28/01/2025
I absolutely love David Shrigley’s poster, ‘This Huge Cat’.
‘This huge cat has been assigned to you. You must accept this situation and find joy in it‘.
And we do, we really do. Photo of my own huge cat so as not to tread on any copyright toes-the much loved and painfully missed Melania/Melly Trump. Once seen (difficult to miss really), always loved.
So then to the hardest of questions-how can anyone decide to say goodbye to their beloved pet? How can you choose that ‘When?’
When talking to families about their pets I’ll often say that in making the decision as to when to euthanize, I want the family to have the least regrets. It would be unrealistic to say no regrets, but least regrets we can work with. I also advocate for it being a planned decision. An acute crisis takes that decision out of your hands but we want to avoid a crisis if at all possible. Now I’m a real hypocrite here as I’ve managed to personally fail on both of the above in the recent past (through poor choices driven by the very real paralysis of anticipatory grief and fear). And I’ve paid dearly for it. Grief really is a tough enough experience to move through without the added burden of huge regrets and the pain of saying goodbye, at speed, in an emergency setting. I know plenty of colleagues who carry that heavy weight too. We’re not infallible. We can fail to think straight when it comes to our own. David Kessler, the grief expert, moots a sixth step to Kubler-Ross’ famous five stages of grief: finding meaning. Perhaps my meaning is in trying to avoid others having to experience that.
So how do you honestly come to the decision as to when to euthanize?
You may have heard the cliches.
‘You’ll know’.
‘Better a day too soon, than a day too late’.
You may have been asked the question, ‘Does your pet still like to do the things they enjoyed when they were young?’
You may have been presented with the HHHHHMM quality of life scale (QOL)-work through that, that will tell you.
I won’t lie. All four of the above I absolutely hate.
How WILL you know? If you’ve no medical training it can be hard to know-is this just a single bad day? Might they get better? They can have a swan song though, can’t they? If you’ve medical training and are emotionally involved you’re often no better off in determining. In fact in some ways I think having the training might make things even more fraught when you’re emotionally wrapped up in it. You can tell yourself a story that may just prove to be wrong (I’ve learnt sadly a bit late in the day that I need external guidance as much as the next person when it comes to my own pets).
Better a day too soon, than a day too late. Personally I find this a trite comment. Unless faced with an acute emergency, there is often a window of time, a zone, where your decision is made neither too early nor too late.
Do I like to do the same things now in my 50s as I did in my 20s? Nope!
And the HHHHHMM scale…All of its parameters,barring one, are based on the physical. A pet’s quality of life should also take in to account social and emotional happiness (with consideration of family quality of life, which I’ll mention later).
I qualified as a veterinary hospice and palliative care veterinarian (CHPV) in 2021 after further post graduate training
And I’m still learning-and always will be as this is a new field and knowledge in it is accumulating fast.
https://thehousevet.co.uk/certified-hospice-and-palliative-care-veterinarian/
So I say to families now, Yes, reach for a quality of life tool if you wish-but make sure it’s more rounded and that it attempts to assess not just health factors but also social and emotional happiness for your companion. As vets we focus on the physical quality of life. When I’m a pet owner I focus on the emotional quality of life. The two approaches can understandably clash across a consult table. Is your pet still interacting with the family-or have they gone in to hiding? How long during a 24 hour period do they interact? Are they clingy? What is their mentation like? I currently recommend Ohio State University’s ‘How will I know?’ as a quality of life tool.
Combine QOL with looking at pain scales. My more experienced palliative care colleagues are now leaning towards scientifically validated chronic pain scales/comfort scores above QOL tools. I recommend the excellent-and yet to be beaten-Feline Grimace Scale. And for dogs I use BEAP in talks with my families as it is so user friendly but I do think there are better pain scales which may benefit from input from your primary care vet (ie Liverpool osteoarthritis in dogs-LOAD; Canine Brief Pain Inventory). The limitation of chronic pain scales is that most of them do specifically relate to osteoarthritis.
We do have access to a few validated disease specific quality of life tools also: for cardiac disease, diabetes, cancer in dogs, and chronic kidney disease in cats.
These QOL tools and pain scales can be used as a standalone. Or they can provide a baseline to revisit over time, including if palliative comfort care has subsequently been introduced. Is that reading stable? Is it deteriorating? Is it improved even?
And then we can get in to the additional fields of patient autonomy and animal advanced directives.
Patient autonomy is a huge consideration in human palliative care and we should consider it also for our pets. Is your pet able to feed themselves, drink on their own? Go out to go to the bathroom, or in a litter box? Can they clean, groom themselves? Are they able to move themselves from place to place or did they need assistance? Can they still jump up on things in the house?
A simple advanced directive could be led by: what do you want to see your pet able to do, and what do you not want to see them go through? Creating an advanced directive for your pet can help facilitate a conversation amongst family members about needs and priorities, defining what is important for them and attempting to determine the wishes of the animal, in effect your pet’s will to live. An advanced directive can help direct palliative care and give you back up at the more emotionally challenging time of making the euthanasia decision. An advanced directive will also consider family quality of life. We get family members who no longer sleep in their beds because they need to be downstairs on the sofa with their pet; aren’t getting a good nights sleep as their pet is pacing backwards and forwards all night and subsequently lack of sleep is impacting on the caregiver’s working day; daren’t go out because they are worried their pet will get stuck somewhere in the house. There should never be any shame in paying attention to just how physically and mentally tough being a caregiver can be.
We all need help in making this big, big decision. Feeling that you are without guidance in thinking it through can feel very scary and very isolating. Please ask for that help-ask your primary care vet, ask us-and use that help to guide you.
https://thehousevet.co.uk/quality-of-life-assessment-tools/
Providing gentle, compassionate at home euthanasia for cats and dogs.
