family or a two-species family.
The science and and art, and it really is both of those things, of assessing seriously ill animals' quality of life is really still in its infancy, and a relatively small number of assessment tools have been developed for use in veterinary care, especially relevant to sorry, relative to how many have been developed in the human realm. Measuring behaviour is, of course, very tricky, particularly when you have, patients who can't speak in language that you understand necessarily. So having some statistically reliable and validated assessment tools is important, I being, albeit quite challenging, and in statisticians speak.
Reliability is the extent to which measurements are repeatable and consistent and free from errors. Validity is the extent to which a measurement actually measures what it is supposed to measure and gives us information that's relevant to the questions being asked. And a validated measurement instrument helps practitioners make clinical decisions about what treatments or interventions are working or not working based upon relatively Objective data as opposed to a caregiver's hunch or gut intuition or some kind of gestalt judgement.
And you'll see why this language is important in a couple of minutes. I'll come back to it here and there. Within the context of clinical research, statistically validated and reliable tools for measuring quality of life are crucial.
Within the context of hospice and palliative care that takes place within the home or within the clinic, what's most important is that a quality of life assessment tool provide an accurate and comprehensive picture of the individual animal's well-being, and that it can help weigh benefits and burdens of disease and treatments and offer a platform for discussion and shared decision making. I'm gonna give you 3 examples of quality of life tools that have been developed to highlight some of the important components and functions of the process itself and some of the strengths and weaknesses. I'm gonna spend the most time talking about Frank McMillan's, what's called the affect balance tool or model, one called Vet Metrica and then one called POSpices, and I'm gonna mention a couple of others beside those but not in very much detail.
So, And all of these, how to find these should be in the materials that were made available, the bibliography and lecture notes, so. So, as the name suggests, Frank MacMillan's affect balance model focuses on animal emotions or affect, and not, for example, on physiological markers like heart rate and cortisol. McMillan theorises that assessing an animal's quality of life involves tracking negative emotional states and positive emotional states, and assigning each of them relative weight based on evolutionary function and on the individual animal's preferences, and then calculating a kind of balance.
Now, MacMillan's model is discursive. So what I mean by that is that it it involves a chapter length discussion of the evolutionary origin of affective experiences in animals and the significance of affective states. And as such, I think it is actually One of the most valuable models because it's a really good learning aid for veterinarians and vet team members.
I think it would appeal to a pretty narrow range of veterinary clients, but, but I'm sure there would be some who would find it very interesting and useful. So McMillan argues that the quality of life assessment begins with determining what factors in an animal's life affect quality of life. And you'll see many of these are going to be overlapping with the slide that I had up a couple of minutes ago and factors affecting quality of life.
The language is a little different and a little more specific in McMillan's case. So, The things that matter to animals, he says, are those things that elicit an effective response from them, an emotional response. Things that might produce positive feelings in animals include things like social interactions and companionship, good food, mental stimulation, play, things that might produce negative feelings, pain, hunger, a full bladder, nausea, itchiness, social isolation, boredom.
And he says that affective responses vary not only in their, their valence, and valence is just a fancy way of saying positive or negative, but also in their intensity. And, this is an important part of his approach. He theorises that feelings that are evolutionarily associated with the most serious and immediate threats to survival, such as hypercapnia or air hunger.
Or severe pain. Or fear should weigh more heavily in quality of life assessments than things that produce weaker negative feelings, and also more heavily than things that produce positive feelings. He says, we should or suggests that we have 4 steps, and these don't really occur step-wise, but in a kind of organic and overlapping fashion that we take an inventory of an animal's feelings, both good and bad, and, and that we weight the feelings relevance to survival, so.
For example, that we weight air hunger very heavily relative to something like incontinence. Third, that we individualise the waiting because each animal is going to have a particular past experiences, particular personality, particular preferences, things that matter to them. And then finally, we try to quantify the weight of these experiences, and this fourth step, he acknowledges really lacks any precision and is really based on what he calls best guesses as to what we should do.
The primary benefit of a quality of life tool that focuses, as McMillan's does, on affective states rather than external parameters. Is that it encourages us to pay attention to what matters to the animal from the animal's point of view, which is the point of a quality of life assessment in the first place. And this really, I think, is effective in engaging our sense of empathy and encourages us to reflect on each individual animal's unique personality and life experiences, and emphasises that the real importance of the quality of life assessment is the process of assessment itself.
It's not necessarily the The answer that you come up with, but the process. Which may lead to changes in the assessor's behaviour and thereby to improvements in the animal's quality of life. And to use MacMillan's language, which, which I really like, the quality of life assessment then becomes both a measurement and an intervention.
So Vetmetrica is derived from what's called GovQuest, that's GUV quest, Glasgow University veterinary school questionnaire, which was an instrument that was developed to measure the impact of chronic pain on health-related quality of life in dogs. Vet Metrica is Unlike most of the other tools that you see out there, statistically validated and reliable web-based measurement instrument, and it sort of developed as a scientifically robust measure of of animal quality of life. This is what the, the website looks like foret Metrica.
So that metric of focuses on measuring quality of life from the animal's perspective, and in that regard, it's novel. As it's used, more data is accumulated, and the instrument is refined and updated, so hopefully it gets better and better over time. The latest version of Emetrica is a structured questionnaire in which the owner rates his or her dog's behaviour using 22.
Terms that are hopefully easily understood, both positive and negative terms, and some examples are lethargic, calm, sore, happy, tired, stiff. And then there's an instantaneous computation of a score by a computer algorithm in 4 domains of quality of life, and the four domains are Energetic slash enthusiastic is the first. The second is happy slash content.
The third is active slash comfortable, and then the fourth is calm slash relaxed. And this, these results are made available, again, instantaneously, it's kind of amazing the power of of computers, to the veterinarian. Who can interpret them in comparison to age matched norms and by the level of change relative to what they call the minimal important difference calculated for each domain, that's more sort of statisticians speak.
Sovetmetria, at least at this point in time is a generic tool for use in dogs, which measures the impact of a variety of conditions. . Generic instruments.
In contrast to a disease-specific instrument, so a generic instrument is really useful because a lot of ill and elderly animals suffer from more than one condition, they have comorbidities, . On the other hand, disease-specific instruments are also really useful, and plans for the future of that metrica include the development of some disease-specific modules for Osteoarthritis and cancer are the two that I know about and maybe they have other plans as well and I know they are hoping to develop, to develop tools that are specific for use in cats and other companion animals. And then, third, and I'm not sure, but my guess is that if you are familiar with Quality of life assessment tool, this is the one that you will have seen.
Alice Villalobos hous scale is also called, not very poetically, the H H H H HMM scale. And you can see why here. This was first introduced in 2004.
It's been through a few permutations, but this is the, I'm giving you here on the screen, kind of the most commonly seen iteration of it. You know, what's nice about this scale is it's really user friendly. It's easy to understand, it's very accessible.
You can, if, if you search quality of life scale animal, this is probably what you'll get. It's really easy to download. As you can see, it's a seven-item scale, guiding caregivers, and this is specifically designed not for veterinarians so much as for, for the caregivers of companion animals, guiding them to look at these seven categories, hurt, hunger, hydration, hygiene, happiness, mobility, and more good days than bad.
As you can see, 5 of these 7 items are dedicated to physical functioning, 1 to psychological, both positive and negative, and then, 1, this more good days than bad sort of tracks relative frequency of positive and negative affect. And it's based on a simple numerical scoring system, so 0 to 10. With 10 being good, and it establishes a numerical cutoff for euthanasia, which is one of the things that I don't like about it.
So if your animal scores less than 35, quality of life is deemed unacceptable, and I'm putting unacceptable in scare quotes there. That's not my language, that's, the language used by Villalobos in this, scale. So in contrast to MacMillan's model, which focuses on animal feelings, this hospice model primarily focuses on physical condition and as determined by the pet owner.
And in contrast to vet metrica, which really attempts to assess quality of life from the animal's own perspective, the pasta scale is really owner-based and will be based on what the owner and not necessarily the animal deems important. The hospice scale has some limitations. For example, the description of the first parameter H states that adequate pain control and breathing ability is of top concern, breathing trouble breathing outweighs all concerns.
This is in line with what we just heard from McMillan, the, you know, air hunger, respiratory distress, really important, should be weighted more strongly. However, as you'll see, this item is scored exactly the same as every other item including hygiene. So even though your instructions are that this should be important, it really doesn't get any heavier weighting in the overall assessment of how the animal is doing.
There is a relatively low relative weight to psychological and social functioning domains. One of the other things that isn't so useful about this scale is that the verbal descriptions of each score in terms of specific behaviour aren't really provided. So, for example, in mobility, You know, it might be useful to have something like, you know, score a 2 if your cat only gets up to drink water and use the litter box, but not otherwise.
Or something a little more specific. I mean, here, a cat who only gets up to drink the water and use the litter box might be given a score of 1 by 1 cat owner and a score of 8 by another. And there's really no Kind of objective way to, to guide the user of this scale.
I'm gonna mention A couple of other tools really quickly, and the, the point of this is really just to give you kind of a lit review and then an overview of the sort of research that has been going on and the sort of tools that are being developed. And I have up in the title of this slide that these are really for researchers and providers mainly, . That's, I mean that's a loose category, but, you'll see what I mean.
So this Jazbek and antoni is an instrument that was designed for dogs with pain secondary to cancer, so quite specific. And like some of the others that we've looked at, it looks at these three broad domains, physical, psychological, and social functioning. The Karnowski's modified score modified for cats.
This was developed by Hartman and Kofer, and they've borrowed something called the Karnovsky Performance status scale, which was a tool designed for use in humans, which rates the functional impairment on a scale from 0 to 100%, and As suggested by the name here, this was developed specifically for cats and breaks down a cat's behaviour into 6 categories. 3 of physical functioning, 2 address psychological functioning, and then 1 to social functioning. The Fetch tool, that stands for functional evaluation of cardiac Health and as the name suggests, assesses quality of life in dogs with cardiac disease.
This Ilioppolo is, this is actually a pretty interesting instrument. It was, it's a 15 question survey designed to assess health-related quality of life in small animal patients with disseminated cancers being treated with chemotherapy. So again, fairly specific.
It's developed for use by clients. I put it into this category because it has been peer reviewed and published in the literature. The I don't even want to try to pronounce this name, but I will.
Wochiowowska. I'm Completely confident that I got that wrong. This scale is a 38 item discriminative questionnaire for veterinarians to use with clients and designed to assess non-physical aspects of quality of life in dogs.
And then finally, there's Levon's CHQLS that stands for canine Health Related Quality of Life survey, . Measures 15 items grouped into 4 domains, happiness, physical functioning, hygiene, and mental status. And it's unique because it's developed for designed for use, in healthy dogs and could be really valuable in offering a baseline measurement.
And then finally, there are, if you do an online search for quality of life, animal assessment, or some such, as I said, the first thing you'll probably get is the pasta scale, but there are a lot of other things that might come up, and some of them are really good, and most of these are designed for clients. I have, I've Have slides of 2. I picked out two that I think are quite good.
The one that you see in front of you is Ohio State University's, Quality of life tool. And I want to draw your attention to the red lettering on the right hand side of the slide. How do I know when it's time.
I'm gonna come back to this in a few minutes. So this is A quality of life assessment tool and also a euthanasia decision tree. And these often get lumped together.
Whether that's a good idea or bad, . And then this one has developed by Danny McVey of Lap of Love. It's also quite good.
And easy to get your hands on. So to summarise this section and grossly oversimplify what I've said so far, there are two kind of broad categories of quality of life tool that have been developed for use in animals. They are the peer-reviewed, validated, kind of hard science, .
Scales. And on the left hand side here and then these softer client oriented, not peer reviewed, not statistically validated, but not necessarily. Not useful scales on the right.
So, if you were gonna, you know, I've Already highlighted some of the limitations and problems of some of these tools. If you were gonna have an ideal tool, what would it look like? What would it accomplish?
And I don't think we're ever going to have an ideal tool, but I think it's useful to think about what it is that we're trying to accomplish with the quality of life assessment. So, and it may be that in practise, a, a clinician could very happily use several different tools for several different purposes. One for certain kinds of clients, another for Other kinds of clients, you know, one for animals who have certain kinds of things going on, another one for other kinds of situations.
And here's a, just a summary of the components of In my opinion anyway, what a good tool would be able to do or should accomplish. And I think the most important thing. That one of these assessment tools can do and should do is invite clients to pay attention.
Invite them to observe and monitor the experiences of their animal. I think taking into account both the positive and negative experiences that animals are having, and I, I think there's a tendency with these tools and with Maybe end of life palliative hospice scenarios in general to focus on the negative and not to take adequate account of positive, both the positive that is that an animal is already experiencing and able to experience and also the positive that with a little bit of work, we can provide for them or ways in which we can enrich their experience. A good tool balances usability.
With some rigour and comprehensiveness, and I think there's always gonna be some trade-offs in that between these things. And I've been kinda harping on this, but I think it's really important. I, some experiences like respiratory distress, air hunger, severe pain, need to count more than others.
They are, they are more significant, experiences. And I, I would agree with McMillan that the, the, these kind of serious negative experiences probably ought to count more than either, the less serious negative and also the positive. Those are really the, the first things that we need to identify in an assessment and pay attention to.
A quality of life assessment really needs to be a dynamic assessment. It's not It is a snapshot in time, but it's, if that's all it is, it has limited usefulness and I'm gonna come back to this point in just a minute, but it needs to take place. Over and over and it's, it's a fluid process.
And then that same point again, it needs to be based on accurate and frequent observations, but It needs to recognise trends over time. It needs to help practitioners see what we can be doing better, so identifying gaps in care, and identifying things that Improvements we can make to, to a home environment or to to pain protocols or whatever it is. One of the most important functions of these tools and, and one of the reasons I do think that they're useful is that I think they can serve as a platform for communication between veterinarians and clients.
Caregivers and they can provide an opportunity to educate caregivers about what pain looks like in an animal and what other experiences they need to be alert to in their animals. And finally, they give attention to the influence of the human-animal bond. On how we perceive and respond to pain in our animals.
So The first step is assessing the animal's current quality of life, and we've been through all of this already, . Seeing how an animal is doing in these various domains, negative experiences. Positive experiences, ability to engage in social relationships, and so forth, and then Assessing over time.
So detecting trends in How an animal's quality of life is fluctuating and not necessarily just going down. I think that's one of the tricky things about assessing quality of life and why the single snapshot isn't necessarily that useful because often You know, an animal will be doing very poorly one day and might get a very low score and under 35 on the POSAS scale, but the next day have bounced back, and be doing significantly better, whether in response to some treatment or just, you know, factors that, that are hard to identify. And, One of the things that's been useful for human physicians who treat patients with terminal illness or at the end of life is understanding common trajectories of decline at the end and there tend to be patterns that that most people and most animals follow, depending on what it is that they are suffering from.
And having an idea of which trajectory an animal might be following, it can be really helpful in, knowing how frequently to assess quality of life and what things to be looking for. And just to give a couple of quick examples, you know, Cancers often follow a trajectory like number one here. So you have a long period of relatively stable but slightly declining quality of life, followed by a short period of really evident and rapid decline.
And during that rapid decline period, palliation of symptoms and around the clock hospice care would likely be really important. In contrast, if you had an animal that was simply suffering from old age and frailty and maybe cognitive dysfunction, you might see this, trajectory 3, you know, prolonged and gradual diminishment. And in this case, where you might focus your Assessments and interventions would be on, for example, adaptations to the home environment or enrichments that help foster social engagement, or, you know, cognitive stimulation or other supportive care.
So, How do or can quality of life assessments help improve care, and how can they, get in the way? So I arguably the quality of life assessment could be and should be one of the most important elements of caring for animals, you know, particularly ill or aged animals, but not necessarily limited to that. I think quality of life assessment would be useful and valuable to every animal at every stage of life.
At its best, a quality of life assessment would provide a relatively objective measure of how an animal patient is feeling, and how illness, age-related changes in treatment protocols are affecting life experience and well-being, from the animal's point of view, as much as we can garner that. The purpose of the assessment then would be to, for example, fine tune our pain protocols, look for improvements to an animal's physical environment, reduce sources of stress and fear wherever we can, and identify and fill gaps in meeting an animal's emotional and social needs. So, and here's Bella again.
I put this slide in just cause, well, partly cause she's really cute. This is her favourite toy in the world, her, her cow. She's looking, I think kind of guilty, and what you don't see in the background is that she's eating the trash can.
But, you know, to, to raise the question, you know, what is she actually feeling, we don't know for sure if animals feel guilty, we think they do, but don't know for sure. . Veterinary medicine relies heavily on owner assessments of how an animal is doing or what they're thinking.
These assessments are unfortunately, often inadequate, and it's likely that a lot of suffering just falls through the cracks because people don't know what to look for. Various studies have shown that pet owners are not reliable historians. They're not very good at assessing how their animal is feeling and may furthermore, have only a rudimentary understanding of the natural history, biology, and behaviour of the animals they keep as pets.
And just a couple of illustrative examples. Studies repeatedly show owners missing important behavioural cues from their animals. Although pet owners can usually recognise sudden changes in behaviour, they're not very skilled at recognising sub subtle behaviours related to pain, or the presence of disease, or at identifying gradual changes in behaviour over time.
For example, in a large survey of dog owners by Marriti and colleagues, only half of the respondents were able to correctly identify what stress is, a short or long-term alteration of homeostasis that can lead to illness. Although many owners were able to recognise overt behavioural indicators of stress such as trembling, whining, or panting, very few could identify more subtle stress behaviours such as the averted gaze, the nose licking, or yawning. Packer and colleagues found that 58% of owners of dogs showing clinical signs of brachycephalic obstructive airway condition did not believe their dog had any breathing problem.
Brown and colleagues found that owners had Remembering the time that the dog was in pain, and that pain scales conducted by by owners didn't correlate with vertical force produced by arthritic dogs, suggesting that dog owners may not be good at detecting when their pet is in pain. These and other similar studies highlight the critical need for caregiver education. Ideally, the education of pet owners into ethology 101 would begin before an animal is even brought into the home and would continue throughout the animal's lifetime.
And as an aside, there was a recent study in the UK that found that fully 25% of all people acquiring a pet knew nothing, admitted to knowing nothing about the type of animal that they chose to buy and had done no prior research. Before purchasing an animal. That goes well beyond the ethical obligations of veterinarians to pro to provide this education for pet owners, but as long as there are such enormous gaps in pet owner understanding of animal behaviour and particularly pain behaviours, veterinarians will need to do what they can to plug the holes.
Maximising end of life care and quality of life for animals is extraordinarily complex endeavour, and as we've seen, it relies on a nuanced appreciation of how pain and behaviour intersect. As if it weren't hard enough to gain access into how an animal is feeling, there are layers of additional complexity arising from the patient's relationship to his or her human caregiver. The knowledge, attitudes and attentiveness of pet owners will influence how well they breed their animal and how responsive they are.
The caregiver's own emotional state can influence what they see in their pet, and as an example, Palliative and hospice veterinarians often report that owners seem blind to their animals suffering because the owners themselves are so caught up in anticipatory grieving and denial. Another area for further work is on the interconnections between what Mary Beth Spitznigel calls caregiver burden and the quality of an animal's care. When caregivers are so stressed out that they suffer from reduced psycho psychosocial functioning themselves, their ability to provide good care and including, presumably, their ability to make and report objective and accurate behavioural observations of their animal may be compromised.
Although attention to the patient, him or herself is always the priority, effective care can't occur in isolation from the animal's family. And then finally, as I warned, I was gonna come back to the issue of the role of quality of life assessments in euthanasia, decision making, . And how they often are functioning as a kind of decision making tool for euthanasia, for better or worse.
And this is my dog Odie, and he was the inspiration for my book, The Last Walk. And what surprised me when I wrote that book and what still surprises me is how little we know about Euthanasia of animals, why people Choose euthanasia when they choose it and what the experience is like for the animals themselves. So, so yeah, we, we really don't know very much about what determines how people make a decision to euthanize or not, but it's likely that judgments about an animal's quality of life are often driving.
A request to euthanize whether or not these these quality of life judgments are guided by some kind of formalised assessment or whether they're simply a kind of gestalt judgement made by pet owners at some point in an animal's life. Researchers in New Zealand recently combed through the medical records, through a a large medical records database to look at how chronic disease conditions and clinical signs of illness influence decision making about euthanasia for ageing companion animals. And what they found was that over 90% of cat and dog patients were euthanized as opposed to dying some other way, for example, by natural death, .
Cost was a driving factor in about 50% of these, and in the remaining cases, most animals were recorded as having at least one clinical sign associated with decreased quality of life, with inappetence and non-specific decline being the two most common, and I think that's worth noting, particularly the outsized role of inappetents here in In euthanasia decision making. This study to me highlights the fact that pet owners are using behavioural cues or quality of life indicators, such as an appetences to drive the decision to euthanize. And if so, it's essential that we find ways to make sure that these behavioural assessments that they're making are as informed and accurate as possible because they are life and death for the animal.
I think this study also elucidates an additional interesting point, which is that many older animals are living with chronic disease conditions and may suffer if we aren't careful to observe, interpret, and respond to behavioural cues of stress, pain or discomfort. Another reason the quality of life assessment may be playing an outsized role in euthanasia decisions is the fact that some animals are euthanized by a veterinarian or in some states, at least in the US, by a veterinary nurse who has never seen the patient before the euthanasia appointment. In these cases, the pet owner is relying on his or her own assessments of how the animal patient is feeling and when it is time, though hopefully with at least some input from the animal's regular veterinarian.
In the US, and this is just anecdotal data that I have collected, so, but I, I I think it's pretty accurate. Maybe 10 to 15% of pets are euthanized by a mobile hospice or euthanasia service, seeing the animal for the first time. And as mobile euthanasia services proliferate, this scenario is likely to become more common.
We really have no idea situations what kind of quality of life assessments have been made, if any. Finally, we need to understand the actual practical outcomes of quality of life tool use or non-use as part of a larger question of whether these scales do more harm than good. Be on first glance, it seems like a quality of life assessment tool is hard to argue with, like, who wouldn't want a caregiver to pay more attention to how their animal is feeling.
Yet, it's far from clear to me that these seed of the pants assessments improve animal well-being or contribute to good end of life care. As far as I'm aware, no research has yet looked at what happens to animal patients when veterinarians and family caregivers initiate the use of quality of life tool. Does quality of care improve?
Does quality of life improve? And in what ways? You know, our dogs whose owner, whose owner uses a quality of life tool more likely to be treated appropriately for pain.
We have really no idea at this point in time. Does the use of a quality of life tool or assessment scale initiate earlier euthanasia? Again, we really have no idea at this point in time.
So, a quick summary, and then I'll open this up for questions. Quality of life assessments should ideally reflect how an animal's physical, emotional, and social well-being is affected by disease, disability, or changes related to advanced age. Good quality of life assessments can be crucial to the provision of good care.
I need to be as thorough and careful as we can possibly make them. And my final slide here, I had to include a puppy picture of this is my grand dog, Poppy, who, and I, I'm really including this partly because she's just so cute, but also because I wanna come back to The point that I've made once or twice throughout his quality of life assessments are not just for elderly or ill animals. They're for all animals through all life stages.
And maybe the first quality of life assessment should, should happen when we first bring, bring a puppy into our home and into our lives. Thank you. And I'm happy to take any questions.
Jessica, thank you very much. I think you have, certainly stimulated a lot of thought processes on the questions of caregivers and quality of life. And one thing that, that you mentioned that is really stuck with me is, you know, if, if these assessments or talking about them does nothing more than stimulate the owners to pay attention to what's going on, I think they've done a great job already in the right direction.
Right. Yes. Yeah, it's always hard though because it's one of those discussions, you know, you're in the consulting room with the client and the dog and And you don't know it as well as they do, but because they know the dog well, they may have noticed it, declining, or not noticed it declining because it's been so gradual, whereas you may not have seen it for 6 or 8 months or a year since its last vaccine and they walk in and you go, oh my nerves, what has happened?
And the owner looks at you and goes, What are you talking about? Yeah. Yeah, and you know that one thing that I didn't say, which I meant to say, and that reminded me is that I think if you are encouraging clients to use these tools.
Writing them down, encouraging them to write, and it doesn't have to necessarily just be like in a written journal, but any kind of documentation, photos, you know, texts, anything that is actual an actual written record or photographic record because It's so easy to forget and also kind of, it's like watching your child grow up. You all of a sudden, they're a teenager and you haven't even noticed because it's happened so gradually. And the same thing happens with declining animals.
It's really, it's hard to see the changes as they occur under your nose. So, writing it down can be really helpful. You notice the kids growing up when they ask for the car keys.
Yeah, wait a minute, you're in preschool, you can't. Yeah, one of my favourite sayings is, what get what gets measured improves. And I think that that this is an apt place for it because, you know, if people are consciously measuring how does the dog move, how long does it take to get up?
Does is it comfortable? Is it eating yada yada yada, they will be able to go, hang on a second, this is not good, or yes, this is great, we can still keep going, you know. Right, right, yeah.
Yeah, excellent. Jessica, that was, certainly very thought provoking, and I thank you for your time all the way from the US. I'm sorry about the technical challenges we had in the beginning, but we got through it and, it, it was fabulous.
Thank you for your time.