Research issues w/ QOL

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MAXIMIZING QUALITY OF LIFE IN ILL ANIMALS
Franklin D. McMillan, DVM, DACVIM (SAIM) Best
Friends Animal Society Kanab, Utah
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I promise to give you the best possible
quality of life.
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Everyone knows what quality of life is

• When you ask a pet owner what she feels her dogs
  quality of life is, you dont 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, its 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.

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The Smith brothers got together one day to walk
their dogs
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
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 safetys 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 dogs life in
Bens 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. Jerrys dog is
not neutered and has plentiful opportunities to
intimately interact with the numerous female
dogs in the neighborhood.
Fraser et al. 1997. Anim Welf 6187-205
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HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
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. Jerrys 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 safetys 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 dogs life in
Bens words.
Each man, judging quality of life from very
different viewpoints
If quality of life has any meaning at all, then
clearly one of these dogs must have a higher QOL
than the other
I FEEL SORRY FOR YOUR DOG
I FEEL SORRY FOR YOUR DOG
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HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
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
Which one is it?
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HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
MORE OF THE IMAGINARY SCENARIO
Bens city dog
Jerrys country dog
Both of these brothers are clients of yours. Your
busy day at your vet hospital ends and your
receptionist has left you a phone message from
Mr. Smith with no first name or pets name
PHONE MESSAGE Mr. Smith called he said My
brother has convinced me that his dog has a
really good quality of life and mine doesnt. 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.
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HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?
MORE OF THE IMAGINARY SCENARIO
Bens city dog
Jerrys country dog
PHONE MESSAGE Mr. Smith called he said My
brother has convinced me that his dog has a
really good quality of life and mine doesnt. 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.
You have all night to ponder what your advice
will be before calling him the next morning.
Everybody knows what quality of life is, youre
thinking, so this should be a no-brainer
. What are you going to tell him?
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Everyone knows what quality of life is Part 2
The scene Your clinic. A drug rep, obviously
excited, scurries in.
We just received FDA approval for a new drug
that youre going to love! Its the closest
thing to a true wonder drug thats ever been
developed!
Whats it do?
Its incredible! Its the first drug that
increases a dogs quality of life! And heres the
amazing part it achieves an increase no matter
what the dogs current quality of life is.
Youve got a dog, dont you Doctor? Just try it
on your own dog. Youll see for yourself.
Hmmm
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Everyone knows what quality of life is Part 2,
Part 2
What are you going to look for to tell if the
drug is working?
You decide to give it a try
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Does Bill Gates have a good QOL?
What about the immaculately groomed silver
Persian cat laying in the Queen of Englands lap
eating caviar out of a crystal goblet?
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The indoor cat is allowed outside
Question I move from Los Angeles to a remote
town in Utah. In Los Angeles my cat could never
go outside because of street traffic. My house
in Utah has a huge fenced in backyard. I decide
my indoor cat can now go outside, so I open the
door and allow her free access. What happens to
her QOL?
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Mental disabilities and QOL
Mentally disabled children

• Does making them like us raise their QOL?
• Why do we assume they would want this?

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Mental disabilities and QOL
Do you assume that dogs with cognitive
dysfunction syndrome have decreased QOL and our
job is to increase it?
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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 (Im 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 dogs QOL is. You expect a certain
  type of answera reflection of what kind of life
  her dog is experiencing overall over the past few
  weeks or so. You dont 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 clients answer implied the existence
  of a long-term mood state you werent inquiring
  about the dogs 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?

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CONFUSION

• Quality of life is one of many similar or
  synonymous concepts regarding the experience of
  life
• Well-being
• General well-being
• Psychological well-being
• Mental well-being
• Emotional well-being
• Subjective well-being
• Quality of life
• Welfare
• Happiness
• Life satisfaction
• Contentment
• Feeling good

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QUESTIONS
What IS quality of life?
Is it something you FEEL?
Or is it something you THINK?
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TWO KEY QUESTIONS
WHAT IS QUALITY OF LIFE?
1.
WHAT FACTORS INFLUENCE QUALITY OF LIFE?
2.
HOW MUCH DO THESE FACTORS INFLUENCE QUALITY OF
LIFE?
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Does NOT have an effect on QOL
Has an effect on QOL
ELICITS FEELINGS
ELICITS NO FEELINGS
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
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THE FEELINGS OF QUALITY OF LIFE
Why do wehave feelings?
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Why do we have feelings?

• Feelings have evolved to ASSIGN VALUE to the
  nearly infinite internal and external stimuli
  constantly inundating the nervous system
• ? sounds, smells, sights, internal and external
  physical sensations, cognitions, knowledge
• The brain/body is constantly evaluating this
  vast array of stimuli and DELIVERING ITS
  ASSESSMENT OF IMPORTANCE to the individual IN THE
  FORM OF FEELINGS

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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
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FEELINGS
Pleasant Unpleasant
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
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By definition, pleasant feelings give life a
pleasant quality, and unpleasant feelings give
life an unpleasant quality
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Beeper studies in people Overall pleasantness
of life relates to time spent experiencing pleasan
t and unpleasant feelings
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Positive (good) QOL coincides with a
preponderance of pleasant feelings, and negative
(poor) QOL coincides with a preponderance of
unpleasant feelings.
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The Affect Balance Model of Quality of Life

• Quality of life is represented by a balance of
  the pleasant and unpleasant feelings of life over
  time

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UNPLEASANT FEELINGS
PLEASANT FEELINGS
? Fear ? Anxiety ? Boredom ? Loneliness ?
Separation distress ? Grief ? Depression ?
Pain ? Hypoxia ? Full bladder ? Nausea ?
Pruritus
? Joy ? Play ? Social companionship ? Mental
stimulation ? Physical contact ? Taste ?
Nurturing young (mammals) ? Sexual activity
? Control
The Affect Balance Model of Quality of Life
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High QOL
PLEASANT FEELINGS
UNPLEASANT FEELINGS
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Low QOL
UNPLEASANT FEELINGS
PLEASANT FEELINGS
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TWO KEY QUESTIONS
WHAT IS QUALITY OF LIFE?
1.
WHAT FACTORS INFLUENCE QUALITY OF LIFE?
Anything which tips the QOL scalesin either
directionplays a role in the animals QOL.
Those things that do not tip the scales do not
affect the animals QOL
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TWO KEY QUESTIONS
WHAT IS QUALITY OF LIFE?
1.
WHAT FACTORS INFLUENCE QUALITY OF LIFE?
2.
HOW MUCH DO THESE FACTORS INFLUENCE 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
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Does NOT have an effect on QOL
Has an effect on QOL
Do NOT tip the QOL scales
Tip the QOL scales
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
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Balance Model of Quality of Life

• This model of QOL explains the reason for the
  intuitive feeling that an animals 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

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Affect Balance Model of Quality of Life
BUT NOT ALL FEELINGS WEIGH THE SAME
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??? 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 ones QOL

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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

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PLEASANT FEELINGS Single malfunction equals loss
of a tasty meal
UNPLEASANT FEELINGS Single malfunction
equals loss of life
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PAY ATTENTION TO ME!
I CAN MAKE YOU FEEL GOOD
Pleasant feelings
Unpleasant feelings
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ALL UNPLEASANT FEELINGS ARE NOT EQUAL
Situations most urgently threatening to life have
evolved to have the most intensely unpleasant
feelings (sufferings)
SITUATION FEELING
Impaired oxygen intake
Hypoxia, terror, panic
Pain
Tissue damage
Threat to life
Fear
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When You Cant Breathe, Nothing Else Matters
American Lung Association
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PHYSICAL vs EMOTIONAL PAIN WHICH IS WORSE?

• Study electrified grid placed between puppies
  and socially-attached human. Puppies endured the
  pain of crossing the grid to reestablish contact
  with the person

Photo by Clay Myers
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PHYSICAL VERSUS EMOTIONAL PAINWHICH IS WORSE?
Scarletts answer
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.
Scarlett
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October 2008
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THE MAJOR CONTRIBUTING FACTORS TO QUALITY OF LIFE
ALL EFFECTS ARE THROUGH FEELINGS

• Social relationshipsSocial 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 stimulationMonotonous, unchanging
  environments elicit signs of boredom.
  Conversely, pleasant feelings are elicited by
  stimulation, challenges, and mental engagement
• ControlThe 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
• HealthCompromised health involves myriad
  unpleasant feelings. Physical disabilities limit
  ones opportunities for experiencing pleasurable
  feeling states
• StressAs 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

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MEASUREMENT OF QUALITY OF LIFE IN ANIMALS
Why measure?
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We all agree that knowing an animals quality of
life is important. But whats the big deal? Why
not rely on what weve always relied onour
intuitive judgment?
WHY DO WE NEED FANCY TOOLS TO MEASURE SOMETHING
SO OBVIOUS?
MANY HUMAN DOCTORS ASK THE SAME QUESTION
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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
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Whats wrong with just using our intuition to
assess an animals quality of life?

• KEY QUESTIONS
• How reliable are our gut-level, intuitive
  assessments of a pets QOL?
• If you judged your own pets 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 theyll
  know when it is time for euthanasia. Youll
  just know. Intuitively.

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Human intuition and animal feelings
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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?

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How good is our intuitionin judging QOL?

• STUDY A DRUG TO TREAT COGNITIVE DYSFUNCTION
  SYNDROME
• More than 600 elderly dogs and their owners were
  enlisted in a field study of a drug that improves
  neurotransmitter function
• Owners assessed their dogs 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.

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How good is our intuition in judging QOL?
OTHER EXAMPLES
Dental work
Hypo- thyroid treatment
NSAID treatment trials
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How good is our intuition in judging QOL? MORE
PROBLEMS
Study in dogs showed that the bond between a
person and dog influences the persons reports
about the dogs health
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A Quality of Life Thermometer
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MEASUREMENT OF QUALITY OF LIFE IN ANIMALS

• In people, the gold standard method of measuring
  QOL is the self-report, using a structured
  questionnaire instrument that is subjected to
  formal assessment
• Measuring even a single component of QOL, such as
  pain, is very difficult thus the much more
  complex totality of QOL is exceptionally
  difficult to assess
• Specific criteria proposed for measuring animal
  QOL include
• Behavior, stress hormone levels, health
  status, physical functioning (disability), immune
  function, brain imaging 
• Barriers language, also differences in species,
  sex, breed, age, and individuals regarding needs,
  preferences, values, and sources of discomfort
  and pleasure

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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

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How accurate are proxy measurements of QOL?

• Studied extensively in adolescent humans by
  comparing data from proxy informants with data
  from pediatric patients themselves.
• Well-documented finding Poor agreement between
  children and parents on measures of private
  experiences, such as emotions and subjective
  states, regardless of whether the child is
  healthy or sick.
• The importance for animal care is that if
  parent-child proxy QOL assessment is inaccurate,
  then person-animal assessment is likely to be
  even more so.

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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 pets QOL as higher than it actually is, in
  order to avoid the decision on euthanasia

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That all seems simple enough
If only it were
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The puzzling aspects of quality of life
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whats 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 persons 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 wouldnt this suggest
  that having sight is irrelevant to QOL?

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whats going on?

• Many people report satisfaction in situations
  that the majority of the population believe that
  they would find unbearable
• Cancer
• Birnbacher (1999) writes of cancer patients who
  successfully adapt to a health situation they had
  thought intolerable at the time of onset of their
  disease.
• Spinal cord injury
• DeLisa (2002) multiple researchers have found
  that the assumptions of those of us who are
  able-bodied bear little relationship to the
  realities of life for the people with SCI

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a paradox
Numerous studies have shown Across a wide range
of health conditions, people with illness or
disability typically report greater happiness and
QOL than do healthy people envisioning themselves
in those very circumstances
The Disability Paradox
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THE DISABILITY PARADOX IN ANIMAL QUALITY OF LIFE

• If the disability paradox shows that we do not
  see our own future QOL clearly, predicting an
  animals 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

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WHAT CAN EXPLAINTHE DISABILITY PARADOX?

• The focusing illusion
• Underestimation of adaptation
• Scale recalibration

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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

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Focusing Illusion

• The focusing illusion is very powerful force and
  EXTREMELY DIFFICULT TO DISREGARD when looking at
  ones own future situation
• Even when the person predicting a QOL (including
  ones own) is aware of focusing illusion, still
  very difficult to incorporate it into predictions
  of well-being
• Degree of persons knowledge and familiarity
  with the animal wont eliminate focusing
  illusions effects

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WHAT CAN EXPLAINTHE DISABILITY PARADOX?

• The focusing illusion
• Underestimation of adaptation
• Scale recalibration

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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
  eventgood or badto 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

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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

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WHAT CAN EXPLAINTHE DISABILITY PARADOX?

• The focusing illusion
• Underestimation of adaptation
• Scale recalibration

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Scale Recalibration

• Appears to be a SHIFT IN THE INTERNAL STANDARD,
  which results in a changed expectation of QOL
  MORE IN FITTING WITH THE INDIVIDUALS CURRENT
  SITUATION IN LIFE
• The QOL scale shifts, so 90 for the elderly
  man means something different than a 90 for the
  young man

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Scale Recalibration in Animal QOL Assessment

• Routinely applied to animals
• Example
• Typical comment from owner of an elderly dog
• Hes 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

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Quality of Life in Health Care
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Why is quality of life important in health care?

• Because QOL is a view of ones life from within
  by that individual and not an outsider it
  forces us to look at the health effects from the
  animals 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 animals
  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 were doing for an
  animal is benefitting or harming them.
• Without QOL, all of these things above are
  guesses (which, right now, many are).

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QOL in the ill animal
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Quality of Life Early illness
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Quality of Life Progressing illness
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Quality of Life Late illness
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Maximizing QOL
can be summarized by a single principle
Tip the QOL scales as far toward the pleasant
side as possible
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THIS MAY BE ACHIEVED BY

• minimizing unpleasant feelings
• increasing pleasant feelings
• both

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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

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PROMOTING PLEASANT FEELINGS
Maximizing QOL in Ill Animals

• 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

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Maximizing QOL indogs with disabilities

• Neuromuscular disease
• Degenerative myelopathy
• Paralysis
• Loss of vision
• Loss of hearing

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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
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IS QUALITY OF LIFE EVERYTHING? IS IT THE ONLY
THING THAT MATTERS? IS ANYTHING ELSE IMPORTANT?
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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?

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

• In clinical practice
• I weigh in quantity of life in many if not most
  of my decisions and recommendations to the pets
  owners
• Recommendation that an owner of a cat with
  kidney disease to feed a less tasty food that
  will slow the progress of the renal failure and
  allow the cat to live longer ? sacrifices quality
  of life for quantity
• Recommendation surgical, radiation, or
  chemotherapy treatments for a dog with a
  malignant cancer ? places quantity (to at least
  some degree) over quality

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A MATH WE DONT UNDERSTAND AT ALL AND AT STAKE
IS AN ANIMALS 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?
  

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QUESTIONS
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