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

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

2. “I promise to give you the best possible quality of life.”

3. “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.

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

9. HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE? Ben and his city dog 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 and his country 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. 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

10. HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE? Ben and his city dog Jerry and his country 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?

11. HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE? MORE OF THE IMAGINARY SCENARIO: Ben’s city dog Jerry’s 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 pet’s 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 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.”

12. HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE? MORE OF THE IMAGINARY SCENARIO: Ben’s city dog Jerry’s 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 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.” 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?

13. “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 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.” Hmmm

14. 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…

15. 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?

16. 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?

17. Mental disabilities and QOL Mentally disabled children • Does making them “like us” raise their QOL? • Why do we assume they would want this?

18. Mental disabilities and QOL Do you assume that dogs with cognitive dysfunction syndrome have decreased QOL and our job is to increase it?

19. 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?

20. 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’

21. QUESTIONS What IS quality of life? Is it something you FEEL? Or is it something you THINK?

22. 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?

23. Has an effect on QOL Does NOT have 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 MATTERS to the animal 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 Does NOT matter to the animal

24. THE FEELINGS OF QUALITY OF LIFE Why do wehave feelings?

25. 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

26. 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

27. FEELINGS Pleasant Unpleasant Physical Emotional

28. By definition, pleasant feelings give life a pleasant quality, and unpleasant feelings give life an unpleasant quality

29. “Beeper studies” in people: Overall pleasantness of life relates to time spent experiencing pleasant and unpleasant feelings

30. Positive (good) QOL coincides with a preponderance of pleasant feelings, and negative (poor) QOL coincides with a preponderance of unpleasant feelings.

31. Quality of life is represented by a balance of the pleasant and unpleasant feelings of life over time The Affect Balance Model of Quality of Life

32. PLEASANT FEELINGS UNPLEASANT 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

33. High QOL PLEASANT FEELINGS UNPLEASANT FEELINGS

34. Low QOL UNPLEASANT FEELINGS PLEASANT FEELINGS

35. TWO KEY QUESTIONS WHAT IS QUALITY OF LIFE? 1. WHAT FACTORS INFLUENCE 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

36. TWO KEY QUESTIONS WHAT IS QUALITY OF LIFE? 1. WHAT FACTORS INFLUENCE QUALITY OF LIFE? 2. 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 HOW MUCH DO THESE FACTORS INFLUENCE QUALITY OF LIFE?

37. Has an effect on QOL Does NOT have 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

38. 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

39. Affect Balance Model of Quality of Life BUT NOT ALL FEELINGS WEIGH THE SAME

40.  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

41. 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

42. PLEASANT FEELINGS Single malfunction equals loss of a tasty meal UNPLEASANT FEELINGS Single malfunction equals loss of life

43. PAY ATTENTION TO ME! I CAN MAKE YOU FEEL GOOD Pleasant feelings Unpleasant feelings

44. 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

45. When You Can’t Breathe, Nothing Else Matters American Lung Association

46. 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

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

48. October 2008

50. THE MAJOR CONTRIBUTING FACTORS TO QUALITY OF LIFE ALL EFFECTS ARE THROUGH FEELINGS Socialrelationships—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 Mentalstimulation—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