Reprinted from
The Latham Letter
/
Spring 2011
www.Latham.org
painful osteoarthritis, obesity or organ disease. When a life-limiting disease,
or cancer and its related treatment, exert added burdens on a compromised
pet, when or how do we determine if QoL is impacted or threatened? How
can pet caregivers condently determine what is satisfactory? Who is capable
of monitoring that pet? How are they making their decisions? At what point
should caregivers abandon further curative therapy? What obligation does the
veterinary team (v-team) have to provide palliative care or to preserve their
clients’ hope for a beloved pet’s well being? Veterinarians are frequently asked,
“When is the right time to euthanize my beloved pet? How will I know?”
The “HHHHHMM” Quality of Life Scale
To help caregivers assess a beloved pet’s QoL, this author developed an easy
to use QoL scale and scoring system. The QoL scale guides pet lovers to work
with their v-teams to look at the necessary ingredients that make pet hospice
a workable end of life program. Some of these items are very difcult to face
especially when one is in denial. Pet owners must ask themselves if they are
truly able to provide enough care to maintain their ailing pet properly. The
“HHHHHMM” QoL Scale acronym allows easy recall for pet caregivers. The
ve Hs and two Ms represent Hurt, Hunger, Hydration, Hygiene, Happiness,
Mobility and More good days than bad days [pawspice.com].
KEY WORDS:
Quality of Life Scale, End-of-Life
Care, Pawspice, Pet Hospice,
Palliative Care, Terminal
Disease, Gift of Euthanasia,
Well Death
Introduction
Every day, pet lovers are requesting
their veterinarians to provide
palliative and pet hospice care. When
families are caring for aging, ailing
or terminally ill pets, especially pets
with advanced or recurrent cancer,
they want and need compassionate
medical care from the local pet
hospital. These end-of-life care
services need to include more quality
of life (QoL) assessment tools so that
caretakers can condently determine
what their ailing pets need. The
time is now for all veterinarians to
embrace the concept of palliative
care, pet hospice and/or Pawspice
care. Pawspice starts around the time
of diagnosis of a life-limiting disease.
Pawspice focuses on relief of pain
and symptoms while offering kinder
more gentle standard care to deal with
the disease. Pawspice transitions to
hospice when the pet declines or when
death is expected within weeks, days
or hours.
How do we know when a chronic,
morbid condition starts to ruin a
pet’s QoL? Most older pets have one
or more morbid conditions such as
Quality of Life to the End of Life:
We Owe It to Them!
By Alice E. Villalobos, D.V.M., DPNAP
Reprinted from
The Latham Letter
/
Spring 2011
www.Latham.org
Animals have basic needs and desires
which should be recognized and
respected by their caretakers. The
Five Freedoms of animal welfare,
developed in the United Kingdom
are: 1. Freedom from Hunger and
Thirst, 2. Freedom from Discomfort,
3. Freedom from Pain, Injury or
Disease, 4. Freedom to Express
Normal Behavior, 5. Freedom from
Fear and Distress. [fawc.org.uk/
freedoms.htm] The Five Freedoms
list was developed in the 1960’s for
farm animals. Several adaptations
improved this list along the way
and it is truly applicable for all pets.
With good veterinary supervision,
pet owners can maintain these basic
desires with a satisfactory level of
comfort and pain control for their
pets during hospice care. When the
score falls below what is felt to be
acceptable, then there is no justi-
cation in continuing the hospice.
The HHHHHMM QoL Scale
(Table 1, page 12) provides useful
guidelines for caregivers to help
sustain a positive and rewarding
relationship that nurtures the human-
animal bond at the end of life.
This simple-to-use tool provides a
framework to assess various aspects
of home care and the well being of
failing patients. The straightforward
QoL Scale, with its objective scoring,
automatically helps family members
face reality without guilt feelings or
confusion. It asks people to quantify
their observations as they struggle
through the difcult decision making
process of whether to maintain their
pet’s end-of-life care or to elect the
gift of euthanasia.
Pet owners can bring the
HHHHHMM QoL Scale to their
veterinarian’s attention so they can
help to correct decient criteria. If the veterinarian can help relieve pain and
discomfort by at least 30-60%, the improvements can create a remarkable
rejuvenation in the pet’s well being. The v-team can teach pet owners to
assess and control their pet’s pain and provide good nutritional and hydration
support. When discussing hygiene, the v-team can demonstrate wound care
techniques and teach caregivers to prevent decubital ulcers by using egg
crate mattresses, soft bedding and body rotation. The v-team might also have
suggestions to prevent self soiling with strategic elevation, absorbent towels,
diapers and so forth.
When family members are empowered to use the QoL Scale for assessment
of the necessary criteria, they may realize that they need to ratchet up certain
aspects of care to properly maintain their pet. A well-managed end-of-life care
program allows more time for tender private moments and sweet conversation
to be shared between family members and their dying pet.
More Good Days than Bad Days
If a terminal pet experiences more than 3-5 bad days in a row, QoL is too
compromised to continue the hospice. This would also correlate with the QoL
score dropping below 35. When a healthy, two-way interactive human-animal
bond is no longer possible, it is time to let go. All family members who make
the effort to work with the QoL scale will become self aware that the end is
near. The nal decision needs to be made if the pet suffers break through pain
despite being on combination pain medications. The veterinary oath clearly
binds the v-team to prevent suffering. It is important to have plan A,B,C
regarding euthanasia and after life needs. It is best to be prepared. When a
beloved pet no longer has quality of life, it is merciful to provide heavy sedation
to relax the pet’s anxiety. Some near-death pets may pass on peacefully. But
the rigors of death may be harsh and unpredictable and too difcult to observe
for most loving families. Most dying pets receive the kind gift of a bond-
centered euthanasia. The gift of euthanasia can be pre-arranged to take place
at home or at the local pet hospital. However, if the pet slips into crisis after
hours or on a weekend, and the nal call must be made for euthanasia, it can
be provided at an emergency clinic.
Don’t Let a Pet Suffer to Death
Due to cultural, religious or personal beliefs, a few pet owners and a small
contingent of veterinarians and counselors prefer natural death over assisted
death. When a client has this bias, it is difcult and disheartening for the
v-team to justify caring for an emaciated, dehydrated, depressed, terminal
patient that is being forced to endure further deterioration, pointless pain and
suffering until liberated by death. When a veterinarian or pet hospice counselor
has this bias, it affects how they think and how they inuence the pet owner’s
decision making for their terminal pet when the bad days persist without any
good days. The attending doctor or counselor may be sincerely attempting
to respect the owner’s wishes, while caring for the patient. Yet, they may be
totally unaware of how they are manipulating their clients into withholding
Reprinted from
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/
Spring 2011
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the mercy of euthanasia for a dying pet if or when it is needed.
It is fortunate if a pet is able to die at home in a painless and peaceful state.
This is ideal and acceptable. This is most predictable when using veterinary
supervision that includes home euthanasia services. It is a sad fact that not
all terminal animals are able to pass away peacefully and naturally at home.
Some dying pets go into terrible respiratory distress and thrash about and
become agonal before death. Witnessing this traumatic scenario is a horrible
experience for loving family members who did not want their beloved pet to
suffer this pointless indignity without having the option of euthanasia. Family
members feel guilty and are haunted for years with these harsh memories.
Therefore, it is important to instruct pet owners who prefer a natural death to
have a backup plan in case their pet goes into a distressful crisis and needs
professional help to change worlds. Caregivers should know where to go 24/7
for immediate assistance for the gift of euthanasia to avoid a beloved pet’s
futile and unnecessary “suffering to death.”
Summary
The HHHHHMM QoL Scale provides useful guidelines for caregivers. It
helps sustain a positive and rewarding relationship that humanely nurtures
the human-animal bond at the end of life during palliative care, hospice or
Pawspice. This simple-to-use tool recruits caregivers and their v-teams to
evaluate and improve important criteria that will promote and maintain a good
quality of life for the dependent pet. The QoL Scale helps family members
face reality without confusion and quantify their observations as they struggle
with the difcult decision of whether to maintain their pet’s end-of-life care
or to elect the gift of euthanasia.
Alice E. Villalobos, D.V.M., DPNAP is Director, Pawspice at VCA Coast
Animal Hospital, Hermosa Beach, CA and Beachside Animal Referral
Center, Capistrano Beach, CA, and Animal Oncology Consultation
Service, at Animal Emergency and Care Center, Woodland Hills, CA
www.pawspice.com and [email protected]
Pawspice &
“HHHHHMM” QoL
Scale Synopsis
Dr. Alice Villalobos, a renowned veterinary
oncologist, developed “Pawspice,” a
conceptual quality of life program for
pets that starts when a well or sick pet
is diagnosed with a life-limiting condition
or disease. Pawspice offers palliative
care that transitions into hospice care
for animals as they approach their final
days and hours of life. Pawspice protocols
should not be considered synonymous
with hospice which implies “giving up.”
Instead, Pawspice care involves kinder,
gentler versions of standard care to avoid
adverse events that may put the pet at risk
or destroy quality of life.
Pawspice simultaneously and consistently
focuses on pain and symptom
management to enhance quality of life. This
approach often results in longer survival
times for geriatric and compromised
companion animals over those pets that
are treated with standard “can do” care. Dr.
Villalobos also developed a scoring system
to help family members and veterinary
teams assess a pet’s life quality,
The HHHHHMM Quality of Life Scale.
The five H’s stand for:
Hurt, Hunger, Hydration, Hygiene
and Happiness.
The two M’s stand for
Mobility and More
good days than bad days.
The QoL scale also serves as a helpful
decision making tool to assist the v-team
and pet lovers as they struggle through
the difficult and emotionally draining
process of making the final call for the gift
of euthanasia to provide a peaceful and
painless passing for a beloved pet.
See next page for QUALITY OF LIFE SCALE
Reprinted from
The Latham Letter
/
Spring 2011
www.Latham.org
Quality of Life Scale
(The HHHHHMM Scale)
Pet caregivers can use this Quality of Life Scale to determine the success of Pawspice care.
Score patients using a scale of: 0 to 10 (10 being ideal).
Score Criterion
0-10
HURT
– Adequate pain control & breathing ability is of top concern and outweighs
all others. Is the pet’s pain well managed? Can the pet breathe properly? Is oxygen
supplementation necessary?
0-10
HUNGER
– Is the pet eating enough? Does hand feeding help? Does the pet need a
feeding tube?
0-10
HYDRATION
– Is the pet dehydrated? For patients not drinking enough, use
subcutaneous fluids daily to supplement fluid intake.
0-10
HYGIENE
– The pet should be brushed and cleaned, particularly after eliminations.
Avoid pressure sores with soft bedding and keep all wounds clean.
0-10
HAPPINESS
– Does the pet express joy and interest? Is the pet responsive to family,
toys, etc.? Is the pet depressed, lonely, anxious, bored or afraid? Can the pet’s bed be
moved to be close to family activities?
0-10
MOBILITY
– Can the pet get up without assistance? Does the pet need human or
mechanical help (e.g., a cart)? Does the pet feel like going for a walk? Is the pet having
seizures or stumbling? (Some caregivers feel euthanasia is preferable to amputation, but
an animal with limited mobility yet still alert and responsive can have a good quality of
life as long as caregivers are committed to helping the pet.)
0-10
MORE GOOD DAYS THAN BAD
– When bad days outnumber good days,
quality of life might be too compromised. When a healthy human-animal bond is no
longer possible, the caregiver must be made aware that the end is near. The decision
for euthanasia needs to be made if the pet is suffering. If death comes peacefully and
painlessly, that is okay.
* TOTAL
*A total over 35 points represents acceptable life quality to continue
with pet hospice (Pawspice).
Original concept, Oncology Outlook, by Dr. Alice Villalobos, Quality of Life Scale Helps Make Final Call, VPN, 09/2004;
scale format created for author’s book, Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond,
Blackwell Publishing, 2007. Adapted for the International Veterinary Association of Pain Management, 2011 Hospice
Guidelines. Reprinted for the Latham Newsletter with permission from Dr. Villalobos & Wiley-Blackwell.
