PETSAVERS PAPER
Assessment of companion animal
quality of life in veterinary practice
and research
OBJECTIVES: Quality-of-life (QOL) assessment is a novel field in
veterinary medicine. It shares similarities with the more established
fields of human QOL assessment and animal welfare science and
could prove similarly useful.
METHODS: This paper draws on existing literature on human QOL
assessment, animal welfare, philosophy and animal QOL
assessment.
RESULTS: It provides practical recommendations for QOL assessment
in veterinary practice and in veterinary research on what should be
assessed, how it should be assessed and who should assess it.
CLINICAL SIGNIFICANCE: These should assist veterinarians intending to
develop their use QOL assessment.
J. YEATES AND D. MAIN INTRODUCTION
Journal of Small Animal Practice (2009)
50, 274–281 Animal quality-of-life (QOL) assessment is
DOI: 10.1111/j.1748-5827.2009.00755.x a central component of veterinary practice,
Accepted: 25 February 2009 but it is still part of the ‘‘art’’ of veterinary
practice. More structured approaches to
QOL assessment are uncommon in veteri-
nary clinical work, and QOL assessment
is a novel discipline in veterinary practice.
The academic literature is limited to
fundamental theoretical analysis and meth-
odological tools in early stages of develop-
ment. There is limited guidance available in
what is an inevitably multifaceted, complex
and controversial matter.
More structured methods of QOL
assessment can be used within veterinary
practice to inform the clinical decision
making and in research to make the results
more meaningful in their application in
decision making. These require the follow-
ing five steps: deciding what is important,
working out what parameters can be
assessed, assessing them, inferring what is
important from the parameters and mak-
ing a decision about actions or recommen-
dations. The second and third can be
informed by scientific methods in animal
welfare science and human QOL litera-
Department of Clinical Veterinary Science,
tures. The first, fourth and last steps require
University of Bristol, Langford House, Stock Lane,
Langford, Bristol BS40 5DU value judgements. Hence, QOL assess-
274 Journal of Small Animal Practice
Vol 50
June 2009
Ó 2009 British Small Animal Veterinary Association
ment in animals needs to draw upon the
disciplines of human QOL assessment,
animal welfare, ethics and philosophy to
provide recommendations for practi-
tioners and researchers hoping to include
more structured QOL assessment in their
case management or research.
A fundamental desire to improve an ani-
mal’s QOL is a central goal of veterinary
practice for all parties involved and is
a major concern for owners (Mellanby
and others 2003, Chang and others
2006). Yet veterinary work may not always
truly achieve such a goal. Interventions
dealing with improving issues for owners,
such as incontinence treatment for hygiene
reasons, aim more at client satisfaction than
animal QOL. The monitoring of condi-
tions using biological parameters, such as
biochemical results, risks treatments being
directed at improving that parameter ra-
ther than the QOL for the animal. Further-
more, in all veterinary work, more QOL
improvements might be achieved by con-
sidering other aspects of the animal’s life
that may be more important for the animal
than the presenting problem. The use of
specific QOL assessment approaches can
increase the scope of considerations to
cover all the aspects of an animal’s life that
are important to that animal. Additionally,
formalising QOL assessment can help
describe the benefits of treatments in
a meaningful way both for individual cases
and in scientific reports.
This paper discusses how to increase the
benefits of QOL assessment for animals by
ensuring that its scope and methods truly
reflect what is important for the animal.
The paper considers four important ques-
tions: when to assess QOL, what to assess,
how to perform assessments and who can
best assess it.
WHEN QOL ASSESSMENT
IS USEFUL
Human QOL assessment is considered
a primary value in decision making by

clinicians in individual cases, clinical audit
and clinical governance (Sanders and
others 1998). It is used to ensure that treat-
ment goes beyond improving health and
is actually beneficial to the patient (Bradley
2001), avoid paternalism (Detmar and
others 2002), provide prognostic indica-
tors (Rumsfeld and others 1999, Kaplan
and others 2007) and assess client per-
ceptions of illness and treatment. Further-
more, studies on human QOL assessment
have suggested that it can improve clini-
cian-client relations and client satisfaction
with treatment (Kumar and others 2007).
For example, Griffiths and others (2007)
used a participatory tool on human
patients and found that it built ‘‘relation-
ship and confidence in the service user that
they are being listened to’’. Perhaps as
a result, QOL assessment can improve
compliance with treatment recommenda-
tions (Anderson and others 1999, Awad
and Voruganti 1999, Kumar and others
2007).
There are several cases in veterinary
practice for which QOL assessment is likely
to be especially useful. QOL assessment
can be used to screen for issues, that is, iden-
tify QOL concerns that had not been
perceived by an owner. This may be partic-
ularly useful as a component of routine
geriatric screening. Indirectly, QOL assess-
ment may also be a good way for practices
to legitimately encourage owners to con-
sider matters such as obesity, parasite
control, analgesia, geriatric concerns, sepa-
ration-related behaviours and exercise.
QOL assessment may be useful in mon-
itoring changes in QOL over time, espe-
cially chronic cases where subtle changes
may benefit from more formal approaches.
Treatment choices that are likely to signif-
icantly impact on QOL, such as chemo-
therapy and analgesia, may benefit from
explicit assessment of QOL. In veterinary
practice, euthanasia decisions often involve
elements of QOL assessment, specifically
in assessing whether the animal’s life is
worth living or not. It may also be a sincere
way to increase customer involvement and
satisfaction.
In addition, the process of assessment
may also have beneficial effects on patient
QOL. The assessment itself (not just the
result) can raise awareness of the broad
scope of issues that may affect an animal’s
Journal of Small Animal Practice
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Ó 2009 British Small Animal Veterinary Association
QOL assessment in veterinary medicine
QOL. As QOL aims to identify aspects of
the animal’s life that is important for it, this
may be different or encompass more issues
than are considered by the health care pro-
fessional whose primary focus may be the
specific health-related outcome they
believe they are tasked to solve.
In veterinary research, QOL assessment
can be useful to monitor both longitudinal
changes over time and comparisons
between treatment groups. For example,
Craven and others (2004) observed a highly
significant association of owner-rated
QOL and outcome, concluding that
‘‘owner perceptions are a valid aspect of
disease monitoring’’. QOL assessment
additionally assists in ensuring that
research provides meaningful patient-
related outcome measurements beyond
the traditional clinical and pathological
assessments. This allows results to be rep-
resented to clinicians and clients in ways
that are directly relevant to their decision
making.
Research areas where QOL assessment
will be important include all in which an
intervention may be hypothesised as hav-
ing deleterious or beneficial QOL effects.
It is especially appropriate for those that
are palliative or expected to have relatively
low chances of effecting a cure, such as che-
motherapeutic protocols (Mellanby and
others 2003, Tzannes and others 2008),
or those where the aim is to improve
QOL rather than life expectancy. The eval-
uation of novel surgeries or treatment
regimes should include assessment of antic-
ipated QOL effects and screening for unex-
pected negative QOL effects from the
novel treatment protocols. This may
become especially significant in clinical
trials.
WHAT TO ASSESS?
The question of what is QOL is a deep phil-
osophical matter that has been debated
since ethics began. The authors suggest that
animal QOL can be best approached prac-
tically by firstly deciding what is important
for the animal, and secondly by working
out what parameters can be assessed for
use in making decisions. This is a combina-
tion of assessing those qualities of a life
from the animal’s point of view and the
assessment from the observer’s point of
view. This combination is necessary: the
first half alone could lead to futile attempts
to know absolutely everything from the
animal’s point of view, whereas the latter
half alone could lead to reducing the con-
cept of QOL to what can be observed from
the outside rather what actually matters to
the animal.
Characterising QOL assessment in this
way establishes the kind of questions that
need to be asked. These are complex ques-
tions but assistance is available from more
established paradigms. Many authors
argue that one can meaningfully compare
human and animal QOL (Appleby and
Sandøe 2002, McMillan 2003). Others
consider that animal QOL and animal wel-
fare are similar or equivalent (DeGrazia
1998, Fraser 1998, Mullan and Main
2007, Wojciechowska and Hewson
2005). The approaches used by human
QOL and animal welfare science cannot
be applied unthinkingly. Human QOL
uses many anthropocentric terms (Bowling
2005, pp. 125-126), such as happiness,
subjective well-being and life satisfaction
(for definitions see Diener 2006), the
uncritical use of which is unsuitable for ani-
mal assessments. Animal welfare science
has been appropriated by scientific and eco-
nomic demands in a way that makes it less
suitable for clinical QOL assessment. Fur-
thermore, there is no universally agreed
method of assessing either human QOL
(Bowling 2005) or animal welfare
(Appleby and Sandøe 2002, Nordenfelt
2006).
These considerations, and analysis
of the human QOL and animal welfare
literatures, suggest two main types of app-
roach to animal QOL assessment: mental
state approaches and external parameter
approaches. The first is more subjective,
the latter more objective, but both
approaches involve subjective and objective
elements, and this represents one balance
that needs to be appropriate to the purpose
of the specific assessment. The ideal
approach may be concerned with mental
states but, in practice, external parameters
can be the only assessable QOL parameters.
Mental state approaches concentrate on
attempting to evaluate the feelings and
emotions of the animal. Important experi-
ences include pain and suffering, and some
275

veterinary research has assessed such indi-
cators (Hellyer and others 2007). Other
more positive experiences, such as pleasure
and enjoyment and relationships and con-
trol, are also valuable (Yeates and Main
2008). This can involve questions aimed
specifically at tapping the respondent’s
empathy. For example, Tzannes and others
(2008) asked the owner how they thought
their cat would rate its QOL during ther-
apy, and Mullan and Main (2007) asked
owners how willing they would be to take
on the life their pet is now living.
The main advantage of mental state
approaches is that they address what directly
matters from the animal’s point of view.
This approach is the central goal of human
QOL assessment (Schwartz and Rapkin
2004), and animal welfare science is also
increasingly making attempts to infer ani-
mals’ experiences (Duncan 1996, Spruijt
and others 2001). Furthermore, mental
states approaches, by encouraging reflection
andempathy,mayalterassessors’behaviour,
leading to improvements in the animal’s
QOL. This can make QOL assessment as
both a measurement and an intervention.
One disadvantage of mental state
approaches is that, because animals
cannot self-report as human patients can,
they necessitate the assessor having to
‘‘mind-read’’ the animal and convert their
observations into linguistic or quantifiable
parameters. This necessitates using proxies,
such as owners, veterinarians, nurses, or
other professionals. Different proxies are
likely to have different response styles
(Jokovic and others 2004, Davis and others
2007), and it might be expected that
they will assess subjective elements of
animal QOL differently. Many human
QOL tools, especially those designed for
children, are designed in self- and proxy-
assessment formats (David and others
2006), and comparing results from each
reveals significant disagreements between
assessments. In different cases, proxies
rated QOL higher or lower than patients
to varying extents (Sprangers and Aaron-
son 1992, Chang and Yeh 2005, Jozefiak
and others 2008). Differences can depend
on the illness (Varni and others 2006, Wil-
son-Genderson and others 2007) and the
facets considered (Eiser and Morse 2001,
Hexdall and Huebner 2007). One veteri-
nary research paper incidentally reported
276
J. Yeates & D. Main
some differences between proxies in assess-
ing demeanour (Graham and others 2002).
Such discrepancies may represent signifi-
cant concerns about the validity of either
group of responses, or it may be that
disagreements are over-represented in
literature. Their existence in veterinary
contexts is unstudied. It may, however,
be significant in research, and the use of
a single consistent assessor warranted for
reliability.
External parameters approaches focus
on parameters that can be directly observed
from the outside. External parameters may
concern the provision of ‘‘inputs’’ to an
animal’s QOL and ‘‘outcomes’’ other than
experiences (Appleby and Sandøe 2002).
Important inputs might include levels of
care (Marinelli and others 2006) and ther-
apy (Föllmi and others 2007) and the ani-
mal’s environment (Ng and others 2005)
and its social interactions (Bengtsson-Tops
and Hansson 1999, Marinelli and others
2006). Inputs also include the characteris-
tics of the individual including its breed,
physical condition and health (Marinelli
and others 2006, Wojciechowska and
Hewson, 2005). Non-experiential out-
comes include achievements (Parfit
1984, Keyes and others 2002), (un)natu-
ralness (Rollin 1996, Alrøe and others
2001) and biological functioning or pro-
ductivity (Barnett and Hemsworth 1990,
Broom and Johnson 1993, Moberg and
Mench 2000, Gregory 2004).
The use of external parameters may be
more useful for researchers, especially in
cross-sectional studies. External parame-
ters are directly observable and there is
likely to be greater agreement between
individual proxy assessors. In practice, they
are cognitively less demanding for asses-
sors, and directing assessors to look at spe-
cific inputs may actively encourage better
provision of those inputs. Some veterinary
studies have usefully assessed particular fac-
ets of QOL. Graham and others (2002)
assessed QOL by the use of two parameters,
demeanour and activity. Their study con-
sidered diabetes mellitus, for which these
are especially relevant facets. Lod and
Podell (1999) asked about changes in the
animal’s attitude and activity level since
before treatment, and Chang and others
(2006) also assessed particular aspects of
QOL by asking owners about changes in
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Ó 2009 British Small Animal Veterinary Association
their pet’s level of activity and interaction
with family members.
However, it must be remembered that
external parameters are indicators; they
should not be taken to be QOL. To rede-
fine QOL as what we can observe from the
outside would be erroneous. External
parameter approaches involve controver-
sial assumptions and subjective judgements
in deciding what inputs or outcomes are
important. There is a risk that assessors
choose external parameters that are less
important, or even irrelevant, from the ani-
mal’s point of view simply because they are
more objective and assessment of overall
QOL would be consequently skewed by
the underlying assumptions.
HOW TO ASSESS QOL
The central question considered in this
paper is how QOL assessment can be
approached. General approaches range
from being almost totally unstructured
and qualitative to being completely formal-
ised, quantitative measures.
BROAD OPEN QUESTIONS
Owners often unreflectively evaluate their
animal’s QOL based on prereflective
empathy and intuition and their first-hand
experience of their animal. This ‘‘gut feel-
ing’’ can be easily tapped by qualitative
assessments in a non-systematic way, with-
out using predetermined structures. One
example is the use of open questions such
as ‘‘How do you think your [animal] would
rate its quality of life?’’ (Mullan and Main
2007, Tzannes and others 2008). In prac-
tice, these questions can also be less explicit
and questions such as ‘‘How is your dog at
the moment?’’ and ‘‘How’s your cat getting
on?’’ may generate useful responses.
These can be quantified in different ways.
Craven and others (2004) recorded overall
QOL for dogs with inflammatory bowel
disease as rated by their owners on a one
to 10 numerical scale. Similarly, Tzannes
and others (2008) asked owners to record
their cat’s QOL on a 10-point scale, with an-
chors of ‘‘could not be worse’’ and ‘‘could
not be better’’. They also asked separate

questions about whether each cat had always
good days, always bad days or more good
days than bad days or vice versa and how
the owner thought the cat would rate its
QOL during therapy, thereby providing
three parameters to triangulate. Mellanby
and others (2003) recorded owner-rated
QOL in a three-point scale of ‘‘the same
as before the condition, ‘‘acceptable but
not as good’’ and ‘‘unacceptable’’ and asked
owners whether or not therapy improved
their dogs’ QOL and about side effects.
A different style was used by Chang and
others (2006), who asked owners to record
how well they agreed with the statement
‘‘My dog’s quality of life is good’’ on a visual
analogue scale and whether QOL had
changed. Similarly, Lod and Podell (1999)
assessed owner’s assessment of their animal’s
overall QOL, attitude and activity by asking
owners the extent to which they agreed with
statements such as ‘‘[their dog] is leading an
unacceptable poor quality of life’’. While
phrasing such as ‘‘unacceptable’’ does not
preclude this response being selected, such
emotive and value-laden terms might be
thought to reduce its likelihood. An owner
answering that they think their animal’s
QOL to be ‘‘unacceptable’’ could make
them feel vulnerable to censure, guilt and
even prosecution for not having had their
animal euthanased despite it having an
‘‘unacceptable’’ QOL. Indeed, between
two studies in which it was used only one
respondent gave this response (Lod and
Podell 1999, Mellanby and others, 2003).
Broad open questions can be further
used to prompt further questions to explore
the animal’s mental state and external
parameters. If the owner reports a dog as
‘‘a bit off colour’’, more specific questions
can be used that focus in on the relevant
mental states and observable behaviours,
such as ‘‘What behaviours have you seen
that makes you think that?’’ or ‘‘Do you
think the dog is in pain?’’. Similarly, if
the owner describes a certain token of
behaviour such as ‘‘slower during walks’’,
the discussion can focus on the possible
mental or physical states, for example
whether it is because of pain (mental state)
or weakness (that is a physical parameter).
Ideally, the practitioner can think what
mental state aspects are important, a rele-
vant question formulated about relevant
external parameters, the answers gathered
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QOL assessment in veterinary medicine
and an inference about the mental state appropriate research questions. These can
made. This is especially useful in practice, structure the closing of open questions or
but can also be used in research. Item to generate questions in the first instance.
response theory, as described below, can The three concepts (mental, physical
allow follow-up questions within formal and natural) used with the various defini-
tools. Less formally, qualitative questions tions of animal welfare (Fraser and others
by researchers can add meaning for practi- 1997) can be useful for asking fundamental
tioners. For example, Chang and others questions about an animal’s QOL. The
(2006) provided additional information mental aspect implements the mental state
for practitioners by recording reasons approach above. The physical and natural-
stated for deterioration in overall QOL. ness aspects are external parameters. Phys-
This approach can be highly specific to ical states refer to the function of the animal
the individual animal and allow the owner in terms of biology and health. Naturalness
to use information and intuition at their assesses the external parameters in relation
disposal. A disadvantage is that the method to how well they correspond to an animal’s
is highly subjective and the question itself is nature. An intervention may affect each
vague and ambiguous both in terms of differently and these assessments may con-
which facets should be included and how flict. For example, reducing an animal’s
they should be subjectively aggregated. anxiety with a tranquilliser in a particular
Consequently, the assessment of each ani- environment may have a beneficial effect
mal will vary with the response style of each on the animal’s mental state, but the ani-
owner because each will understand and mal’s inability to respond normally may
approach the question differently, and each reduce its ability to cope biologically and
owner may have different relationships is less natural than an animal responding
with their animals. appropriately. Thus, the approach does
not provide a definitive answer but is more
a means to generate considerations and rel-
FRAMEWORK QOL evant questions.
ASSESSMENTS The ‘‘Five Freedoms’’ are a well-
established framework (Farm Animal
The frameworks presented in Table 1 can Welfare Council 1993) and, although
be used in consultations or to provide developed for farm animals, they can
Table 1. Possible approaches to QOL assessment
Three concepts framework (Fraser and others 1997)
This approach distinguishes three different conceptualisations of animal welfare
Physical – biological states of animals are measured (for example physical, physiological and
pathological characteristics)
Mental – emotional states of animals are considered
Natural – the states of an animal (for example behaviour) is compared with its wild
counterparts
Five Freedoms (Farm Animal Welfare Council 1993)
This approach combines elements of the three different concepts of animal welfare
Freedom from hunger and thirst by ready access to fresh water and a diet to maintain full
health and vigour
Freedom from discomfort by providing an appropriate environment and a comfortable resting
area
Freedom from pain, injury and disease by prevention or rapid diagnosis and treatment
Freedom to express normal behaviour by providing sufficient space, proper facilities and the
company of the animal’s own kind
Freedom from fear and distress by ensuring conditions and treatment which avoid mental
suffering
Input assessment
This approach concentrates on the external parameters
Carer
Environment
Animal
Affective assessments (McMillan 2003, Morton 2007)
These approaches concentrate on the experiences of animals
Positive feelings
Negative feeling
277

be applied to companion animals. They
represent a combination of both mental
state and external parameter approaches.
It can be useful for practitioners to infor-
mally consider each freedom separately to
establish what the animal’s needs are and
whether they can still be fulfilled. Inassessing
the impact of sudden onset blindness, for
example, it can remind veterinarians to con-
sider whether access to food and water are an
issue, whether the blindness leads to fear or
distress and whether it prevents the animal’s
normal behaviour, such as companionship
with people and other dogs, and exploratory
behaviour during walks. The Five Freedoms
can be related to care of the animal by con-
sidering what resources are necessary to
ensure satisfaction of the identified needs.
An input-assessment framework can
assist in focusing on whether the animal’s
QOL can be improved by providing differ-
ent resources. Such resource factors that
can influence QOL can be related to the
(1) carer (for example knowledge, skills
and attitude), (2) environment (for exam-
ple food, lying area and space) and (3)
animal itself (for example breed and tem-
perament). This approach can be usefully
combined with the Five Freedoms as it is
useful to examine what carer, environment
and animal factors are necessary to provide
for each QOL aspect defined within the
Five Freedoms. For example, improve-
ment of separation-related distress may
be achievable by different handling or
training by the carer, altering the environ-
ment in which the animal is separated
and altering the personality of the animal
itself.
The affective assessment frameworks,
which consider the negative and positive
experiences of an animal, provides an
assessment of what matters directly.
McMillan (2003) has produced a quick list
of questions that relate to positive and neg-
ative feelings. Consideration of positive
experiences can be easily overlooked during
the management of chronic illnesses as the
focus of the intervention is normally
focused on managing the negative con-
sequences such as pain. Yeates and Main
(2008) proposed a framework for consider-
ing positive experiences based on (a) ple-
asures (eating, play, tactile pleasure,
exercise, sleep, and thermal comfort), (b)
engagement (curiosity, novelty, confi-
278
J. Yeates & D. Main
dence, optimism and contact with other
animals, humans, objects) and (c) realisa-
tion (achievement, space and opportunity).
FORMAL ASSESSMENT TOOLS
More objective assessment methods may be
more suitable for researchers or clinicians
who require qualitative data. Assessments
of different facets can be structured, usually
in a questionnaire-style format, and these
can be aggregated together to assess overall
QOL either by the subjective interpreta-
tion of the veterinarian or by predeter-
mined formal methods. These can be
based on responses from a single proxy
or can incorporate the responses from own-
ers and members of the veterinary team.
There can be considerable work
involved in administering more formal
tools for use in human QOL assessment:
selecting or designing tools, distributing
tools, assisting respondents where neces-
sary, collecting responses, validating
responses, data entry, analysing and inter-
preting results and determining further
action (Bliven and others 2001, Jones
and others 2007). In a veterinary context,
the use of tools might also indirectly add to
workload by increasing requests from own-
ers for further information. On the other
hand, appropriate use of QOL tools may
decrease veterinarians’ workload. Precon-
sult screening by owners in the waiting
room or in nurse clinics may be used to
increase efficiency during history taking.
The pain assessment tools (Holton and
others 2001, Wiseman-Orr and others
2004) are intended for both practical and
research settings. Their scope is largely
restricted to pain assessment. Assessors give
scores on number of external parameters
based on their observations of the animal’s
behaviour, and the overall assessment pro-
vides a summative inference about the ani-
mal’s mental state. By making assessment
consistent, the tool increases both intraob-
server and interobserver reliability. Valid-
ity has been demonstrated in several
settings. One main advantage is that it
allows quantitative assessment. One main
disadvantage is the time costs.
Morton (2007) proposed a numerical
scoringsystemthatinvolvedassessingbehav-
ioural parameters that may infer positive and
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Ó 2009 British Small Animal Veterinary Association
negative mental states. The obvious advan-
tage is that the quantitative system could be
used to measure longitudinal change in an
individual animal or cross-sectional varia-
tion in research protocols. A weakness is that
it may not engage the assessor and, until it is
validated, the possibility of subjective varia-
tion may cause scepticism over the validity of
the numerical scoring system.
The QOL screening tool (Mullan and
Main 2007) has different sections for asses-
sors to rate inputs, subjective assessment of
mental states and behavioural parameters.
It includes a summary of the pain assess-
ment tool of Wiseman-Orr and others
(2004). It is not intended to compare
between dogs and is therefore inappro-
priate for cross-sectional research. In the
practice setting, it may be useful for screen-
ing for issues and encouraging reflection on
how the animal’s care could be improved.
Its benefit is increased by its combining
a number of approaches from a wide scope
of concerns, but this comes with significant
time costs.
A possible future development for veter-
inary QOL includes the use of item banks
and item response theory (Hays and others
2000, Ware and others 2000, Bjorner and
others 2007, Edelen and Reeve 2007, Mar-
tin and others 2007, Reeve and others
2007). In such methods, follow-up ques-
tions are selected from a stock, based on
the respondent’s responses to previous
questions and according to an algorithm.
This allows particular respondents to give
detailed information without the same
questions being asked of respondents for
whom they would be irrelevant.
The choice or design of tool involves
balancing different demands. Although
those who develop tools will favour those
tools (Hyland 2002), there is – and can
be – no such thing as an absolute, perfect
QOL approach. Each tool has its limita-
tions (Scientific Advisory Committee of
the Medical Outcomes Trust 2002). Tools
should be chosen for a balance of sensitivity
(responsiveness for longitudinal tools and
discrimination for cross-sectional tools),
range, reliability, subjectivity, specificity
(for example to individual); universality
and feasibility that is appropriate for
the use.
As with the general approach, the choice
of tool should depend on the purpose of

the assessment. The existence of over
a thousand different human patient-related
outcome measures (Bielli and others 2004)
is partly because of the increasing recogni-
tion that tools must be appropriate to the
specific needs of the clinician. Approaches
should be appropriate to the patients
(breed, age and conditions), to the owners
(feasibility, cognitive abilities, demograph-
ics of client, response style, including any
shift in responses, etc.), to the administra-
tor (feasibility and knowledge) and to the
purpose of the assessment and use of the
information once it is gathered.
PARTICIPATORY TOOLS
The use of a more interactive participatory
assessment tool is rare in veterinary practice
but may be a development of the frame-
works and formal tools. These can maxi-
mise the usefulness of the first-hand
experience and empathy of the owner,
while increasing and directing their ref-
lection. Studies have shown that partici-
patory methods based on dialogue or
pictorial responses can be valid and reliable
(Griffiths and others 2007) and can
improve reflection and clinician-client dia-
logue and relations. In addition ‘‘think-
aloud’’ techniques can allow researchers
and clinicians to understand the bases
and significances of the owner’s prereflec-
tive assessments (Jobe 2003). No such tool
currently exists for veterinary practice, but
work is currently underway to develop such
approaches.
WHO CAN BEST ASSESS QOL?
The impossibility of self-assessment, the
unavoidability of subjectivity and the dis-
agreements between proxies mean that
the identity of the QOL assessor is an
important question for veterinarians. Can-
didate groups of proxies include the own-
ers, veterinarians, nurses and researchers.
The disagreements between these groups
should not be taken to mean that any
one group of assessors is wrong. Each proxy
provides separate, independent informa-
tion (Higashi and others 2005, Varni
and others 2007) and each will have
strengths and limitations.
Journal of Small Animal Practice
Vol 50
June 2009
Ó 2009 British Small Animal Veterinary Association
QOL assessment in veterinary medicine
Where objectivity or reliability is espe-
cially desirable, trained clinical staff may
be the most suitable proxies. Veterinary
surgeons will generally have more experi-
ence of more structured QOL assessment
than owners. Veterinary nurses can spend
more time than surgeons with inpatients,
but rarely with outpatients. Assessment
by veterinary surgeons and nurses can also
help them to avoid over-treatment and
improve the meaningfulness of their advice
to owners.
In comparison, owners will have more
experience of the individual animal
(McMillan 2003). They often know the
animal’s history and spend more time with
it in a greater range of environments and
activities than the veterinary staff could fea-
sibly achieve. This allows them both more
objective knowledge of the animal’s exter-
nal parameters and more awareness of how
these matter from the individual animal’s
point of view. This may be especially
advantageous when greater specificity or
range is required, such as screening or
assessing longitudinal changes in individ-
ual cases. Assessment by owners may
increase their level of reflection concerning
their animal. This can help owners to per-
ceive problems or improvements, which
may lead to desirable behaviour changes.
For example, parental QOL assessment
can determine whether children receive
medical care (Janicke and others 2001)
and the same is plausible in the veterinary
context.
The limitations of each proxy might be
partially offset by combining the strengths
of different proxies in various forms of joint
assessment (Föllmi and others 2007). This
can be performed by one proxy with some
strengths formalising the style of response
remotely, for example by acting as a tool
designer, and another proxy completing
the specific assessment. This approach
has been used in determining pain in dogs
(Holton and others 2001, Wiseman-Orr
and others 2004). Alternatively, joint
assessment can involve face-to-face dia-
logue between parties, which may improve
mutual respect and cooperation. Graham
and others (2002) used this approach for
assessing patients’ activity, which was
scored by the veterinarian after discussion
with the owner.
DISCUSSION
Although QOL assessment is now fairly
well established in human medicine, the
introduction and development of any
QOL assessment method in veterinary
practice and research is dependent upon
demonstrating its feasibility and benefits
to potential users, in terms of time, money
and ease. If a method is not considered fea-
sible, then it is unlikely to be implemented.
Another barrier may be scepticism about
the benefits. This may be because of
unawareness of the possibilities. In some
cases, this is deliberate, as some vets con-
sider themselves to be concerned with
health, rather than QOL, or they may
equate QOL with health. Other practi-
tioners may consider that their informal
methods of QOL assessment, developed
over hundreds of consultations, cannot
be improved. Other veterinary surgeons
may be concerned about QOL but perceive
limited value in the existing measures and
feel unable to develop novel ones them-
selves.
These problems will hopefully improve
as time goes on. Vets may become incre-
asingly aware that their area of expertise
and responsibilities to animals go beyond
health-related matters. In other aspects of
practice, such as consulting and public rela-
tions skills, more vets are realising that
unreflective or informal methods can be
improved and that consulting room skills
can be learnt by methods other than tri-
al-and-error, and this mindset may encour-
age vets to develop QOL assessment skills
and to share their experiences with others.
For example, Mellanby and others (2003)
were usefully explicit about ways that their
assessment could have been improved. Per-
ceived value may be improved as more
approaches are developed and propagated.
However, the idea of an absolutely per-
fect QOL measure that takes no time is
completely comprehensive and is without
controversial assumptions is unrealistic
(Hyland 2003). Despite the extensive
research field, there is no universally agreed
method of assessing human QOL (Bradlyn
and others 1995, Clarke and Eiser 2004). It
is therefore important that an approach to
animal QOL assessment has a balance of
limitations and benefits appropriate to
279

the purpose of the assessment. This balance
is of primary importance in deciding what,
who and how to assess animal QOL.
The impossibility of an absolute, perfect
QOL tool should not prevent clinicians or
researchers from using and developing
existing tools. Many of the advantages of
QOL assessment can be achieved by any
QOL assessment. Asking both staff and
owners simple questions such as ‘‘How is
[your] dog’s QOL?’’ may encourage subjec-
tive, individual-based reflection, improve
client satisfaction and ensure that medicine
is always in the interests of its patients. The
feasibility of simpler methods can offset the
possible lower statistical reliability and
objectivity. The advantages of more sophis-
ticated tools can enhance veterinary QOL
assessment further and clinicians and
researchers designing or selecting tools to
maximise the benefits of QOL assessment
should use the best theoretical bases and
methodological approaches available.
However it is performed, companion
animal QOL assessment represents an
excellent opportunity for small animal vet-
erinarians to reflect upon what is important
for animals, and what is important for vet-
erinarians to assess.
Acknowledgements
The authors thank Martin Owen and
Michael Stevenson for reading drafts of this
article and Petsavers which has funded
James Yeates’ residency in animal welfare,
ethics and law.
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293-300

Petsavers Dog Quality of Life Project

Advising owners on how to improve their animal’s lives is a fundamental desire

of veterinary practice. James Yeates, the Petsavers funded resident in animal
welfare, ethics and law will soon be contacting BSAVA members regarding
a newly funded Petsavers project. This project will investigate important
issues, as perceived by vets, and look at ways of improving these issues.
BSAVA members will shortly be contacted by email and provided with a link
that will lead them to a two-page questionnaire (which should take about four
minutes to complete). Vets will be asked to share their opinions on issues
concerning particular species. If you are not a BSAVA member but would like to
contribute to the discussion you can contact James Yeates -
james.yeates@bristol.ac.uk - for further information.

Journal of Small Animal Practice
Vol 50
June 2009
Ó 2009 British Small Animal Veterinary Association 281