HHHHHMM quality-of-life scale — how to score your pet honestly
HHHHHMM (Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility, More good days than bad) is the most widely used quality-of-life scoring tool in veterinary palliative care. Below: the rubric, how to use it weekly, the averaging trap that ruins most attempts, and what the number cannot capture.
The HHHHHMM Tracker
A printable weekly scoring sheet with the rubric on the back. Stick it on the fridge.
What HHHHHMM is
A scoring rubric, not a verdict. Dr. Alice Villalobos, the American veterinary oncologist who built the modern palliative-care framework, published the scale to give owners a structured way to track an animal’s decline without anchoring on the worst day or the best day. Seven axes. Each scored 0-10. Maximum 70.
The seven axes
Score each on a 0-10 scale where 10 is normal, healthy function and 0 is severe distress or absence.
| Axis | What you are scoring | 10 = | 0 = |
|---|---|---|---|
| Hurt | Pain. Including breathing distress. | Comfortable, no analgesia needed | Severe pain unrelieved by medication |
| Hunger | Eating willingly, holding weight | Eats normally without coaxing | Refuses food; tube-feeding required |
| Hydration | Drinking, mucous membranes moist | Drinks freely, well hydrated | Severely dehydrated, IV needed |
| Hygiene | Clean, dry, sores absent | Self-grooms, no soiling | Sores, soiling, unable to self-clean |
| Happiness | Engagement, response to family | Bright, interested, social | Withdrawn, unresponsive, depressed |
| Mobility | Rising, walking, posture | Moves freely, no aids needed | Cannot rise without assistance |
| More good than bad | The week-on-week ratio | Most days are good | Most days are bad; bad days dominate |
How to use it
- Score weekly, same day, same time. Sundays after the morning walk is the standard recommendation.
- Score in pen, not pencil. You will want to revisit your earlier scores honestly, not retrospectively edit them.
- Keep one chart for the duration. A second chart started later loses the trend line that informs the decision.
- Show the chart to your vet at the next visit. The chart is the conversation starter; the vet is the interpreter.
The averaging trap
A score of 50 sounds reassuring. It is not, if all 50 points come from five axes scoring 10 and two scoring 0. An animal with a 0 in Hurt has a quality-of-life problem regardless of how high it scores in Hunger, Hygiene, and Happiness. Always look at the lowest axis, not the total.
The clinical question to ask: “is there a single domain where my animal is failing badly enough that no amount of compensation in other domains makes the day acceptable?” If yes, the average is misleading you.
What the score misses
- Owner exhaustion. The scale does not include the human caregiver’s capacity. A score of 40 in a household where the owner has not slept for two weeks is not the same as a score of 40 in a supported household.
- Cognitive decline. Confusion, sundowning, and disorientation in elderly dogs do not map cleanly onto Happiness. Track them separately.
- Anticipated trajectory. The scale captures today, not the next four weeks. A diagnosis of progressive disease should weight the conversation even when the current score is acceptable.
- The animal’s own preference. We have no instrument that measures it. We have inference from behaviour. The scale is a structured form of that inference, not a substitute for it.
Common questions
What does HHHHHMM stand for?
What score means euthanasia is appropriate?
How often should I score?
Should I score with my partner or family?
Editorial reference, not veterinary advice. — Dr. NRS, last reviewed 27 April 2026.