The goal of EoLC should be to achieve the best quality of life for a patient until a point is reached where its welfare and wellbeing is compromised. This would include repeated or prolonged failure to meet the five needs set out under the Animal Welfare Act [ 5 ] and would also take into account the impact of the side effects of treatment, for example, if analgesia used to control a patient ' s pain was having a profound impact on the patient ' s ability to maintain normal behaviour expected for its species, breed and age. QoL assessments can be used to ascertain when the suffering of the patient( and potentially the owner) can no longer be managed [ 6 ].
During any early discussions of age-related changes and QoL, veterinary professionals must be mindful of the phenomenon of anticipatory grief, that is, grieving before a pet ' s death. Anticipatory grief can bring a range of physical, emotional and mental responses. These may include feelings of sadness, denial and difficulty taking in or processing information [ 7 ]. Anticipatory grief is more likely to occur if an owner reflects on a previous loss.
What is QoL assessment?
In human medicine, assessment of QoL, although a complex process, is much easier than in veterinary medicine, as it is a personal review of an individual ' s experience of life, provided by the patient. In veterinary medicine, QoL assessment is much more challenging and can be subject to heavy bias. However, QoL is commonly considered to be defined by an animal ' s overall wellbeing, considering both physical and mental wellbeing and the animal ' s ability to interact with the environment it is in; this is also referred to as the animal ' s physical, emotional and social needs [ 6 ].
Some owners have clear expectations and limits when it comes to the provision of care and treatment for their pets, which can be the result of previous experience( s), financial constraints or personal values, and the owner ' s views should be respected and acknowledged by the veterinary team, and care for the patient adapted accordingly. For many owners, though, the emotional impact of their pet becoming ill can make care provision daunting and the decision-making process overwhelming. The important thing for all members of the veterinary team to remember is that QoL assessment and EoLC are not‘ one size fits all’ processes. The assessments and aspects of care will need to be adapted for each owner, pet and medical condition.
Resources for QoL assessment
Contrary to popular belief, a QoL assessment does not just focus on the patient ' s appetite, weight and mobility. More difficult considerations are included, such as the owner ' s financial, personal and ethical constraints and what these mean in terms of the veterinary provision. The simplest method of assessing QoL would be to ask owners to list five things their pet enjoys( such as food, walks, etc.) with the view that, when the pet is consistently unable to perform or enjoy these things, QoL and euthanasia may need to be discussed [ 7 ].
A formal QoL assessment considers key behavioural and medical factors for the animal, and rates them on a scale. A cumulative score is then produced, which indicates the patient ' s QoL. Many veterinary practices create their own assessments, but these are often based on the few formal veterinary QoL assessments that have been published.
Ageing Canine Toolkit
In conjunction with BSAVA PetSavers, the University of Liverpool has developed an excellent introduction to the concept of QoL assessment through the Ageing Canine Toolkit [ 4, 8 ]. This simple step-by-step questionnaire is based on a traffic light system( yes = red, maybe = amber and green = no) and requires owners to consider questions covering several health topics. Completion of this questionnaire enables some of the more subtle‘ normal’ age-related changes [ 4 ] to be highlighted, resulting in better provision of care for senior dogs. With the inclusion of a QoL and end-of-life section, this resource is a good way for the veterinary team to support the owners of dogs entering their‘ golden years’. Additionally, the toolkit introduces more sensitive topics, meaning that when QoL does need to be discussed, owners are better informed and may have already considered their limitations as well as EoLC, including provisions for euthanasia if needed. At present, this toolkit exists only for canine patients, but a similar toolkit for cats would no doubt be welcomed.
Although it might appear premature, it would be good practice to introduce owners to this toolkit when dogs reach their‘ senior’ years. This is usually at the age of 7 or 8 years; however, it varies depending on the size and breed, with dogs of larger breeds reaching their senior years earlier than smaller breeds, due to differences in the ageing process and expected lifespan. The toolkit could then be repeated annually by the owner, for example, before the dog ' s booster vaccinations or annual VN health check, and reviewed at their appointment. Practices could then look to increase the frequency of assessment, perhaps to quarterly, when a patient displays an increase in the clinical signs of ageing, if the owner becomes increasingly concerned or the score starts to indicate a deterioration. Completed questionnaires should always be kept as part of the animal ' s records so they are readily available and can be used to enable comparison over time.
Although the Ageing Canine Toolkit is a fantastic and accessible resource, it does not provide the detail required for those patients receiving EoLC.
20 Veterinary Nursing Journal