Viewpoint articles represent the opinions of the authors and do not represent AVMA endorsement of such statements.
Introduction
Pets provide their families with companionship and support. Intuitively, we believe that having a pet as a member of our family is overwhelmingly positive. However, having a pet also comes with responsibilities, and research has shown that pet ownership affects individuals and families differently.1 A pet owner’s perception of and ability to cope with those responsibilities may depend on the owner’s circumstances and stage of life as well as the pet’s stage of life.2,3 When a pet’s needs increase, as is the case with illness or injury, the stresses inherent in pet ownership are accentuated. Pets are completely dependent on their owners to provide for their physical and behavioral welfare, make informed decisions about medical care4 and bear the financial responsibility for it, take them to appointments and follow up with treatments at home. Caring for a pet with a medical condition or behavioral challenge affects a family in many ways, and decisions about a pet’s care can impact the well-being of the family.5
Previous publications have advocated for veterinarians to present clients with a spectrum of diagnostic and treatment options ranging from “technologically advanced and expensive interventions to less advanced and less costly options.”6 It has also been proposed that the veterinarian discuss treatment options and evidence-based data about outcomes that are in accordance with the family’s goals of care for their pet.7 These previous publications focus primarily on the pet’s physical health and welfare. While a pet’s health and welfare are the primary drivers of pet owners’ veterinary care decisions, additional factors are also important. Commonly cited factors include the family’s available financial resources,8,9 the time the family can devote to the pet’s treatment based on work and school schedules and other responsibilities,10 and the pet’s tolerance for separation from the family, the stress of a hospital stay, and travel to multiple medical appointments.5 Beyond these, a family may consider an extensive set of unique pet and family characteristics and circumstances in choosing a course of diagnostic testing and treatment. When considering all of these factors, pet owners are evaluating their Family Quality of Life (FQoL).
FQoL in human health has been described as the “dynamic sense of well-being of the family, collectively and subjectively defined and informed by its members, in which individual and family level needs interact.”11 For many families, pets are an integral part of the family structure12 and must be included when evaluating FQoL. We have found no specific literature directed toward veterinarians about FQoL and its impact on veterinary care decisions. Veterinarians lack guidance on how to incorporate the FQoL concept into discussions with clients and support resulting care decisions. Literature on FQoL theory in human disability studies discusses the intersections of individual factors, family factors, and outside structures such as governmental agencies and non-profit organizations.11,13 Based on this model, we propose three inter-related domains be considered in FQoL for pet care decisions: 1) pet-centric factors including the pet’s medical condition and mental health, 2) family-centric factors including how decisions will affect individuals, other pets, and the family as a unit, as well as the family’s resources, culture, values, and history, and 3) external factors such as housing restrictions, social service provider requirements and animal control regulations (Table 1).
Examples of domain-specific factors that influence Family Quality of Life.
| Pet-centric | Family-centric | External |
|---|---|---|
| Medical condition/prognosis | Financial resources | Social support-family/friends |
| Cognitive function | Time constraints | Housing/landlord |
| Behavior | Lived experiences | Social services/case workers |
| Quality of Life | Culture, values | Law enforcement/animal control |
With increasingly advanced and costly veterinary diagnostic and treatment capabilities available, families must often make exceedingly complex choices. Veterinarians may falsely see the choice as binary; a family may choose what is best for the pet or what is best for the people.14 This perception may be reinforced if the family chooses not to volunteer information about their circumstances, which is their prerogative and may be more likely with circumstance that that they fear may reflect negatively on them. If the family does disclose details about their situation, the veterinarian remains unable to accurately assess FQoL as an outsider since it is dependent on the subjective assessments of the individual family members.11,15 When FQoL is considered, the binary is broken down and it becomes apparent that the interests of the pet and the people are not in opposition to one another, but rather are both factors in what is best for the family holistically.
Many veterinarians consider it their duty to advocate for their patients by encouraging owners to pursue the course of treatment perceived to offer the best medical outcome for the pet. This is often the most advanced and costly option.6,16 When pet owners do not opt for the veterinarian’s primary recommendation and the veterinarian must provide care that they perceive as offering an inferior medical outcome, it creates an ethical dilemma for the veterinarian and may result in the veterinarian experiencing moral distress.17–19 Understanding that decisions about the pet’s care are made by balancing positive and negative influences on FQoL may decrease this moral distress,18 whether the recommendation is for treating serious disease and end of life care or for less serious, more frequently treated conditions.20 Reframing veterinary care decisions in the context of FQoL may give veterinarians the confidence and motivation to proactively offer and provide alternate evidence-based options.4
When veterinarians and owners acknowledge the role FQoL plays in decision-making, the result may be a less stressful experience for clients and veterinarians and increased trust between them. Discussing FQoL and supporting its consideration may decrease a family’s guilt or self-judgment when the path forward considers family members’ interdependencies with the pet and therefore the overall effect of pet care decisions on the family.4 Being aware of the myriad of factors that make up FQoL and its importance can increase veterinarians’ and their teams’ empathy toward clients and allow them to assume positive intent when there is no evidence to the contrary.21 Veterinarians benefit by decreasing their moral distress, decreasing burnout, and increasing their awareness that they are helping families. When veterinarians trust that families are making the best decisions based on FQoL,4 the relationship between the veterinarian and their clients will be strengthened and families will feel accepted and supported and will be comfortable moving forward with current recommendations and seeking veterinary care in the future.
Throughout this paper, we will discuss in depth each of the 3 primary domains of pet care related FQoL that we have proposed in more detail to provide insights into how pet owners make care decisions for their pets. We will also present case examples that highlight common decision-making dilemmas for families. These insights may help veterinarians discuss FQoL with clients when providing treatment options, understand and accept client care decisions without judgment, and feel less moral distress and anxiety about providing the course of veterinary care a family chooses.
Pet-centric Factors
Families may think of the pet’s health in terms of their quality of life (QoL). Historically, QoL scales for pets have been applied to end-of-life decisions and disease-specific QoL evaluations have been used to monitor response to treatment. However, the concept of QoL applies to pets in any life stage.22 When thinking about the pet’s QoL, the owner may think in broad terms about the pet’s happiness23: whether they are perceived to be currently happy and whether they will continue to be happy in the future based on the information provided by the veterinarian. Owners may consider the pet’s happiness to be tied to activities they enjoy and their interaction with family members. If those activities are no longer possible, the owner may consider the pet’s QoL to be extremely diminished and that will in turn affect FQoL. This is especially true if it is a shared experience enjoyed by the pet and the family.10 In Case 1, Beau’s decreasing interaction with the family is a primary factor in the decision-making process (Supplementary Table S1).
In addition to a pet’s medical condition, owners may factor in the pet’s behavior when considering diagnostic or treatment options and evaluating the pet’s QoL and FQoL.24 One aspect of the pet’s behavior that may directly impact treatment decisions is the ease with which the pet can be medicated. Does the pet take oral medication easily? Does the pet accept injections or the administration of subcutaneous fluids at home? In Case 2, a chaotic situation was created in the home because Willow was not amenable to taking the prescribed medications (Supplementary Table S2).
A significant pet behavioral and mental health concern arises when a pet is anxious or afraid and exhibits signs of stress resulting in a decreased FQoL, not only because the pet’s QoL is diminished, but also because witnessing this is upsetting and stressful for the family. When such behaviors are associated with infrequent circumstances, owners may believe the situation is tolerable for the pet5 and the family and there is minimal negative affect on FQoL. However, when a pet is consistently stressed or afraid, or suffers from severe anxiety that persists despite attempts at intervention, the pet’s mental health status may significantly decrease the pet’s QoL and FQoL. In Case 3, Kaylee’s anxiety was a major consideration in the owner’s decision not to pursue advanced treatment which would have required serial office visits and multiple stays at the hospital (Supplementary Table S3).
Owners have unique insights4 into how their pet is feeling and are often aware of subtle changes in their daily activities that would not be apparent during a clinic visit. This includes changes in the pet’s pattern of eating and drinking, urination and defecation, and activity level and mobility. Owners worry about whether their pet is physically comfortable or in pain15 and how the pet’s status will change over time.10 Owners may also anticipate how progression of their pet’s condition will affect the pet and the family25 as Beau’s family did in Case 1. These concerns weigh on family members and the stress of worrying about the pet further affects FQoL.15
Family-centric Factors
A family’s past experiences with other pets and with human and veterinary health care, values, religion, and culture all influence their decisions. Families have differing amounts of resources, be it time, space, money, or people to care for their pets. These circumstances change over time due to a multitude of life events such as job loss, illness, moving, having a baby, or the loss of a family member.15 In Case 2, the owner had experienced several life changes since adopting Willow.
A major factor leading the family to choose not to pursue radiation therapy for Willow in Case 2 was their finances. In an ideal world, the cost of care would not play a role in a family’s treatment decisions. In reality, the cost of veterinary care is the most common limitation owners face in providing care for their pets.8 Financial concerns are not isolated to whether the family can afford immediate care but also whether they can afford the ongoing treatments and visits that the pet may need. Families must consider whether they will be able to reallocate funds and afford necessities such as food, utilities, and housing if they pursue treatment for their pet, and how the financial implications of pursuing care will affect their FQoL.
Another limitation families may encounter in providing care is having the available time needed to pursue treatment. Families have many important commitments including work, school, childcare, and taking care of their own health or providing care for other family members. They must consider the time needed for the pet’s follow up visits to the clinic and the time needed for care at home. Just as financially committing to a pet’s treatment may mean that the family must make adjustments, time commitments may also lead to changes that will factor into FQoL. Multiple veterinary visits may lead to a loss of wages, jeopardize employment,26 or negatively impact a family member’s ability to attend school or go to their own doctor’s visits. Owners may also consider whether they are able to commit to giving medications regularly multiple times a day based on their schedule.
Transportation27 to and from veterinary visits is another hurdle that some pet owners may need to overcome in providing care for their pets. The cost and feasibility of transporting a pet may be complicated by the logistics of traveling with a pet, especially when bringing the pet precludes the use of public transportation.
Families often face additional challenges in caring for their pet. A pet caregiver may have a personal health issue that limits their ability to care for the pet and impacts FQoL and pet care decisions. Examples include an owner who is not physically able to medicate or perform other treatments for a pet at home or assist a pet up and down stairs, an owner who is immunocompromised and is faced with a pet with a zoonotic disease, or an owner with a coagulopathy for whom a nip or scratch is a major medical concern. In Case 1, Beau’s behavior exacerbated an ongoing issue that one of the children in the family was experiencing. In other cases, owners may be uncomfortable seeing open wounds and changing bandages, administering injections such as insulin or subcutaneous fluids, or even giving pills, causing stress and anxiety for the caregiver.
Some behaviors which may result from a pet’s stress or anxiety will significantly affect the FQoL as well as reflect on the pet’s QoL. A pet may consistently urinate or defecate inappropriately without an underlying treatable medical condition. This is the major concern in Case 4 in which the owner feared eviction as a result of Chester’s inappropriate urination (Supplementary Table S4). A pet may exhibit destructive behavior that damages the owner’s home or other property. Such behavior decreases the family’s ability to live securely with the pet, decreasing FQoL, and factoring into care decisions.
Pets that show unpredictable aggression or have a history of injuring people or other pets may significantly diminish FQoL. Even with an identified trigger, the family may be unable to control exposure to the trigger with complete surety. Owners may feel isolated and experience anxiety around safety planning and the need for hypervigilance.9 The presence of children or other family members unable to react quickly and appropriately to prevent injury to themselves or others due to pet aggression may increase tensions in the home. All of this factors into FQoL.
External Factors
In addition to intrinsic pet and family factors, FQoL may be affected by forces outside of the family. The influence of external factors may not be the sole reason for an owner to choose a specific treatment option, however, it can often play a role in the larger mosaic of factors considered in FQoL.
The accessibility of resources outside the home can greatly impact FQoL and care decisions.28 Owners who have the social support and practical assistance of an extensive network of friends and extended family may be able to take on treatments at home or repeat trips to the clinic. Families without this support and the associated stability may find it difficult to take on long-term care or commit to intensive treatment protocols for their pet. Paradoxically, pet owners that lack social support may also find it difficult to elect euthanasia for a pet and seek to prolong the pet’s life, regardless of the patient’s condition and prognosis. An unintended consequence may be that the patient suffers longer than necessary. This creates a treatment dilemma and moral distress for veterinarians and their teams.
Many families receive much needed services from government agencies or other social service providers. Loss of these services would negatively affect FQoL. Case workers, whose primary focus is a child, a person with disabilities, or a senior citizen in the household, often make home visits and may have requirements or recommendations that directly or indirectly affect the pet. These recommendations may impact the pet’s care or the pet’s ability to remain in the home. In Case 4, the fear of losing custody of her children was a major factor that led the owner to decide to relinquish Chester.
Landlords and insurance companies can impose dog breed restrictions. Some rental properties may have size limits for dogs and may require a pet deposit and/or monthly pet fees. Housing authorities or landlords may also intervene when there are complaints related to a pet’s behavior or nuisance complaints related to noise or odor, leading pet owners to fear eviction or other consequences. This is an additional consideration in Case 4. Secure housing is a necessary component of an acceptable FQoL.
Law enforcement, animal control, or other authorities may exert pressure on owners through citations, fines, or other penalties related to mandatory vaccines, microchip or spay/neuter ordinances, or licensing requirements. Public health agencies may be alerted when someone has been bitten by a dog or cat and authorities may intervene if an aggressive dog is deemed a threat to public safety.29 These situations may result in additional consequences not directly related to the pet by bringing attention to the owner or another family member. When there have been previous interactions with law enforcement or there are questions as to immigration status, this additional attention can cause harm to the individual or family, decreasing FQoL.
Discussion
“It’s complicated!” Factors that affect FQoL are often nuanced, cumulative, and layered and although we presented them as falling neatly into three specific domains, pet-centric, family-centric, and external, many factors bridge those distinctions and affect both the pet and the people in the family. None of the factors discussed exist in a vacuum. The case examples presented in this paper highlight these subtleties and how this interconnectedness influences the weighing of negative and positive factors for FQoL (Figure 1).
The interdependency of Family Quality of Life (FQoL) domains.
Citation: Journal of the American Veterinary Medical Association 261, 8; 10.2460/javma.23.01.0016
The challenge
Veterinarians evaluate pets in the artificial setting of an office visit or hospital stay when patient reactions and behaviors may be influenced by unfamiliar, stressful surroundings. The family sees the pet in a full range of situations4 and has objective and subjective insights into all aspects of their FQoL. The family may choose to keep confidential some or all of the information that factors into their FQoL, and rank and weigh these factors in ways that only they can determine to maximize their FQoL. In this void, the veterinarian and their team may make assumptions to fill the information gaps. Even if the family chooses to share information about their circumstances, owner care decisions may seem counterintuitive or enigmatic to the veterinarian, as the veterinarian lacks the ability to subjectively evaluate FQoL as an outsider.
When faced with difficult care decisions, clients often ask their veterinarian what they would do. Even without prompting, it has been our experience that veterinarians often advocate for how they would proceed with treatment if the patient were their own pet. This not only overlooks each family’s unique FQoL determination but disregards the advantage veterinarians have in deeply understanding medicine and potential complications or adverse events, being able to bring their pet to work for treatment rather than making separate trips for care, being an expert in administering medications, and having colleagues who are also experts and willing to assist. Veterinarians also often pay significantly reduced costs for care compared to clients. These advantages, as well as veterinary education and training, may lead veterinarians to have an inherent bias toward more aggressive and expensive care and may decrease their appreciation of the challenges owners face.
Not recognizing FQoL or its role in a pet’s veterinary care creates stress for both veterinarians and families. Families, for a myriad of reasons, may be unable to follow through on a veterinarian’s primary treatment recommendation and opt for less intensive treatment or no treatment at all. Without understanding the complexities of the owner’s decision, veterinarians could experience excessive moral distress if they perceive that the patient is not getting optimum care or is suffering.18,20,30 Likewise, the families may experience guilt and shame for not pursuing the recommended treatment option.
The solution: awareness of and discussing FQoL
Veterinarians’ awareness of the complexity and importance of FQoL, as well as its unique and subjective nature, is an important first step in addressing this challenge. Acknowledging FQoL increases veterinarians’ empathy for their clients,21 which allows veterinarians to communicate with clients more effectively and leads to deeper trust between them. Understanding how owners make pet care decisions and that the ultimate decision is often based on FQoL, may ease the ethical dilemma that many veterinarians grapple with when asked to provide care that does not align with their primary recommendation.16 By applying the concept of FQoL, veterinarians can relieve one of the main drivers of moral distress and burnout in the profession.17,18
Another important step in addressing this challenge is for veterinarians to openly discuss FQoL with families. Veterinarians can facilitate discussion and decision making by ensuring that information is presented using language that the family can understand and process and by being available for follow up discussions and questions.4,21,31 Employing client-centered communication skills such as asking open ended questions, active and reflective listening and maintaining nonverbal communication that aligns with the ongoing discussion helps to build trust between veterinarian and client. In this trusting environment, veterinarians can open the door to FQoL consideration by clearly stating that it is reasonable for families to consider how their veterinary care decisions will affect the family as well as the pet. The veterinarian can also support the family by letting them know that there is rarely one “correct” course of action and that different families will make different decisions and give the family adequate time and space32 for them to consider the range of factors that may influence their FQoL.
Sharing with clients that evaluating FQoL is ostensibly the process by which families make veterinary care decisions may also relieve stresses on the family as they may struggle with guilt and worry. Families may feel that they are being selfish or failing their pet when considering factors aside from those directly related to the pet. Families may be overwhelmed by a flood of thoughts and emotions32 as they consider the proposed diagnostic and treatment options and the responsibilities of being a caregiver for their pet.33 This is compounded when the pet is diagnosed with a serious or life-threatening illness or when the decision needs to be made urgently as is the case with a sudden illness, injury, or other emergency situation.
Conclusion
While FQoL is driving most pet owners’ treatment decisions, it is often overlooked in the exam room, with potentially deleterious effects on veterinarians, families, and pets. Awareness of FQoL and discussing it with clients provides an opportunity to decrease veterinarians’ stress and improve the veterinary-client-patient relationship. Discussing FQoL enables veterinarians to better support families and patients by encouraging families to consider the various factors that may influence their FQoL and validating the process. When veterinarians and pet owners are principally motivated by the best interests of the pet and the family and seek to maximize the family’s FQoL, they can work together to find the most appropriate diagnostic and treatment plan for the patient. This helps both veterinarians and families be comfortable with their collaborative treatment decisions.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org
Acknowledgments
No third-party funding or support was received in connection with the writing or publication of the manuscript. The authors declare that there were no conflicts of interest.
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