Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D....

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Franklin D. McMillan, DVM, DACVIM (SAIM) Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Best Friends Animal Society Kanab, Utah Kanab, Utah MAXIMIZING MAXIMIZING QUALITY OF LIFE QUALITY OF LIFE IN ILL ANIMALS IN ILL ANIMALS

Transcript of Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D....

Page 1: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Franklin D. McMillan, DVM, DACVIM (SAIM)Franklin D. McMillan, DVM, DACVIM (SAIM)Best Friends Animal SocietyBest Friends Animal Society

Kanab, UtahKanab, Utah

Franklin D. McMillan, DVM, DACVIM (SAIM)Franklin D. McMillan, DVM, DACVIM (SAIM)Best Friends Animal SocietyBest Friends Animal Society

Kanab, UtahKanab, Utah

MAXIMIZING MAXIMIZING QUALITY OF LIFEQUALITY OF LIFEIN ILL ANIMALSIN ILL ANIMALS

MAXIMIZING MAXIMIZING QUALITY OF LIFEQUALITY OF LIFEIN ILL ANIMALSIN ILL ANIMALS

Page 2: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

“I promise to

give you the best possible quality of

life.”

Page 3: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

“Everyone knows what quality of life is” When you ask a pet owner what she feels her dog’s quality

of life is, you don’t 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, it’s 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

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 safety’s 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 dog’s life” in Ben’s 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. Jerry’s dog is not neutered and has plentiful opportunities to “intimately interact” with the numerous female dogs in the neighborhood.

HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

Fraser et al. 1997. Anim Welf 6:187-205

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Jerry and hiscountry dog

Ben and hiscity 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. Jerry’s 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 safety’s 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 dog’s life” in Ben’s words.

I FEEL SORRY FOR YOUR DOG

I FEEL SORRY FOR YOUR DOG

If quality of life has any meaning at all, then clearly one of these dogs must have a higher

QOL than the other…

Each man, judging quality of life from very different viewpoints…

HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

Page 10: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Jerry and hiscountry dog

Ben and hiscity dog

If quality of life has any meaning at all, then clearly one of these dogs must have a higher

QOL than the other…

HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

Which one is it?

Page 11: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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 pet’s name…

Ben’s city dog Jerry’s country dog

MORE OF THE IMAGINARY SCENARIO:

PHONE MESSAGE

Mr. Smith called – he said “My brother

has convinced me that his dog has a

really good quality of life and mine

doesn’t. 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.”

PHONE MESSAGE

Mr. Smith called – he said “My brother

has convinced me that his dog has a

really good quality of life and mine

doesn’t. 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.”

HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

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Ben’s city dog Jerry’s country dog

MORE OF THE IMAGINARY SCENARIO:

PHONE MESSAGE

Mr. Smith called – he said “My brother

has convinced me that his dog has a

really good quality of life and mine

doesn’t. 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.”

PHONE MESSAGE

Mr. Smith called – he said “My brother

has convinced me that his dog has a

really good quality of life and mine

doesn’t. 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.”

HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

You have all night to ponder what your advice will be before calling him the next morning. “Everybody knows what quality of life is,” you’re 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

“We just received FDA approval for a new drug that you’re going to love! It’s the

closest thing to a true ‘wonder drug’ that’s ever been developed!”

“What’s it do?”

“It’s incredible! It’s the first drug that increases a dog’s quality of life! And here’s

the amazing part: it achieves an increase no matter what the dog’s current quality of life

is.”

“You’ve got a dog, don’t you Doctor? Just try it on your own dog. You’ll see

for yourself.”

The scene: Your clinic. A drug rep, obviously excited, scurries in.

Hmmm

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What are you going to look forto tell if the drug is working?What are you going to look forto tell if the drug is working?You decide to give it a try…

Everyone knows what quality of life is – Part 2, Part 2

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Does Bill Gates have a good QOL?

What about the immaculately groomed silver Persian cat laying in the Queen of England’s lap eating caviar out of a crystal goblet?

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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?

The indoor cat is allowed outside

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Mental disabilities and QOL

Mentally disabledchildren

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 (“I’m 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 dog’s QOL is. You

expect a certain type of answer—a reflection of what kind of life her dog is experiencing overall over the past few weeks or so. You don’t 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 client’s answer implied the existence of a long-term mood state; you weren’t inquiring about the dog’s 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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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’

CONFUSION…

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QUESTIONSQUESTIONS

What IS quality of life?

Is it something you FEEL?

Or is it somethingyou THINK?

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TWO KEY QUESTIONSTWO KEY QUESTIONSWHAT FACTORS WHAT FACTORS INFLUENCE QUALITY INFLUENCE QUALITY OF LIFE?OF LIFE?1.1.

2.2. HOW HOW MUCHMUCH DO THESE DO THESE FACTORS INFLUENCE FACTORS INFLUENCE QUALITY OF LIFE?QUALITY OF LIFE?

WHAT IS QUALITY OF LIFE?

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Does NOT havean effect on QOL

Has an effect on QOL

1. painted toenails2. Neuticals3. expensive collar4. small lipoma5. no Starbucks

nearby6. toe amputation7. food looks like bacon 8. male w/ female

name

1. osteoarthritis2. lots of playtime3. abuse4. tasty treats5. always alone6. nausea from CKD7. new ‘bully’ dog8. pulmonary edema

MATTERS to

the animal Does NOT matter

to the animalELICITS

FEELINGSELICITS NO

FEELINGS

Page 24: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

THE FEELINGS OF QUALITY OF LIFE

Why do wehave feelings?

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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

Why do we have 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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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

Pleasant Unpleasant

FEELINGS

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By definition, pleasant feelings By definition, pleasant feelings give life a pleasant quality, give life a pleasant quality,

and unpleasant feelings give and unpleasant feelings give life an unpleasant qualitylife an unpleasant quality

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“Beeper studies” in people:Overall pleasantness of life

relates to time spent experiencingpleasant and unpleasant feelings

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Positive (good) QOL coincides withPositive (good) QOL coincides with a preponderance of pleasant feelings, and a preponderance of pleasant feelings, and

negative (poor) QOL coincides withnegative (poor) QOL coincides with a preponderance of unpleasant feelings. a preponderance of unpleasant feelings.

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Quality of life is represented by a balance of the pleasant and

unpleasant feelings of life over time

The Affect Balance Modelof Quality of Life

The Affect Balance Modelof Quality of Life

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The Affect Balance Model of Quality of Life

UNPLEASANTFEELINGS

PLEASANT FEELINGS

● Joy ● Play ● Social companionship ● Mental stimulation ● Physical contact ● Taste ● Nurturing young (mammals) ● Sexual activity ● Control

● Fear ● Anxiety ● Boredom ● Loneliness● Separation distress ● Grief ● Depression● Pain ● Hypoxia● Full bladder ● Nausea ● Pruritus

Page 33: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

PLEASANTFEELINGS

UNPLEASANTFEELINGS

High QOL

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UNPLEASANTFEELINGS

PLEASANTFEELINGS

Low QOL

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TWO KEY QUESTIONSTWO KEY QUESTIONSWHAT FACTORS WHAT FACTORS INFLUENCE QUALITY INFLUENCE QUALITY OF LIFE?OF LIFE?1.1.

WHAT IS QUALITY OF LIFE?

Anything which tips the QOL scales—in either direction—plays a role in the animal’s QOL. Those things that do not tip the scales do not affect the animal’s QOL

Page 36: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

TWO KEY QUESTIONSTWO KEY QUESTIONSWHAT FACTORS WHAT FACTORS INFLUENCE QUALITY INFLUENCE QUALITY OF LIFE?OF LIFE?1.1.

2.2. HOW HOW MUCHMUCH DO THESE DO THESE FACTORS INFLUENCE FACTORS INFLUENCE QUALITY OF LIFE?QUALITY OF LIFE?

WHAT IS 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

Page 37: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Does NOT havean effect on QOL

Has an effect on QOL

1. painted toenails2. Neuticals3. expensive collar4. small lipoma5. no Starbucks

nearby6. bacon look to food 7. male w/ female

name8. toe amputation

1. osteoarthritis2. lots of playtime3. abuse4. tasty treats5. always alone6. nausea from CKD7. new ‘bully’ dog8. pulmonary edema

Do NOT tipthe QOL scales

Tip theQOL scales

Page 38: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Balance Model of Quality of Life

This model of QOL explains the reason for the intuitive feeling that an animal’s 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

Page 39: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Affect Balance Model of Quality of Life

BUT NOT ALL FEELINGS WEIGH THE SAME

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 one’s 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 FEELINGSSingle malfunction equalsloss of a tasty meal

UNPLEASANT FEELINGSSingle malfunction equalsloss of life

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Unpleasantfeelings

Pleasantfeelings

PAY ATTENTION

TO ME! I CAN MAKE YOU FEEL GOOD

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ALL ALL UNPLEASANTUNPLEASANT FEELINGS FEELINGS ARE NOT EQUALARE NOT EQUAL

SITUATION FEELING

Impaired oxygen intake Hypoxia, terror, panic

Tissue damage Pain

Threat to life Fear

Situations most urgently threatening to life have evolved to have the most intensely unpleasant feelings (sufferings)

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When You Can’t Breathe,Nothing Else Matters

American Lung Association

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

PHYSICAL vs EMOTIONAL PAIN – WHICH IS WORSE?

Photo by Clay Myers

Page 47: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

PHYSICAL VERSUS EMOTIONAL PAIN:WHICH IS WORSE? Scarlett’s answer

Scarlett

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.

Page 48: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

October 2008

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Page 50: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

THE MAJOR CONTRIBUTING FACTORS TO QUALITY OF LIFE

Social relationships—Social 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 stimulation—Monotonous, unchanging environments elicit signs of boredom. Conversely, pleasant feelings are elicited by stimulation, challenges, and mental engagement

Control—The 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

Health—Compromised health involves myriad unpleasant feelings. Physical disabilities limit one’s opportunities for experiencing pleasurable feeling states

“Stress”—As 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

ALL EFFECTS ARE THROUGH FEELINGS

Page 51: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

MEASUREMENT OF QUALITY OF LIFE IN ANIMALS

Page 52: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

MANY HUMAN DOCTORSASK THE SAME QUESTION

We all agree that knowing an animal’s quality of life is important. But what’s the big deal? Why not rely on what we’ve always relied on—our intuitive judgment?

WHY DO WE NEED FANCY TOOLSTO MEASURE SOMETHING SO OBVIOUS?

Page 53: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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

Page 54: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

What’s wrong with just using our intuition to assess an animal’s quality of life?

KEY QUESTIONSHow reliable are our gut-level, intuitive assessments of a pet’s

QOL? If you judged your own pet’s 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 they’ll know when it is “time” for euthanasia. “You’ll 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?

Page 57: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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 dog’s 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.

How good is our intuitionin judging QOL?

Page 58: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

How good is our intuition in judging QOL?

OTHER EXAMPLES

Dentalwork

NSAIDtreatment

trials

Hypo-thyroid

treatment

Page 59: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Study in dogs showed that the bondbetween a person and dog influences

the person’s reports about the dog’s health

How good is our intuition in judging QOL?

MORE PROBLEMS

Page 60: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

A Qualityof Life

Thermometer

Page 61: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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

MEASUREMENT OF QUALITY OF LIFE IN ANIMALS

Page 62: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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

Page 63: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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.

How accurate are proxy measurements of QOL?How accurate are proxy measurements of QOL?

Page 64: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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

Page 65: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

That all seemssimple enough

If onlyit were…

Page 66: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

The puzzling aspects ofquality of life

Page 67: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

…what’s 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 person’s 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 – wouldn’t this suggest that having sight is irrelevant to QOL?

Page 68: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Many people report satisfaction in situations that the majority of the population believe that they would find unbearableCancer

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”

…what’s going on?

Page 69: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

…a paradox

The Disability 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

Page 70: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

If the disability paradox shows that we do not see our own future QOL clearly, predicting an animal’s 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

THE DISABILITY PARADOX IN ANIMAL QUALITY OF LIFE

Page 71: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

WHAT CAN EXPLAINTHE DISABILITY PARADOX?

1. The focusing illusion2. Underestimation of adaptation3. Scale recalibration

Page 72: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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

Page 73: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Focusing Illusion The focusing illusion is very powerful

force and EXTREMELY DIFFICULT TO DISREGARD when looking at one’s own future situation Even when the person predicting a

QOL (including one’s own) is aware of focusing illusion, still very difficult to incorporate it into predictions of well-being

Degree of person’s knowledge and familiarity with the animal won’t eliminate focusing illusion’s effects

Page 74: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

WHAT CAN EXPLAINTHE DISABILITY PARADOX?

1. The focusing illusion2. Underestimation of adaptation3. Scale recalibration

Page 75: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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 event—good or bad—to 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

Page 76: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Adaptation in AnimalsEvidence 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

Page 77: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

WHAT CAN EXPLAINTHE DISABILITY PARADOX?

1. The focusing illusion2. Underestimation of adaptation3. Scale recalibration

Page 78: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Scale Recalibration

Appears to be a SHIFT IN THE INTERNAL STANDARD, which results in a changed expectation of QOL MORE IN FITTING WITH THE INDIVIDUAL’S CURRENT SITUATION IN LIFE

The QOL scale shifts, so “90” for the elderly man means something different than a “90” for the young man

Page 79: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Scale Recalibration in Animal QOL Assessment

Routinely applied to animalsExample

Typical comment from owner of an elderly dog:

“He’s 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

Page 80: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Quality of Life in Health Care

Page 81: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Because QOL is a view of one’s life from within – by that individual and not an outsider – it forces us to look at the health effects from the animal’s 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 animal’s 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 we’re doing for an animal is benefitting or harming them.

Without QOL, all of these things above are guesses (which, right now, many are).

Why is quality of life importantin health care?

Page 82: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

QOL in the ill animal

Page 83: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Quality of LifeEarly illness

Page 84: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Quality of LifeProgressing illness

Page 85: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Quality of LifeLate illness

Page 86: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

can be summarized by a single can be summarized by a single

principle: principle:

Tip the QOL scales as far toward the pleasant side as

possible

Maximizing QOLMaximizing QOL

Page 87: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

minimizing unpleasant feelings

increasing pleasant feelings

both

THIS MAY BE ACHIEVED BY:

THIS MAY BE ACHIEVED BY:

Page 88: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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 restoredUse all means possible to decrease the

unpleasant feelingsDrugs, surgery, human contact

Page 89: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

PROMOTING PLEASANT FEELINGS

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

Maximizing QOL in Ill Animals

Page 90: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

Neuromuscular disease Degenerative myelopathy

Paralysis Loss of vision Loss of hearing

Maximizing QOL indogs with disabilities

Page 91: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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…

Page 92: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

IS QUALITY OF LIFE “EVERYTHING”?

IS IT THE ONLY THING THAT MATTERS?

IS ANYTHING ELSE IMPORTANT?

Page 93: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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?

Page 94: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

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

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

Page 95: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

A MATH WE DON’T UNDERSTAND AT ALL – AND AT STAKE IS AN ANIMAL’S 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?

Page 96: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,
Page 97: Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab, Utah Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Society Kanab,

QUESTIONSQUESTIONS