Pet Quality of Life Scale (HHHHHMM) for End-of-Life Decisions
The HHHHHMM Quality of Life Scale, developed by Dr. Alice Villalobos as part of her "Pawspice" hospice care concept, scores seven domains to help families and veterinary teams evaluate whether a seriously ill or aging pet's quality of life remains acceptable.
Score each category from 0 (worst) to 10 (best), based on the patient's condition over recent days - not just right now.
Hurt
Adequate pain control, including breathing ability. Pain should be assessed and managed - including oxygen therapy where needed - as the highest priority.
Hunger
Is the patient eating enough? Hand-feeding, appetite stimulants, or a feeding tube may be needed to meet nutritional needs.
Hydration
Is fluid intake adequate? Subcutaneous fluids may be needed for patients not drinking enough on their own.
Hygiene
Kept clean and dry, especially after urination or defecation. Brushed regularly. Bedsores avoided and pressure points padded for recumbent patients.
Happiness
Expresses interest and joy, responds to family and surroundings, isn’t isolated, bored, anxious, or depressed.
Mobility
Able to get up without assistance, wants to go on walks or move around. Mobility issues managed to avoid pressure sores and preserve quality, not just quantity, of life.
More Good Days Than Bad
When bad days outnumber good days, or the patient seems to be suffering, quality of life may be too compromised to continue - and if the caregiver is suffering watching the bad days, that is meaningful too.
How to use this tool
The seven categories
Hurt - adequate pain control, including breathing ability. Hunger - adequate caloric intake. Hydration - adequate fluid intake. Hygiene - kept clean and dry, bedsores avoided. Happiness - expresses interest and joy, isn't isolated or depressed. Mobility - able to get up and move without excessive assistance. More good days than bad - the balance of good versus bad days, for the patient and the caregiver.
Interpreting the total
Scored out of 70. A commonly cited threshold is 35 or higher supporting continued palliative/hospice care, with lower or declining totals - especially more bad days than good - signaling it's time for an honest conversation with your veterinary team about end-of-life options.
What this scale is - and isn't
It's a framework to structure and support a difficult conversation, not a pass/fail test or a replacement for clinical judgment and personal values. Reassess regularly rather than relying on a single score, since quality of life in a seriously ill patient can change quickly.
Frequently asked questions
What is the HHHHHMM Quality of Life Scale?
Developed by Dr. Alice Villalobos as part of her "Pawspice" hospice and palliative care concept, it scores seven domains - Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility, and More Good Days Than Bad - each 0-10, to help families and veterinary teams evaluate whether a seriously ill or aging pet’s quality of life remains acceptable.
What does the total score mean?
The total is scored out of 70. A commonly cited threshold is that a total of 35 or higher suggests quality of life remains acceptable to continue supportive or palliative care, while a lower or declining total - especially with more bad days than good - suggests it may be time to discuss end-of-life options with your veterinarian.
Is this scale meant to make the euthanasia decision for me?
No - it’s meant to structure and support a conversation between the family and their veterinary team, not replace clinical judgment or personal values. Use it as a framework for discussion, reassessed over time, rather than a single pass/fail test.
How often should this be reassessed?
Regularly - weekly, or even daily for patients on hospice/palliative "pawspice" care - since quality of life can change quickly in a seriously ill patient. Tracking the trend over time is often more informative than any single score.