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When is it time?

A humane and practical quality of life index for companion animal euthanasia

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During my 45 years of practicing veterinary medicine, I have had the privilege of practicing companion animal medicine at three select institutions, the pleasure and aggravation of starting and maintaining a bricks-and-mortar companion animal practice, the mind-opening experience of working as a locum tenens veterinarian and the ultimate satisfaction of being a companion animal house call veterinarian. I have performed thousands of companion animal euthanasias.

During my house call years, my veterinary nurse and I developed a humane and practical quality of life (QL) index. It clarifies when euthanasia is most appropriate for the patient’s sake. The index also helps ease the emotional pain of companion animal euthanasia for caregivers and veterinary medical personnel.

Euthanasia guidelines, indices, and scales

Much published material exists about the proper timing of companion animal euthanasia.1-30 The advice and recommendations are invariably caring, compassionate, and thoughtful. But they are almost always either overly general or ambiguous or both. Some examples: Is your animal experiencing untreatable pain and how much? List the activities that your animal loves most, and consider how many have been lost. Do tough days outnumber good days? Are the gums pink? Prevent suffering. Pray. Talk to friends and family.

A notable advance is the QL scale by Alice Villalobos, DVM,30 which provides a guide as to whether euthanasia might be the most humane option. This scale is a set of seven criteria, including hydration, uncorrectable self-soiling, mobility, and happiness, each of which is graded on a scale of 0 to 10. That’s a total of 70 measures to consider in making a humane decision on euthanasia.

Yazbek and Fantoni propose a QL scale of 12 questions, each with four possible answers for a total of 48 considerations.26

These two QL scales reduce toward a more objective reckoning some of the complexity and subjectivity associated with end-of-life decisions; the two scales provide detailed numerical guides as to whether euthanasia might be the most humane option.

Can we make these emotionally charged and wrenching choices even simpler and more objective? Can we make the decisions easier, more valid, and kinder to all concerned, especially the patient? We can.

The QL index that we offer here is based on three principles. First, we cannot yet communicate directly with our animal companions; they can’t tell us about their feelings, whether they wish to live or die, etc. Second, our animal companions almost never conceal or disguise their mental state. There is a simple way to tell how they are feeling overall, and that way is the animal’s overall behavior and activity, taking into account everything that the animal normally does or doesn’t do. If an animal is feeling “off” in any way (e.g., physically or mentally uncomfortable, out-of-sorts, anxious, etc.), its behavior and/or activity will change, however slightly and subtly. If an animal is feeling exceedingly “off” in any way, behavior/activity will change a lot. In other words, the correlation between the animal’s state of mind and overall behavior/activity will be direct and equal. The lousier the animal feels, the greater the negative change in overall behavior/activity; the better the animal feels, the greater the positive change in overall behavior/activity. Third, there is substantial emotional comfort for caregivers who are considering or requesting euthanasia to know that they are one of a multitude of others who have come to the same conclusions—or have the same doubts—about their companion animal.

Prelude: History-taking

Can we make these emotionally charged and wrenching choices even simpler and more objective? Can we make the decisions easier; more valid, and kinder to all concerned, especially the patient? We can.

A fully realized history is essential to most effectively guiding treatment decisions and giving the most accurate possible prognoses.

Most clients could easily come up with such observations as “She’s less interested in her food than usual,” or “He’s coughing way, way less than when I saw you two weeks ago,” or “Her behavior is different than usual” and so on. But a significant minority of clients could not provide—or had great difficulty providing—any kind of semiquantitative guesstimate regarding signs of illness and could talk only about “better” or “worse” and “more” or “less.” A few clients had trouble identifying a direction of change. So I began to offer three options to clients who gave only a vague history: “Is the change more like 10, 50, or 90 percent?” Still, a minority of clients could not be more specific than vague generalities.

One day, I suggested to vague-reporting clients something like the following: “Let’s call the frequency and severity of the cough a ‘10’ when I saw her two weeks ago at the peak of her coughing; if she now had zero coughing, let’s call that a ‘0.’ Where would you rate the frequency and severity of her actual cough now between 0 and 10?”

I discovered that 99.9 percent of clients could come up with a number easily, such as between 1 and 2 or 5 and 6. (Why vague-reporting clients found 0 to 10 so easy to deal with but 0 to 100 [i.e., percent] impossible, I do not know. I suspect that it has to do with 100 choices being overwhelming but 10 choices being manageable, plus the general innumeracy of Americans.)

The index

So it went. I was happy, and clients providing clinical histories seemed relieved and even happy to be able to be so helpful to me and to their animal. Then, I sold my fixed practice, and my veterinary nurse and I began a house call practice. About 20 to 25 percent of our house calls were euthanasias—a total of more than 3,000 patients. Almost all of those visits were for first-time clients.

Our house call appointment times allowed for 45 to 60 minutes of client/patient contact. This interval allowed us to listen to caregivers, family members, and friends talk about the patient and their time together, to answer questions in detail, to ask questions when appropriate about the patient’s clinical history and current state, to explain the euthanasia process in detail, to give the family as much time alone as they desired with the deceased, and to remove the body in a caring and dignified manner.

At many euthanasia house calls, caregivers would ask some variation on the question, “Am I doing the right thing?” “Is this the right time?” “Am I acting prematurely?” “Have I waited too long?” A desire to appropriately and compassionately answer such questions was the primary impetus for developing our humane and practical QL index.

My answer to the caregivers would begin with a hypothetical situation: “Let’s consider Fluffy’s overall activity and behavior—that is, everything about her life before she had any signs of her current condition, and let’s call that state a ‘10,’ which is perfect for her. Then, let’s imagine that Fluffy is flat out on her side 100 percent of the time, 24/7—maybe taking a lap of water now and then—and let’s call that state a ‘0.’ Where would you put Fluffy’s behavior and activity now (or in the last day-or-week) between 0 and 10?”

Sometimes, I had to repeat or rephrase the question, as some clients would first answer with reference to only one factor, such as appetite or cough. So I would need to emphasize the “overall” and “everything” concept when re-asking the question.

We found that the rating numbers 2 or 3 came up by far the most frequently when the house call was for euthanasia. Also, when we discussed a euthanasia house call on the way to our next appointment, we discovered over time that our respective, experienced professional opinions were that the animal whose caregivers gave a QL rating of 2 or 3 was a candidate for euthanasia because of the apparent suffering and minimal QL. An animal whose caregivers gave us a QL rating of 4, 5, or 6 seemed to us not yet a candidate for euthanasia. To those caregivers, I counseled—gently—that giving the animal a little more time and possibly diagnostic or therapeutic efforts might be in order. Those caregivers often exhibited relief and followed through on my suggestions.

Some caregivers gave their animal companion a QL rating of 0 or 1. My nurse and I usually felt that those caregivers had waited too long from a humane standpoint. Their loved companion had been allowed to suffer too long and too much. From time to time, a caregiver who said 0 or 1 would remark, somewhat sheepishly, “I think that I waited too long.” When that or a similar statement was made as an implied question to me, I would redirect the question. I might gently ask questions about the animal’s clinical history, diagnosis, or current condition. I could not see any positive purpose in responding “yes” to the client’s question. I believe that these moments are some of those rare times in life when a little dissembling is in order. So that’s how I responded, at least on my better days.

In the end

This QL index is a humane and practical way to encourage appropriately timed euthanasia and help ease the emotional pain of companion animal euthanasia for caregivers and veterinary medical personnel. The index helps focus them on the welfare of the animal as the primary criterion when considering euthanasia and other end-of-life issues. Our single criterion—overall behavior and activity on a 0 to 10 scale—is a structured assessment that encourages caregivers to see more clearly the changes in their animal and to address the question of euthanasia.

The focus of our QL scale is patient QL and caregiver psychological comfort. A veterinarian’s and veterinary nurse’s advice and counsel can facilitate those objectives. In our experience, after taking a detailed history and examining the patient, our professional veterinary judgments coincided nearly 100 percent with caregiver scores on the 0 to 10 index. This concordance is evidence—albeit subjective—that client perceptions may indeed be accurate and valid when using a 0 to 10 index of overall behavior and activity as a guide to QL.

Scientific validation of caregiver and veterinary assessment of QL and timing of euthanasia must await interspecies communication that is more direct and unambiguous than exists today. Until we can communicate directly and unambiguously with our animals, we must rely on indirect evidence to evaluate their state of mind. As Spofford and Lefebvre et al noted, there are no scientifically validated assessment tools extant to quantitatively measure QL in companion animals from the perspective of their physical and mental well-being; and companion animal caregivers do vary in their aptitude to recognize and interpret subtle signs of illness.31 However, QL must be addressed as best one can. Scientifically validated and reliable assessment tools for assessing canine QL are, as Shakespeare might have put it, “a consummation devoutly to be wished.”

We all grieve when a loved one is no longer physically present. Companion animal caregivers struggling with raw emotions and euthanasia will eventually recognize and appreciate that when their animal needed them most, the caregivers were there. With time, happy memories of lives shared are what endure.32

Euthanasia of our patients is one of the most fraught and demanding aspects of trying to be a caring and compassionate companion animal veterinarian
or veterinary nurse. Indeed, euthanasia has been called the No. 1 reason that companion animal veterinarians leave clinical practice. Use of this QL index will foster appropriate timing of euthanasia and make it less painful and onerous for clients, veterinarians, and veterinary nurses.

The authors thank Anna Guadarrama and Michael McIntyre Johnson for technical assistance.

References

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