Assessment of Quality of Life in Cats

This month, our newsletter considers how to assess a cat’s quality of life and when it may be necessary to take end of life decisions.

Although this is a subject none of us like to think about, it is a harsh reality of owning a pet and at some stage, most of us will need to address this.

Many vets are often asked the questions about quality of life and end of life issues such as:

“How will I know if my cat is suffering?”

“I’m not sure whether to put my cat through any more treatment.”

”How do I know my cat still has sufficient quality of life?”

“How will I know when it is time?”

“What would you do if this were your cat?”

A common response is often that “You will know when the time is right”; however, this can place pressure on pet parents, as it is not always clear when the time is right.

From the moment a cat is diagnosed with a lifelong or life-limiting condition, or is approaching old age, a caregiver may start looking at everything their cat does and analysing what it means in terms of quality of life.

This often leads to a bad day, making a caregiver think that their cat is suffering, or it is time for euthanasia. However, then the next day is a better day and this leads to putting off the decision. Rather than looking at each day in isolation, caregivers can look at the number of good and bad days over a week or several weeks and when the balance is moving towards more bad days than good, it will become clearer that it is time to make a decision.

Having said that, before you reach this point, with an aging cat or a cat suffering from a chronic disease, you can use a quality of life (QoL) assessment tool on a regular basis, to monitor your cat’s QoL (quality of life) while it is still good. This will give you a baseline for comparison when QoL starts to deteriorate and can be helpful when it comes to making a decision. There are several QoL assessment tools for pets and also specific to cats available on the internet, or your vet may have one they prefer to use and can give you guidance on how to use it.

Although each cat and caregiver’s definition of a good QoL will be unique, it is generally accepted that QoL may be thought of as to what degree a cat is healthy, comfortable and able to participate in or enjoy life events.

Their relationship with their caregiver(s) is also a big part of a cat’s QoL. Research has shown that owners of cats with heart disease would trade longevity for QoL and treatment associated with improvement in QoL, is very important for cats with chronic kidney disease (Hoit et al., 2021).

Instruments designed to measure HRQL (health related quality of life) can be generic - designed for use in a variety of contexts in which health is good or is poor for a variety of reasons, or they can be disease-specific - designed for particular conditions and their treatment.

Some pet QoL assessments have more questions relating to physical needs and clinical signs with only one or two questions relating to your cat’s social and emotional needs; this can mean that a total QoL score in a cat with high pain levels may make the other scores less evident.

It is important to look at the relevance of the questions and scores for you and your cat’s situation. Some QoL instruments either generate a single index score that indicates that a patient is better or worse, or a profile of scores that offers more information and may be more sensitive to group differences and to changes in health status over time.

While it is impossible to devise an assessment method that will work perfectly for every cat and caregiver, below are two that are relatively easy to use, given that you know your cat’s medical condition(s), relationship with you and the things they enjoy that are unique to them, better than anyone.

The first scale is adapted from the Minster Veterinary Practice. ^a The questionnaire asks you to take some time to consider each of 8 aspects of your cat’s life in the last week or two, giving a score from 0 to 10, where 10 is ideal. The maximum score is 80, representing an ideal QoL although even healthy cats often don’t live a perfect QoL every day, so don’t worry if your cat’s score isn’t perfect. Scores between 60 and 80 represent a good QoL while scores between 40 and 60 represent an acceptable QoL and scores below 40 represent a low QoL.

Discussing changes in your cat’s scores with your vet are a good way to communicate your cat’s QoL with your vet practice and may indicate a need for a change in treatments to maintain as good a QoL as possible, for as long as possible.

If treatments are failing to improve life for you and your pet, humane euthanasia may need to be considered as the kindest option. The score can never replace an open and honest discussion with your veterinary healthcare team. They are there to listen to your concerns, discuss options and assist you in making decisions.

Aspect	Guidance	Score
Mobility	10: Good, no difficulty getting around, enjoys walks and going outside
	5: Poor, difficulty getting up, difficulty positioning to toilet, short walks
	0: None, needs assistance, can’t position to toilet, drugs don’t help
Nutrition	10: Good, consistent robust appetite, eats willingly, seeks food
	5: Poor, requires hand-feeding or enticing to eat
	0: None, anorexic or requires feeding tube, or vomiting what they eat
Hydration	10: Good, drinking normal volumes at normal times
	5: Poor, not drinking much, or drinking excessively/always thirsty
	0: None, not drinking, relies on a drip or subcutaneous fluids, vomiting
Comfort	10: Good, pain well-managed, breathing with normal effort
	5: Poor, pain not well-controlled, or difficulty breathing
	0: None, drugs not helping pain, works hard to breathe/requires oxygen
Hygiene	10: Good, able to keep self-clean
	5: Poor, needs frequent bathing or matt removal, sometimes soils self
	0: None, soils self often, skin scalded by urine, matts restrict motion
Interaction	10: Good, interacts with family and other pets, on own initiative
	5: Poor, reduced interaction or enthusiasm, needs persuasion
	0: None, withdraws/hides away, negative or no response to family
Toileting	10: Good, regular normal urination and defaecation
	5: Poor, constipation, diarrhoea, excessive or difficult urination
	0: Very poor, severe diarrhoea, needs assisted bowel/bladder care
Favourite Things	10: Good, keen for favourite things eg play, toys, walks, cuddles
	5: Poor, reduced interest in or ability to enjoy favourite things
	0: None, no interest in or ability to enjoy favourite things
Total Score

The second scale was developed by Dr. Alice Villaloboos, the veterinarian who started PawSpice; it is called the HHHHHMM Scale for the 7 aspects of Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility, and More Good Days than Bad.

Each aspect is also scored from score from 0 to 10, where 10 is ideal, giving a maximum score of 70. A score of 5 or greater for each aspect with a total score of 35 being considered acceptable. When the total score drops below 3 or an individual score drops below 5, intervention is considered necessary.

Aspect	Description	Score
Hurt	Adequate pain control & breathing ability is of top concern. Trouble breathing outweighs all concerns. Is the pet's pain well managed? Can the pet breathe properly? Is oxygen supplementation necessary?
Hunger	Is the pet eating enough? Does hand feeding help? Does the pet need a feeding tube?
Hydration	Is the pet dehydrated? For patients not drinking enough water, use subcutaneous fluids daily or twice daily to supplement fluid intake.
Hygiene	The pet should be brushed and cleaned, particularly after eliminations. Avoid pressure sores with soft bedding and keep all wounds clean.
Happiness	Does the pet express joy and interest? Is the pet responsive to family, toys, etc.? Is the pet depressed, lonely, anxious, bored or afraid? Can the pet's bed be moved to be close to family activities?
Mobility	Can the pet get up without assistance? Does the pet need human or mechanical help (e.g., a cart)? Does the pet feel like going for a walk? Is the pet having seizures or stumbling? (Some caregivers feel euthanasia is preferable to amputation, but an animal with limited mobility yet still alert, happy and responsive can have a good quality of life as long as caregivers are committed to helping their pet.)
More good days than bad	When bad days outnumber good days, quality of life might be too compromised. When a healthy human-animal bond is no longer possible, the caregiver must be made aware that the end is near. The decision for euthanasia needs to be made if the pet is suffering. If death comes peacefully and painlessly at home, that is okay.
Total Score

Hopefully, many of you will not need to use the charts in relation to a particular illness or condition your cat has currently. Instead, it can be useful to use at any stage of a cat’s life to help consider the overall well-being of your cat, and whether any changes may be required in its daily routine, or diet to enable you to make any improvements you feel may help it to live a happier, more fulfilled lifestyle.

At such point that your cat does have a serious / terminal condition, and the time comes to consider its quality of life in relation to any pain or suffering, hopefully the charts will help you to monitor your cat and make your own assessment, as to when euthanasia may be the best option.

In the meantime, we can all give our cats the best possible diet, exercise, stimulation and love to make every day of their lives as happy & content as possible. 

Footnotes

a. Adapted from https://minstervets.co.uk/what-we-offer/end-of-life-care

b. Adapted from the original concept, Oncology Outlook, by Dr. Alice Villalobos, Quality of Life Scale Helps Make Final Call, VPN, 09/2004; scale format created for author’s book, Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond, Blackwell Publishing, 2007. Revised for the International Veterinary Association of Pain Management (IVAPM) 2011 Palliative Care and Hospice Guidelines.

References

Burckhardt CS and Anderson KL. 2003. The Quality of Life Scale (QOLS): Reliability, Validity, and Utilization. Health Qual Life Outcomes 1, 60. https://doi.org/10.1186/1477-7525-1-60.

Doit H et al. 2021. A systematic review of the quality of life assessment tools for cats in the published literature. Vet J. 272:105658. doi: 10.1016/j.tvjl.2021.105658.

Freeman LM et al. 2016. Development and initial validation of the Cat HEalth and Wellbeing (CHEW) Questionnaire: a generic health- related quality of life instrument for cats. Journal of Feline Medicine and Surgery, 18 (9), pp. 689-701. https://doi.org/10.1177/1098612X16657386

Noble CE et al. 2019. Development, initial validation and reliability testing of a web-based, generic feline health-related quality-of-life instrument. Journal of Feline Medicine and Surgery, 21 (2), pp.84-94. https://doi.org/10.1177/1098612X18758176

Scott EM et al. 2021. Validity and responsiveness of the Generic Health-Related Quality of Life Instrument (VetMetrica™) in cats with osteoarthritis: comparison of vet and owner impressions of quality of life impact. Frontiers in Veterinary Science, 8, p1124. https://doi.org/10.3389/fvets.2021.733812