On the internal-medicine floor at Angell, I watched two kinds of families come in with the same question. The ones who came early, asking “is it time?” when the answer was still “not yet.” And the ones who came late, knowing the answer before they said it out loud, carrying the weight of wondering whether they should have come sooner.
Both carry the same weight afterward. The early family wonders about the good days they might have cut short. The late family wonders about the suffering they let go on too long. I don't think either is wrong. I think the question itself is the hardest thing about loving a senior dog. There's no blood test for it. No imaging study. The only way through it is to watch carefully, write it down, and let the pattern show you what a single bad afternoon can't.
The scale that gives the watching a shape
Dr. Alice Villalobos, a veterinary oncologist who spent most of her career in end-of-life care, published a framework for exactly this kind of watching. She called it the HHHHHMM Quality of Life Scale: Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility, and More Good Days Than Bad. It appeared in Veterinary Practice News. The AAHA, the American Animal Hospital Association, references the scale in their end-of-life care guidelines as one of the most widely used decision tools available to families and veterinarians.
The scale isn't a formula that tells you the day. It's seven questions to ask every day, scored 1 to 10, so the answer isn't “I think she's worse” but “her mobility dropped from a 7 to a 3 over two weeks, and here's the day it changed.”
Diane and Henry: seven months with the scoresheet
Diane, whose German Shepherd Henry was diagnosed with degenerative myelopathy, or DM (a progressive nerve condition that weakens the hind legs over months to years), at 10, used the scale for the last seven months of his life. She sent me the notebook she kept. What follows is from it.
Henry was 82 pounds of opinions about where people should sit and when dinner should happen. When his back legs started slipping on the kitchen tile, we thought it was a senior thing. Big dogs slow down at 10. That's what we told ourselves.
The vet said degenerative myelopathy. She explained it was progressive, that the nerves serving his hind legs would keep deteriorating, and that nothing would stop it. Only management. She said some dogs have years. Some don't. Henry, she thought, was somewhere in between.
His back legs got weaker over months, not weeks. He could still walk for the first year after diagnosis. He needed a harness for the stairs by month fourteen. By month eighteen, the harness was for everything.
The scoresheet started because I couldn't trust my own judgment anymore. Some mornings I'd look at him and think “today is a bad day.” Then he'd find the sunny spot in the living room and fall asleep with his tongue out, perfectly content, and I'd realize I was the one having the bad day. He was fine.
That's what the scale fixed. It separated what I was feeling from what I was seeing.
I scored each factor 1 to 10 every night after dinner. I didn't think about it during the day. I just watched him and wrote it down after.
Hurt was the hardest because Henry didn't show pain the way I expected. He didn't whimper or limp more than usual. He just got quieter. A dog who barked at the mailman every single day stopped caring about the mailman. That was pain. I didn't recognize it until the vet pointed out that withdrawal is one of the most common pain signals in dogs. The Merck Veterinary Manual, the reference textbook most clinicians use, describes the same thing: behavioral changes like reduced activity, loss of interest in routine, and social withdrawal are among the earliest and most missed indicators of pain in dogs.
Hunger was straightforward. Henry ate everything put in front of him until the last ten days. When a German Shepherd stops eating, something has changed. I didn't need a scoresheet to know that. But having six months of 10, 10, 10, 9, 10 made the single 3 impossible to explain away.
Hydration was a number I had to learn to see. The vet showed me how to tent the skin between his shoulder blades to check turgor. I did it every night. I also marked the water bowl level in the morning and checked it at dinner. It became part of the routine the way brushing my own teeth is part of the routine.
Hygiene was where the DM made itself most visible. When a dog can't control his back end, accidents happen. Henry hated it. He'd look at me when it happened and his ears would go flat. Keeping him clean was part of my day. When the effort to keep him clean started to cause him more distress than the mess itself, that number moved.
Happiness was the score I trusted most. Henry's happiness was specific: lying next to my daughter on the couch while she did homework, the sunny spot in the living room, the peanut-butter Kong after his evening check. When the couch got too hard to reach and the sunny spot was on the wrong side of the stairs, the number reflected it before my gut did.
Mobility drops fastest with DM. The harness bought us four months. I tried a wheelchair cart for three weeks. Henry refused it after the third day, and I didn't push. When he couldn't get from his bed to the water bowl without me lifting his back end, I wrote 2 and sat with it.
More Good Days Than Bad was the last column, tallied every Sunday. For five months, good days outnumbered bad 5-to-2 or better. Then 4-to-3. Then 3-to-4. The week it flipped and stayed flipped, I called the vet.
I didn't make the decision the day the numbers said to. I made it three days later. I needed those three days. The vet said that was fine. She said the scale doesn't tell you the day. It tells you the week.
What I wish someone had told me at the beginning is that the notebook isn't for the bad days. You know the bad days when they happen. The notebook is for the good days that are getting shorter without you noticing. It's for the week you would have missed if you hadn't written it down.
Diane is the family of Henry, a German Shepherd who was diagnosed with degenerative myelopathy at 10. She said goodbye when he was 12. This account covers the seven months the scoresheet was part of their household. It was edited for length by Rachel Howland; Diane's rhythm, word choice, and emphasis are her own.
The daily check-in
A daily check-in takes five minutes after dinner. Score each of the seven factors 1 to 10. Don't analyze in the moment. Write it down and look at the weekly trend on Sunday. That seven-day view is what you bring to the recheck appointment. It replaces “I think he's doing worse” with “his mobility went from 6 to 3 over two weeks, and here's when it changed.”
Four signals to watch in the weekly trend:
- A single factor dropping more than 3 points in one week.
- Three or more factors declining in the same week.
- Two consecutive weeks where bad days outnumber good.
- One factor stuck at 2 or below with no improvement after a vet adjustment.
Weight belongs alongside the scoresheet. Unexplained weight loss in a senior dog with a chronic condition is its own signal, separate from the seven factors. Weekly weigh-ins, same time of day, same scale, show what a single reading at the vet can't. The quality-of-life tracker on this site walks through the scoring in more detail. If you're starting a scoresheet for the first time, that's a good place to begin.
If your dog is also managing a diagnosed condition like chronic kidney disease or cancer, the scoresheet becomes more important, not less. The disease has its own trajectory. The scoresheet tracks the dog. And if you're unsure whether what you're seeing is a crisis or a bad afternoon, the emergency triage guide can help you sort it.
Veta's passport logs daily QoL scores and weight trends across months so the pattern is visible when you need it, not reconstructed from memory in a 15-minute exam room. The notebook Diane kept by hand is the same information. The tool doesn't matter. The consistency does.
Questions about the quality of life scale
How do I score the HHHHHMM scale?
Each of the seven factors gets a score from 1 to 10, where 1 is the worst and 10 is the best. Score once a day, ideally at the same time. Don't overthink the number. If mobility looked like a 5 yesterday and a 4 today, write 4. The precision comes from the trend, not from any single entry. After a week, add up each day's total. A declining weekly total over two or more weeks is the signal, not a single bad score on a Tuesday.
What counts as a 'good day' versus a 'bad day'?
A good day is one where your dog engaged with the things that make them themselves: food, a person they love, a place they like to rest, a sound they used to respond to. A bad day is one where most of those signals are absent or the dog seems to be enduring the day rather than participating in it. The threshold is personal to your dog. For Diane's Henry, a good day meant the sunny spot, the Kong, and his daughter's homework session. A bad day meant none of those, plus a mobility score below 4.
Should I involve my vet in the scoring?
Bring the scoresheet to every recheck. Your vet can help calibrate what you're seeing, especially for pain. Dogs don't show pain the way most people expect, and a vet who sees the weekly trend can often identify a decline you're too close to notice. The conversation changes when you hand your vet a page of numbers instead of a vague feeling that things are getting worse.
Does the scale work for cats?
The seven factors apply to cats, but the observable signals are different. Cats hide pain and illness more aggressively than dogs, which means the hygiene and happiness scores require closer watching. A cat who stops grooming is communicating something a dog's coat might not. A cat who withdraws from a favorite perch is the equivalent of a dog who stops greeting you at the door. The framework is the same. The things you're watching for are species-specific.
What if my family disagrees about whether it's time?
This is one of the most common sources of grief in the process. The scoresheet helps because it moves the conversation from feelings to observations. Two family members can look at the same dog and feel differently about whether today is a bad day. But if both are scoring independently and the numbers converge on the same decline, the discussion shifts. Some families assign different factors to different people. The point isn't agreement on a feeling. It's agreement on what you're both seeing.
How long should I track before making a decision?
There's no minimum. Some families track for months because the decline is gradual and the scale helps them see what's changing. Others start the scoresheet when a crisis makes the question urgent, and track for two or three weeks to confirm what they already suspect. If you're starting now because you're worried, two weeks of daily scoring usually gives enough data to see the direction. If the trend is flat or improving, keep tracking. If it's declining and the last column, More Good Days Than Bad, has flipped for two consecutive weeks, that's the conversation to have with your vet.
Diane said goodbye to Henry on a Tuesday in October. She brought the notebook to the appointment. She told me she didn't need it by then. But the vet read through two pages of it in the exam room, nodded, and said, “You gave him a really good last stretch.” That sentence mattered more to Diane than anything else anyone said that week.
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Rachel Howland, CVT (ret.), spent a decade in clinic: seven years in a mixed practice in upstate New York, then three on the internal-medicine floor at Angell Animal Medical Center in Boston. She left practice in 2017 and has written about small-animal health since. She does not diagnose or prescribe; she explains what your vet's records are telling you and what questions are fair to ask.