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Helping vets assess quality of life
  1. Adele Waters

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I am sometimes intrigued or surprised, even, by some of the things I learn about the veterinary world and it might be interesting to share some of those insights.

The first is something I picked up at this year’s Animal Welfare Foundation discussion forum. Equine vet Lesley Barwise-Munro gave a presentation on the management of geriatric horses and said there was no accurate qualitative tool available for equine vets to assess a horse’s quality of life.

While assessing quality of life is relatively easy in emergency cases, she said it becomes much more challenging in older horses with chronic conditions where decline is gradual. It is also particularly challenging for younger or less experienced vets.

Every day, therefore, Barwise-Munro relies on her clinical judgement in managing cases. But she has also developed a framework to guide her decision-making.

My first thought was ‘did I hear this correctly?’ In human medicine, you can’t move for guidelines and protocols on everything from oral health to routine preoperative tests, so to find out that something so fundamental to veterinary practice was not codified, was surprising. Since most equine vets regularly euthanase horses, surely it would make sense to guide them using some agreed decision-making pathway?

During the question and answer session it became clear that I had heard correctly. Vets, rightly, corrected any assumption that there was no guidance, pointing out the existence of general guidance, for example the BVA’s advice on treatment decision-making and, separately, on euthanasia.

There are also a number of research papers on methodologies for measuring quality of life (more for dogs, fewer for cats and horses) and on exploring factors that need to be considered. But there are no evidence-based guidelines that are species-specific and useable in the field right now.

Yet assessing quality of life surely is at the heart of veterinary endeavour. Under the code of professional practice, all practising vets must make animal health and welfare their first consideration when attending to animals. When euthanasing animals they must consider their current welfare versus their potential quality of life. Would it not be helpful to have guidance?

Yes, says Zoe Belshaw, a vet and welfare expert at Nottingham university. She says welfare is not sufficiently defined and therein lies the problem – if you can’t define it, you can’t measure it. This is unhelpful, she argues, because vets have to make welfare decisions all the time. As a result, there is a tendency for some vets to talk about welfare rather glibly or advise owners about euthanasia in an unspecific way, saying things like ‘you’ll know when the time is right’, but that simply isn’t true or helpful, she says.

Of course, there is recognition within the profession that this is complex territory. Making difficult ethical decisions is highly challenging, especially given the range of scenarios presented to vets. Benchmarks for acceptable levels of animal welfare can be quite different across species and circumstances.

The stakes are also high for vets themselves, as poor decisions can lead to poor animal welfare and that’s a heavy and stressful burden to shoulder. Added to that, there is the ever-present need to work efficiently with high volume caseloads, leading vets to develop pragmatic approaches, with decisions not always underpinned by clear ethical rationale.

It does feel like some guidance could really help vets to come to decisions more satisfactorily and efficiently. In human medicine, for example, the burden of treating depression and anxiety has fallen mainly to GPs. They use scoring systems (PHQ9 and GAD7) to identify and track ill health and progress over time. These are well embedded into their practice and help them manage complex and time-consuming conditions efficiently.

Could something similar be developed to assess quality of life in some animal species? Would it not at least be helpful to agree the key questions that need to be addressed for different species? These could be developed further to agree some additional parameters, such as clinical status of the animal in question. The addition of a scoring system would allow vets to assess, record and evaluate quality of life over time.

This isn’t about designing the perfect gold-standard decision-making tool, but about creating some species-specific guidelines to help vets in their everyday practice. They could even share that process with owners – to make decision-making transparent.

James Yeates, RSPCA chief vet who has published in this area, says such a tool would be a useful way to prompt difficult conversations with clients regarding treatment plans and euthanasia.

Sarah Wolfensohn, professor of animal welfare at Surrey university, is an expert in this area of work. With colleagues, she has developed a software package that can measure quality of life over time. Having developed it as a way of improving the welfare of laboratory animals, she has successfully piloted it in monkeys and birds in zoos and is now seeking to develop it across multiple species. Ultimately, her goal is to offer the profession an app that vets can use to assess and measure the quality of life in animals, both in clinics and on visits.

The programme uses an animal welfare assessment grid, which is based on four parameters (physical wellbeing, psychological wellbeing, environment and clinical status). Each parameter is then scored according to a series of factors. Under psychological wellbeing, for example, behaviour deviations are judged. In monkeys, the presence of alopecia is a factor, but in dogs it could be chewing. It is these factors that need to be informed by species experts.

The ultimate success of this – or any other species-specific quality of life framework – depends on building a professional consensus on what constitutes the key welfare factors or questions for each species.

Veterinary Record would like to advance this area of work. We actively invite vets and veterinary researchers to submit academic papers (at https://mc.manuscriptcentral.com/vetrec) or letters (e-mail: letters@bva-edit.co.uk) sharing their observations and judgements about the most important welfare considerations for their area of expertise. We would encourage experienced specialists to identify the key questions that they use to assess the quality of life of the animals in their care.

There is no question that vets must be free to exercise their professional judgement – that is an important distinction of any profession and this journal would not seek to undermine that. However, given the demand for constant and complex decision-making, it would surely be possible to develop a tool or guidance to support decision-making in this fundamental area of veterinary practice.

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