Introduction

Suffering and quality of life (QoL) are widely used terms in veterinary medicine, but what do they mean and how do we assess these in our patients? The prerequisites for suffering are sentience and consciousness and our patients meet these criteria. Suffering is a mental state associated with unpleasant physical and emotional experiences. Suffering, in turn, disrupts an animal’s QoL. Quality of life is a balance between positive and negative inputs; put simply it is “how an animal feels about its current circumstances.” The challenge for us, as animal caregivers, is how do we “measure” something that is multifactorial and cannot be directly accessed? We cannot always appreciate what is going on in a person’s mind, so it is even more difficult to determine the internal states of animals who cannot self-report. In addition, what constitutes a good or bad QoL is unique to each individual. Although rigorous scientific proof of suffering is difficult to obtain, we can make logical arguments for its existence in different patients under a wide variety of conditions. Historically, veterinary medicine has focused on physical health, but we are now embracing the impact of mental health on an animal’s overall enjoyment of life. This is reflected in the veterinarian’s oath which states that will use our “scientific knowledge and skills for the prevention and relief of animal suffering.”

Because dogs and cats are living longer, and we can provide more advanced medical and surgical procedures, monitoring QoL is essential—we must always remember that if we prolong a pet’s life it should never be at the cost of quality. As new treatments and procedures become available always ask yourself “just because I can, should I?” One key factor to keep in mind is that we may opt for a radical procedure or an unpleasant round of therapy for ourselves because we can rationalize that temporary suffering may lead to a long and good life. Animals on the other hand “live in the now” so QoL needs to be good on many more days than it is bad. Monitoring over time will help you and the owner make difficult decisions including electing euthanasia.

Our goal should be the best quality of life possible, not just the absence of a poor QoL. QoL is a team effort involving the veterinarian, veterinary staff, and the owner. There are multiple inputs to physical and mental health, and some are shown in Table 1.

Table 1. Examples of physical and mental states that cause suffering and a poor QoL

Quality of Life Assessment Tools

In animals, all assessments depend on clinician or owner (a proxy) so are “observer-related outcomes [OROs]”. There are many tools, instruments, and questionnaires in the literature, some are disease specific and some are generic to “overall health”. Disease-specific tools for dogs include but are not limited to those for atopic dermatitis,¹ cancer,² cancer-related pain,³ obesity,^4,5 and osteoarthritis⁶. These, and others are critically reviewed by Belshaw et al.⁷ Quality of life tools for cats with diabetes mellitus,⁸ cardiac disease,⁹ and degenerative joint disease have been published.

In many cases, the dog or cat does not have a single ailment but several comorbidities, and sometimes adverse side effects from treatment, so another approach is to use health-related quality of life (HRQofL) instruments, which are more generic and capture overall physical and emotional wellbeing.^10-12

Technology

With today’s rapidly advancing technology and how we now communicate with each other, including veterinarians and clients, web-based or “app” based tools are gaining popularity and have many benefits including speed, ease and reliability of assessment. Examples of these tools are those developed by NewMetrica (www.newmetrica.com) which take as little as 5 minutes for the owner to complete in the comfort of their home.

For cats, the major domains assessed are vitality, comfort, and emotional well-being (20 owner questions) and in dogs, energy, happiness, comfort, and calmness (22 questions). The patient is compared to healthy animals of the same age and breed, and to itself over time. The interval between assessments and alerts can be individualized for each patient.

Where Does the Owner Fit In?

When a pet has a chronic disease that negatively affects its QoL, this can also affect the owner. For example, dogs that scratch all the time, or have nighttime restlessness may disrupt the family’s sleep. Owners have four budgets that must all be considered when making treatment plans; these are outlined in Figure 1. The “weight” of these will vary among different owners and these, combined with the pet’s QoL will guide clinical decisions.

Figure 1

Where Do Veterinarians Fit In?

Veterinarians may have a different perspective to the owner about a particular pet’s quality of life, or prospects for quality of life. We must remember the four budgets that owners have when helping them make decisions.

Clinical Example

No two cases are the same and owners and veterinarians will have very different opinions about an individual pet. There may be outright dismissal of the option to have a non-ambulatory dog fitted with a cart (Figure 2), there may be uncertainty and there may enthusiasm. This decision will depend on many factors but at the heart of the discussion should be the question “is it the right thing for the pet”?

Figure 2

“Pup-Tart” the chihuahua suffered a traumatic spinal cord injury and is non-ambulatory despite surgery and medical treatment. He is 7 years old and continent (fecal and urinary)—is fitting him for a cart the right thing to do?

References

1.  Favrot C, Linek M, Mueller R, Zini E, International Task Force on Canine Atopic D. Development of a questionnaire to assess the impact of atopic dermatitis on health-related quality of life of affected dogs and their owners. Vet Dermatol. 2010;21(1):63–69.

2.  Giuffrida MA, Brown DC, Ellenberg SS, Farrar JT. Development and psychometric testing of the Canine Owner-Reported Quality of Life questionnaire, an instrument designed to measure quality of life in dogs with cancer. J Am Vet Med Assoc. 2018;252(9):1073–1083.

3.  Yazbek KV, Fantoni DT. Validity of a health-related quality-of-life scale for dogs with signs of pain secondary to cancer. J Am Vet Med Assoc. 2005;226(8):1354–1358.

4.  Yam PS, Butowski CF, Chitty JL, et al. Impact of canine overweight and obesity on health-related quality of life. Prev Vet Med. 2016;127:64–69.

5.  German AJ, Holden SL, Wiseman-Orr ML, et al. Quality of life is reduced in obese dogs but improves after successful weight loss. Vet J. 2012;192(3):428–434.

6.  Wiseman-Orr ML, Scott EM, Reid J, Nolan AM. Validation of a structured questionnaire as an instrument to measure chronic pain in dogs on the basis of effects on health-related quality of life. Am J Vet Res. 2006;67(11):1826–1836.

7.  Belshaw Z, Asher L, Harvey ND, Dean RS. Quality of life assessment in domestic dogs: An evidence-based rapid review. Vet J. 2015;206(2):203–212.

8.  Niessen SJ, Powney S, Guitian J, Niessen AP, Pion PD, Shaw JA, et al. Evaluation of a quality-of-life tool for cats with diabetes mellitus. J Vet Intern Med. 2010;24(5):1098–1105.

9.  Freeman LM, Rush JE, Oyama MA, et al. Development and evaluation of a questionnaire for assessment of health-related quality of life in cats with cardiac disease. J Am Vet Med Assoc. 2012;240(10):1188–1193.

10.  Reid J, Wiseman-Orr ML, Scott EM, Nolan AM. Development, validation and reliability of a web-based questionnaire to measure health-related quality of life in dogs. J Small Anim Pract. 2013;54(5):227–233.

11.  Reid J, Wiseman-Orr L, Scott M. Shortening of an existing generic online health-related quality of life instrument for dogs. J Small Anim Pract. 2018;59(6):334–342.

12.  Tatlock S, Gober M, Williamson N, Arbuckle R. Development and preliminary psychometric evaluation of an owner-completed measure of feline quality of life. Vet J. 2017;228:22–32.