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Quality of Life

Perhaps one of the most common questions we are asked concerns quality of life and euthanasia. When is the right time? Is my pet in pain? Are they suffering? None of us, I mean none of us want to make this final decision. There are a lot of things that must go into a decision like this. This week we explore some of the hardest choices we may ever have to make regarding the care and well being of our pets.

If you have a pet, chances are you have already faced this dilemma, do I continue to care for and treat my pet, is my pet in pain or just plain miserable, or do I consider euthanasia. Euthanasia is a topic that no one wants to discuss, yet sometimes it can be the most humane choice available. Euthanasia ends suffering, pain and misery. It can and should be viewed as just a different type of treatment option.

Before we get there, let’s look at quality of life (QoL). One of the hard parts of this discussion is to define Quality of Life. While many of us are well aware that our pets can and do communicate with us, it can be very difficult to tell how they feel. Animals are unable to verbalize their feelings and choices and we really don’t know what they are thinking. These questions have plagued both veterinarians and human physicians. On the human side, the Scandinavian Journal of Primary Health Care tried to define QoL in a 1990 paper. They came to the conclusion that quality of life assessments need to focus on 3 main factors: Subjective well-being, Health and Welfare.

“Subjective well-being” is the central component in the evaluation of Quality of Life, referring to the individual’s perception of his life situation, “Health” is a subjective as well as objective evaluation of physical and mental status, while “Welfare” reflects the objective environmental factors. This definition is lacking from a veterinary standpoint on several points: the subjective well being must be assessed by an observing party, we as the pet owner must make that decision for our pet, we don’t get to ask for input we observe them and think “how would I feel if I couldn’t……”. This of course has problems of it’s own. For example, we may think that because we are unable to go and enjoy a movie or drive a car, our QoL is diminished, and it would be. For our pets, do they feel less because they are unable to go for a ride in the car?

Health, according to this definition is something that we can determine, with the help of your veterinary team you can make an assessment of your pets health and likely-hood to survive in a given situation. This determination can be very hard to make on your own and you may not have all of the information available at that time, therefore, it is imperative that you seek out and listen to your veterinary team. Typically, the team will have some degree of emotional detachment, they can also counsel you on wether a treatment will make them worse temporarily or if a condition is likely to be permanent. Some patients may come through a surgery fine, but look terrible for a while as they are recovering and in the end do very well. Welfare is an area that we can control to a degree, are we able to care for the pet, can we provide the proper nursing care that is needed? Can we provide some type of environmental enrichment in this difficult time to make our pets lives easier?

So for a veterinary definition we can look at the London Journal Veterinary Medicine from November 2015. In this article they were trying to asses different ways to determine QoL based upon published assessment scales. They started with this definition ” ‘an individual’s satisfaction with its physical and psychological health, its physical and social environment and its ability to interact with that environment’. In this definition, health was taken to mean ‘the state of being free from illness or injury’, and satisfaction to be ‘the fulfilment of one’s individual needs, or positive mood or valence derived from this’.”

An important part of this definition is to be able to interact with the environment. Many times we can examine a patient and see that they are unable to interact with their surroundings. Are they mobile enough to join the family during dinner or when the family is watching television? Can the pet react to environmental changes such as temperature, are they able to get into the shade when it is sunny or move to warmth when it is cold?

The determination of QoL is not a simple determination, we bring our own predetermined thoughts, we have emotional bonds that are already stressed making assessment harder, sometimes we even have religious views that can play a role in this decision.

In the coming entries we will look at assessment tools, personal thoughts, and once the decision is made to euthanize a pet what is the process.

Stay tuned and feel free to provide me with your thoughts on this tough subject.

Let’s look at some of the ways to evaluate quality of life (QoL). Because our patients, your pets, can’t speak to us, we have to find other ways to evaluate how they are feeling. Sometimes we get a “gut” feeling. More often than not, this can be a very accurate way to asses a pet’s comfort. No one knows a pet better than their owner. We honestly believe that there is a special bond between the pet and the pet guardian. In many cases there is a tremendous amount of non verbal communication present and our subconscious mind can really tune in to our pet. A lot of the time we spend more time with our pets than our own families. We take care of our pets in ways that we don’t for any other living being and this creates a special place in our hearts. None of us want our pet to suffer but trying to figure this out has been the focus of a great deal of research.

In several articles researchers have tried to produce a standardized formula to asses the quality of life for a patient. Many of these assessments have targeted either a specific disease or type of disease for example, in the Veterinary Clinics of North America Small Animal Practice, Dr. Noil from the Italian Veterinary Dermatology Service, designed a tool to asses the QOL in patients with skin conditions. Other doctors have published assessments for patients with cancer, neurological problems and patients undergoing radiation therapy.

So how do we look at the individual patient in front of us? Dr. Alice Villalobos, a well-respected oncologist has suggested a QoL scale based upon 7 parameters:

  • Hurt – is there any pain? If so, can we control it
  • Hunger – is your pet able to eat on their own?
  • Hydration – is your pet drinking water and not becoming dehydrated?
  • Hygiene – is your pet able to stay free from feces and urine scald? Are you able to maintain them?
  • Happiness – is your pet happy to see you when you come home? Do they even notice you?
  • Mobility – is your pet able to get around? This can include assistance if we are able to provide it.
  • More good days than bad – a calendar can help us monitor “good or bad ” days, and allow us to look back over a period of time.

Of course, these parameters are very subjective and no two members of the same family may have the same opinion.

What is important to remember is that many of these issues can be addressed or mitigated to improve your pet’s QoL. For example, we have new methods of pain control, we use many of the same medications that are used in human medicine, including Non steroidal anti-inflammatories, opiates, receptor blockers and others. Additionally at Hopewell Animal Hospital we offer laser therapy, acupuncture, traditional Chinese medicine, and spinal manipulation to help with discomfort.

Also, there are many nursing steps that can be taken to help with pain. Another area that has seen recent growth is the area of diet: there are lots more palatable foods than in the past, there are also new appetite stimulants for dogs and cats and of course, there are feeding tube interventions if indicated. As for mobility, we are seeing the use of carts (wheelchairs) for animals on the rise, with the advent of 3-D printing, it won’t be long before we will have reasonably priced prosthetics.

We are always available to help you asses your pet’s QoL, our compassionate staff members are trained to answer your questions.

So far we have tried to define Quality of Life (QoL) and we have looked at some scales to help us evaluate QoL, this post we will examine improving QoL. If we look closely there are many ways to improve your pet’s QoL, they can vary from very simple things that you can do at home to some interventions that will require veterinary assistance.

First, let’s look at comfort: many pets in the end stage of life are very arthritic or have lost a considerable amount of muscle. They may not be able to move well or even walk at all. To increase your pet’s comfort we can start with some changes to bedding. Remember, we must protect the entire body but especially the bony joints, such as hips, elbows, and knees. These areas are very close to the surface of the skin and are often the first to suffer from muscle loss.

There are many orthopedic pet beds available, the increased thickness can protect these sensitive areas but remember with the increased thickness your pet may have trouble getting into the bed. Also remember to make sure the bedding cover is able to be removed for laundering. If wounds develop, please contact us to discuss options, sometimes we can prescribe creams that will help, but as older pets do not heal as well it is important to address any issues early. It is very important to change your pets position often if they are unable to perform this themselves.

Mobility is also very important. Many pets can be candidates for carts, there are many companies that will manufacture these for you. We are very happy to help you measure your pet. Just set up an appointment. There are carts that can be custom made for dogs that are paralyzed in the rear legs or the front legs. Being paralyzed does not need to decrease the pet’s quality of life. We have had patients that did great in these carts, there are, however, special requirements for the care of those pets. In fact, I remember one dog who had different wheels for each season. Studs for winter and mud tires for the spring!!

Hydration must also be addressed, many older pets have trouble getting to the water. Please remember to bring it to them. You can try different size bowls, water fountains, and even flavor the water with chicken broth (just watch the sodium). There are several products that can add calories and moisture for your pet, for short term use we can investigate the use of feeding tubes such as a nasogastric tube which is a not invasive to put in. In many older pets we will use fluid therapy at home. In this case we will teach you how to administer fluids by injection.

Often the older pet feels left out of daily family activities. One study showed that almost 90% of cats over the age of 10 have some type of arthritis. So for the older cat that is accustomed to sitting on your lap, you can help them by picking them up.

Stairs and ramps can be helpful for both dogs and cats but it can take some training to teach them to use those devices. It is also important to make sure that your pet is able to spend time with the family, try to keep your pet in the room by providing a comfortable bed to be on when around the family.

Dementia can also occur in older pets, both dogs and cats. There are several things that can be done to help mitigate the signs of dementia, for dogs there are foods that have been proven to help with dementia. Hills b/d diet has been shown to help dogs with dementia, there are also several supplements that can be helpful. It is important to not move around furniture with the older pet who’s vision is decreased. After pets have lived in an environment for years they know their way around the house. Several years ago we treated a cat that had lost both eyes. When we visited the cat in his own environment he was jumping from couch to couch and running around the house as if nothing was wrong.

Another area that we need to be aware of is self-grooming and hygiene. Many pets, as they get older, start to decrease the amount of self grooming that they do, possibly due to decreased mobility/arthritis, or sometimes because they are becoming a little senile, or possibly just don’t feel well enough or have enough energy. It will be beneficial if you can brush and groom your pet as needed to maintain a clean and knot free coat. Often we can determine the causes of decreased grooming with an exam, and can help relieve the underlying problem. Also in the area of grooming maintenance, are pets who may soil themselves with either urine or feces. There can also be several reasons for this. It is important to clean these pets regularly because these waste materials can be very irritating and damaging to the skin, creating even more problems.

You can use very mild shampoos or even water-less shampoos if it is too difficult to get your pet into the tub. If your pet is experiencing problems with soiling, we should give them a thorough diagnostic workup. If your pet has urinary problems or some neurologic problems they may not be able to fully empty their bladder, this can lead to very malodorous urine which can indicate an infection, often times an antibiotic can solve this problem.

Sometimes we are able to determine a pet’s quality of life with measurable statistics such as different scales and assessment tools, other times we can determine the QoL by studying objective data such as radiographs or laboratory testing, but more often we are faced with a “what do I do” decision. These choices can, and should be, very difficult. We are discussing ending the life of someone that you love and have many shared memories with. None of us relish the idea of making a decision about euthanasia, we are programed from an early age by society that these types of decisions are not ours to make. Who are we to make these decisions? What if I make the wrong choice, is it too early, is it too late? Often we can be faced with family and friends who don’t see the situation as we do or can’t feel your pain as you struggle with the decision. In her book The Dead Girl’s Dance, Rachel Caine writes “I am sorry my decisions do not meet with your approval, but nevertheless, they are mine, and the consequences are also mine.” This is a great response to those who are trying to “nudge” you in the “right” direction. People will freely give advice or an opinion on your pet’s condition but it is you who is responsible to make the choice, it is you who chose to care for this pet so many years ago, and it is you who knows this pet the best.

From a spiritual prospective, we often call upon our higher power to help us make the decision, we meditate on the choices and the possible outcomes of those choices and we agonize over the decision. In the end, our own morals and values will guide our choices and we should rely on our foundation principles to help us with this choice. In many cases, we will counsel a client that you will know when it is time. For those that have never made a decision concerning euthanasia that can be a terribly cold, unhelpful and unsatisfying answer. And it is, it is designed to be. The decision can only be yours, not ours, not your friends, not your clergy, but yours and yours alone. If we allow other people to make this decision for us, we give up our responsibility, we lose control and we have someone else to blame. It is important to make these hard choices for ourselves so that we own the decision, we all learn from our past decisions and each choice leads us to another choice. The world is full of infinite choices.

Often times our pets will tell us when they are ready to go. You can look them in the eyes and see that the light within them is growing very dim, their face has a droop to it and they just don’t seem to be there any more. In those cases your instinct can take over, when you listen to that inner voice and put all the available information together you know what to do. We say to our clients, you will know when it is time, if you are aware and present in the moment and examine your own heart, you really will know when it is time to let go.

Saying good bye is never easy, but it is even harder to hang on and see a loved one suffer.

The process of euthanasia

Unfortunately, there are times when we are unable to help our friends. In these cases we must consider euthanasia. Euthanasia comes from the Greek words eu meaning easy or good and thanos meaning death. While many do not consider any death good, we have to realize that there are times when we know our pets are suffering, are in pain, or will be going through a protracted death. In these cases it is fair and humane to view euthanasia as just another treatment option, no different than using insulin for a diabetic patient. Our goal is the care and comfort of our pets and in some cases this is the only truly humane option.

For many people this may be their first experience with death and likely the first time having to make multiple decisions about the process. During this post we would like to explain the process and the options that go along with the process.

Location

The first decision to make is under what circumstances the euthanasia is to occur. Is this going to be at home, in the office, or at your pet’s favorite spot outside. Many patients struggle to stay mobile when they are sick and are unable to walk into a clinic. Often times, a pet can get very anxious with the car ride into the office, other pets enjoy the car trip and this gives the owner some extra time with their pet. In either case it is important to think about where you would like this to happen. Please keep in mind that some people will avoid an area where a pet has been euthanized. We have had many clients that get very upset if they are brought into the same examination room where a beloved pet was euthanized, also people may avoid an area outdoors where the pet has been euthanized or even have trouble walking into a living room that was the final location of their pet.

If you choose to have a home euthanasia it is important to arrange the procedure with the veterinarian. While we do not typically make house calls, we will for a euthanasia because we understand how difficult and painful this decision is. While no one likes to pick the exact time for euthanasia, it is important that all parties involved are aware of the timing. In most cases we will try to accommodate people’s schedules and do this before or after hours, sometimes on weekends as well. If you do decide to have a home euthanasia, there are some things that you will want to have handy. We will normally like to have the pet on some type of non permeable bedding as they can leak urine or feces after the injection is given. Also, a well lit area makes it easier to have access to the vein to give the medication. If you are burying your pet at home, it is best to have the grave prepared prior to the euthanasia.

If you choose to have a euthanasia at the office, it is best to try to pick a time late in the day, or very early so that it will be a little quieter, also many hospitals, including our new facility have special rooms for euthanasia that are typically more comfortable and home like and less clinical than other exam rooms. Additionally, if you think your pet may get anxious during the ride over we can prescribe medications that can ease the anxiety.

The Process

Regardless of the location of the euthanasia, there are several steps and decisions that must be made. The first choice you will need to make is are you going to be present for the procedure. Over the years, we have had many clients who could not be present for the euthanasia, some of these people would leave the pets with us knowing that we will be as caring and kind as they would be and that someone will be with their pet at the end. Other times, people have left after a sedative is given, there is no single choice and each family should decide for themselves what is best.

Typically, unless pre-planned arrangements have been made, there will be some paper work to fill out. We are required to ask and have the owner sign a statement attesting that the pet has not bitten anyone in the last 10 days. We will also ask you to decide on the care of the body. There are several options for this, including taking your pet home for burial or cremation.

If you choose to bury your pet at home, it is best to check on local ordinances concerning burial. Normally, no one will say anything but it may be worth finding out the rules. Cremation is by far the most popular option in today’s mobile society. There are 2 choices for cremation. The first is a group cremation. In a group cremation, several pets are placed in the crematory at the same time. The ashes will generally be co-mingled and spread at the cemetery. In a private cremation, each pet is individually placed in the crematory and the ashes are then returned in a container. Each cemetery will have a different protocol to ensure that your pet is actually returned to you. The cemetery will then return the ashes to the hospital, generally within a few days. There are many different options for containers. The types of urns can be overwhelming. In our hospital, there are several urns included in the price of the cremation, but we also have many other options available.

Recently, there has been an increase in other options, such as making some of the ashes into jewelry or art glass pieces.

Whatever you decide, make sure that you are comfortable with the final solution, you can always ask the hospital to hold your pet’s body for a little while as you make a decision.

In the room

When it is time and all the paperwork and decisions are made we will begin the process. We will normally give a sedative to the pet by injection. This injection may be given in the muscle which can sometime sting for a few seconds. The sedative will take 5-7 minutes to work, this helps your pet to relax and sometimes even fall asleep. After the medication has worked we will then place either an IV catheter or a butterfly catheter. This allows us access to the vein to give the euthanasia solution. The medication that is used is a barbiturate and will affect the brain first, causing sedation and a coma like state, it then slows the respiration and heart causing a quick, comfortable death. After the medication is given the veterinarian will listen the the heart and pronounce the death. One thing to note, animals do not close their eyes after death. This is because it takes active control to close the eyes and move the muscles around the eyes. Additionally, many animals will urinate or defecate after they die.

When we are finished we will try to leave you alone with your pet to begin or complete the grieving process. Sometimes it is nice to just sit with your pet one last time. Afterwards, we will prepare the body for the trip to the crematory.

It is always a difficult time when a pet dies or is euthanized, but sometimes just understanding the process can make it a little bit easier. If you every have any questions about this process, do not hesitate to contact our office.