The question "is it time?" is the question almost every family asks us during a hospice consultation — sometimes multiple times. There is no perfect answer. But there are signs to watch for, and there is a framework to use.
The framework is called the Quality of Life Scale, sometimes the HHHHHMM Scale, developed by Dr. Alice Villalobos and adopted by the International Association for Animal Hospice and Palliative Care. We use it with every hospice family. It is not a verdict and it is not a calculator. It is a way of taking the question out of your gut, onto a piece of paper, where you can look at it together as a family.
Here is what we look at.
The Seven CategoriesThe seven things we watch.
Hurt
Is the animal in pain? Is the current medication controlling it? This is the first category for a reason — pain is the thing we can most often address and the thing we should never ignore.
Dogs and cats are both very good at hiding pain. Cats are especially good — feline pain is one of the most under-recognized conditions in veterinary medicine, even by veterinarians. Signs to watch for: panting at rest, hiding in unusual places, reluctance to be touched in certain spots, vocalizing at night, change in posture, change in gait, loss of grooming behavior in cats.
If you are watching for pain and feel uncertain, call us. We can come for a comfort check and tell you honestly what we see.
Hunger
Appetite changes are one of the most common signals in end-of-life care. The animal who used to inhale dinner now picks at it. The cat who used to come running when the can opener clicked no longer does.
Some loss of appetite is temporary — a side effect of a medication, a hot day, an upset stomach. Some loss of appetite is a signal. The line between the two is usually time: more than 24 hours of true refusal, especially of favorite foods, especially of treats, is a signal worth a phone call.
Honest note: refusing food in the last 24 to 72 hours is very common and often appropriate. The animal knows. We do not need to force food in those moments; we need to keep them comfortable.
Hydration
Drinking patterns matter. Dehydration in a senior animal can come on quickly and is one of the most common reversible sources of discomfort. Signs of dehydration: tacky gums, reduced skin elasticity when you gently pinch and release at the scruff, sunken eyes, lethargy.
Subcutaneous fluids — given under the skin at home, often by the family with our coaching — can extend comfortable days significantly in some hospice protocols, especially for cats with chronic kidney disease. They are not always appropriate, especially in the final week, when force-hydrating can extend distress rather than ease it. We can help you read which is which.
Hygiene
Is the animal able to keep themselves clean? Cats who stop grooming, especially around the hindquarters, are telling you something. Dogs who can no longer get up to relieve themselves outdoors and are having accidents indoors are also telling you something — not because accidents are unbearable, but because many animals are aware of them and are losing dignity in a way they feel.
Pressure sores can develop quickly on animals who are spending more time lying down. Soft bedding, frequent repositioning, and careful skin checks help. We can show you what to look for.
Happiness
Interest in the family. The dog who used to greet you at the door no longer doing so. The cat who used to come to bed no longer coming. The dog who would rouse for a tennis ball who no longer rouses. The cat who would purr on your lap who no longer purrs.
Happiness in this scale is not the dramatic happiness of a young animal. It is the quiet daily interest in being alive — looking out the window, leaning into a scratch, walking to the front door when you come home. When those quiet interests fade and do not return, the scale is telling you something.
Mobility
Difficulty rising. Refusing stairs. Frequent slipping on hardwood floors. Falling. Inability to get to the litterbox or to outside in time. Loss of the rear legs in particular is common in older large-breed dogs and is one of the most demanding categories to manage at home.
Mobility aids — non-slip rugs, harnesses with a handle, ramps, lifting slings — can extend comfortable days. There comes a point in many hospices, though, where mobility is no longer something we are managing but something the animal is suffering through.
More Good Days Than Bad
The big-picture question. The one to ask weekly, not hourly. We recommend a small notebook — even just a calendar — where the family marks each day with a simple notation: G for a good day, B for a bad day, M for a mixed day. After two or three weeks, the pattern becomes clear in a way that no individual day can be.
When the bad days outnumber the good days, when the mixed days are mostly bad, when the run of bad days starts to extend — the scale is telling you it is time, or close to it.
Using the ScaleHow to use it at home.
The simplest use of the scale is to score each of the seven categories on a 1-to-10 basis, where 10 is "best possible" and 1 is "worst possible." Add up the seven scores. The total falls between 7 and 70.
The IAAHPC guideline: a total of 35 or above generally indicates an acceptable quality of life; below 35 indicates that hospice care is appropriate and that euthanasia discussions are reasonable. These numbers are not magic. They are a starting point.
We recommend doing the scale once a week during a hospice, not every day. Daily scoring tends to over-react to bad mornings or good afternoons. Weekly scoring catches the trend.
If you'd like, we can email you a printable version of the scale during your first hospice consult, along with a one-page guide on how to score each category in the specific context of your animal's diagnosis.
The scale will tell you what you already know. The point is not the number. The point is to take the question out of your gut, into your hand, and onto a piece of paper, where you can look at it together as a family.When to Call
When to call us.
Signs that warrant a hospice consultation now:
- Terminal diagnosis recently received from your general-practice vet or a specialist.
- Persistent pain that current medication is not controlling.
- Refusal of food and water for more than 24 hours.
- Sudden inability to rise.
- Signs of distress — panting at rest, whining, vocalizing — that don't resolve.
- Family is in active conflict about the decision.
- You are just looking at your animal and the question is in the air, and you cannot find the answer alone.
What to do tonight.
If you are reading this at ten o'clock on a Sunday, here is the short version:
- Call us if you want to talk. The phone line is open until 8 PM, voicemail after that, returned first thing in the morning or sooner if you ask. (503) 555-2840.
- Make the animal as comfortable as you can — soft bed, quiet room, dim light. Lay down with them if that's what feels right.
- If pain is severe and the GP has prescribed pain medication that is at home, give what was prescribed.
- Sit with them. Talk to them. They know your voice. The voice itself is medicine.
- Get rest yourself if you can. We will come.
If your animal is in active distress and the morning is too far away, call DoveLewis Emergency Animal Hospital in NW Portland, open 24/7, at (503) 228-7281. They can stabilize tonight. We can come tomorrow.