Research issues w QOL by liuqingyan

VIEWS: 1 PAGES: 98

									 MAXIMIZING
QUALITY OF LIFE
IN ILL ANIMALS
Franklin D. McMillan, DVM, DACVIM (SAIM)
         Best Friends Animal Society
               Kanab, Utah
“I promise to
   give you
   the best
   possible
  quality of
     life.”
“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.
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

   The Smith brothers got together one day to walk their dogs

Ben and his dog live in a busy part of the   Jerry lives in a rural area at the outskirts
city. His dog is neutered, wears a collar    of town. His dog is allowed to roam free
with ID tags as well as having a tattoo      and has never worn a collar in his life.
and microchip. The dog receives three        Jerry feeds his dog generously but
walks a day and for safety’s sake is never   sporadically. The dog is rarely bathed and
allowed outside without a leash. Ben         usually has burrs in his coat from his
feeds his dog two measured meals a day       frequent exploratory ventures into the
of a low-fat dog food. He is fastidious      woods surrounding their property.
about bathing and grooming his dog           Jerry’s dog is not neutered and has
regularly. His dog is trained to obey        plentiful opportunities to “intimately
commands. When Ben is at work his dog        interact” with the numerous female dogs
lounges in his house – “a dog’s life” in     in the neighborhood.
Ben’s words.

                                                            Fraser et al. 1997. Anim Welf 6:187-205
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?



          Ben and his
Ben and his dog live in a busy part of the             Jerry and his
                                           Jerry lives in a rural area at the outskirts
city. His dog is neutered, wears a collar  of town. His dog is allowed to roam free
           city dog
with ID tags as well as having a tattoo
                                                       country dog
                                           and has never worn a collar in his life.
and microchip. The dog receives three      Jerry feeds his dog generously but
             and for man, judging          sporadically. The dog is very
walks a day Each safety’s sake is never quality of life fromrarely bathed and
allowed outside without a leash. Ben       usually has burrs in his coat from his
            If two measureddifferent viewpoints…
                                life a day
feeds his dog quality of meals has any meaning at all, then the
                                           frequent exploratory ventures into
           clearly one fastidious          woods surrounding a higher
of a low-fat dog food. He is of these dogs must have their property.
about bathing and grooming his dog         Jerry’s dog is not neutered and has
                               QOL than the other…
     I FEEL SORRY FOR
regularly. His dog is trained to obey             I FEEL SORRY FOR
                                           plentiful opportunities to “intimately
commands. When Ben is at work his dog      interact” with the numerous female dogs
         YOUR DOG
lounges in his house – “a dog’s life” in              YOUR DOG
                                           in the neighborhood.
Ben’s words.
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?



   Ben and his                   Jerry and his
    city dog                     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?
  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…
HOW SIMPLE IS THE CONCEPT OF QUALITY OF LIFE?

MORE OF THE IMAGINARY SCENARIO:
  Ben’s city dog       Jerry’s country dog

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




     You are you going it look for
    What decide to give to a try…
    to tell if the drug is working?
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?
          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?
      Mental disabilities and QOL

Mentally disabled
    children
  Does making
 them “like us” raise
 their QOL?

  Why do we
 assume they would
 want this?
       Mental disabilities and QOL
Do you assume
that dogs with
cognitive
dysfunction
syndrome have
decreased QOL
and our job is to
increase it?
                    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?
        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’
  QUESTIONS
What IS quality of life?

Is it something you FEEL?
   Or is it something
     you THINK?
   WHAT IS QUALITY OF LIFE?

TWO KEY QUESTIONS

1.   WHAT FACTORS
     INFLUENCE QUALITY
     OF LIFE?


2.
     HOW MUCH DO THESE
     FACTORS INFLUENCE
     QUALITY OF LIFE?
Has an effect            Does NOT have
   on QOL               an effect on QOL
                          1. painted toenails
1.   osteoarthritis       2. Neuticals
2.   lots of playtime     3. expensive collar
3.   abuse                4. small lipoma
4.   tasty treats         5. no Starbucks
5.   always alone               nearby
6.   nausea from CKD      6. toe amputation
7.   new „bully‟ dog      7. food looks like bacon
8.   pulmonary edema      8. male w/ female
                                name
  Why do we
THE FEELINGS OF
 have feelings?
QUALITY OF LIFE
    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
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
               FEELINGS
                Pleasant                 Unpleasant
            Taste, physical      Hypoxia, pain, thirst,
            contact with others, hunger, illness, nausea, full
            sexual activity      urinary bladder,
 Physical                        constipation, pruritus,
                                 bright lights, temp
                                 extremes, etc


            Joy, social           Fear, anxiety, loneliness,
            companionship,        boredom, frustration,
Emotional   mental stimulation    anger, depression, grief,
                                  helplessness
By definition, pleasant feelings
 give life a pleasant quality,
 and unpleasant feelings give
   life an unpleasant quality
    “Beeper studies” in people:
    Overall pleasantness of life
relates to time spent experiencing
 pleasant and unpleasant feelings
   Positive (good) QOL coincides with
a preponderance of pleasant feelings, and
   negative (poor) QOL coincides with
a preponderance of unpleasant feelings.
The Affect Balance Model
   of Quality of Life



Quality of life is represented by a
    balance of the pleasant and
unpleasant feelings of life over time
 PLEASANT                    UNPLEASANT
 FEELINGS                       FEELINGS
                                   ● Fear
 ● Joy
                                   ● Anxiety
 ● Play
                                   ● Boredom
 ● Social
                                   ● Loneliness
companionship
                                   ● Separation
 ● Mental
                                   distress
stimulation
                                   ● Grief
 ● Physical contact
                                   ● Depression
 ● Taste
                                   ● Pain
 ● Nurturing young
                                   ● Hypoxia
(mammals)
                                   ● Full bladder
 ● Sexual activity
                                   ● Nausea
 ● Control
                                   ● Pruritus

The Affect Balance Model of Quality of Life
High QOL



             UNPLEASANT

  PLEASANT    FEELINGS




  FEELINGS
           Low QOL


PLEASANT
FEELINGS
           UNPLEASANT
            FEELINGS
         WHAT IS QUALITY OF LIFE?

 TWO KEY QUESTIONS

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
           WHAT IS QUALITY OF LIFE?

   TWO KEY QUESTIONS

  1.         WHAT FACTORS
             INFLUENCE QUALITY
             OF LIFE?


  2.
              HOW MUCH DO of the
On the QOL scales the intensity THESEfeelings
dictates the degree to which the scales are
              FACTORS INFLUENCE
tipped, and hence defines the magnitude of
influence thatQUALITY OF LIFE?
               factor has on QOL
  Has an effect          Does NOT have
     on QOL             an effect on QOL
                          1. painted toenails
  1. osteoarthritis       2. Neuticals
  2. lots of playtime
  Doabuse tip
  3. NOT                      Tip the
                          3. expensive collar
                          4. small lipoma
the QOLtreats
  4. tasty scales          QOL scales
                          5. no Starbucks
  5. always alone               nearby
  6. nausea from CKD      6. bacon look to food
  7. new „bully‟ dog      7. male w/ female
  8. pulmonary edema            name
                          8. toe amputation
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
Affect Balance Model of Quality of
               Life


BUT NOT ALL FEELINGS
  WEIGH THE SAME
       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
   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
                       PLEASANT FEELINGS
                       Single malfunction equals
                       loss of a tasty meal




UNPLEASANT FEELINGS
Single malfunction equals
loss of life
   PAY
ATTENTION              I CAN
                       MAKE


  TO ME!
                      YOU
                   FEEL GOOD




    Unpleasant   Pleasant
     feelings    feelings
      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


    Tissue damage                          Pain


     Threat to life                        Fear
When You Can’t Breathe,
 Nothing Else Matters
        American Lung Association
    PHYSICAL vs EMOTIONAL PAIN –
         WHICH IS WORSE?

Study: electrified
  grid placed
  between puppies
  and socially-
  attached human.
  Puppies endured
  the pain of crossing
  the grid to
  reestablish contact
  with the person
                             Photo by Clay Myers
   PHYSICAL VERSUS EMOTIONAL PAIN:
WHICH IS WORSE? Scarlett’s answer




                           Scarlett
October 2008
THE MAJOR CONTRIBUTING FACTORS
       TO QUALITY OF LIFE
       ALL EFFECTS ARE THROUGH FEELINGS
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
MEASUREMENT OF QUALITY OF LIFE IN ANIMALS
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 TOOLS
TO MEASURE SOMETHING SO OBVIOUS?



          MANY HUMAN DOCTORS
         ASK THE SAME QUESTION
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
 What’s wrong with just using our intuition
   to assess an animal’s quality of life?
KEY QUESTIONS
 How 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.
Human intuition and animal feelings
  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?
          How good is our intuition
             in judging QOL?
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 intuition in judging QOL?

        OTHER EXAMPLES


Dental                        Hypo-
work                         thyroid
                           treatment
               NSAID
             treatment
                trials
      How good is our intuition in judging QOL?
              MORE PROBLEMS



    Study in dogs showed that the bond
   between a person and dog influences
the person’s reports about the dog’s health
MEASUREMENT OF QUALITY OF LIFE IN ANIMALS

 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
    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
How accurate are proxy measurements of QOL?

  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.
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
  If only
That all seems
 it were…
simple enough
The puzzling aspects of
    quality of life
            …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?
       …what‟s going on?
Many people report satisfaction in situations
 that the majority of the population believe
 that they would find unbearable
  Cancer
     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”
        …a 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

   The Disability Paradox
    THE DISABILITY PARADOX
   IN ANIMAL QUALITY OF LIFE
 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
   WHAT CAN EXPLAIN
THE DISABILITY PARADOX?


1. The focusing illusion
2. Underestimation of adaptation
3. Scale recalibration
        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
      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
   WHAT CAN EXPLAIN
THE DISABILITY PARADOX?


1. The focusing illusion
2. Underestimation of adaptation
3. Scale recalibration
                    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
     Adaptation in Animals
Evidence 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
   WHAT CAN EXPLAIN
THE DISABILITY PARADOX?


1. The focusing illusion
2. Underestimation of adaptation
3. Scale recalibration
     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
  Scale Recalibration in
 Animal QOL Assessment
 Routinely applied to animals
 Example
   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
Quality of Life in Health Care
       Why is quality of life important
              in health care?

 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).
QOL in the
ill animal
Quality of Life
 Early illness
 Quality of Life
Progressing illness
Quality of Life
 Late illness
  Maximizing QOL
can be summarized by a single principle:

Tip the QOL scales as far toward
  the pleasant side as possible
THIS MAY BE ACHIEVED BY:

 minimizing unpleasant feelings
 increasing pleasant feelings

 both
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 restored
    Use all means possible to decrease the
     unpleasant feelings
    Drugs, surgery, human contact
         Maximizing QOL in Ill Animals

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
   dogs with disabilities

 Neuromuscular disease
    Degenerative myelopathy
 Paralysis
 Loss of vision
 Loss of hearing
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…
   IS QUALITY OF LIFE
      “EVERYTHING”?

IS IT THE ONLY THING THAT
         MATTERS?

    IS ANYTHING ELSE
       IMPORTANT?
  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?
   IS QUALITY OF LIFE ―EVERYTHING‖?
 IS IT THE ONLY THING THAT MATTERS?
 IS ANYTHING ELSE MORE IMPORTANT?
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
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?
QUESTIONS

								
To top