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attention was paid to DJD in cats; however, estimates from published studies suggest that 40–92% of all cats may have some clinical signs associated with DJD.136 Feline DJD is now recognized as a serious welfare problem, particularly in older cats, which is a rapidly growing demographic.136,137 The most frequently affected joints appear to be the hip, stifle, tarsus, elbow, thoracolumbar, and lumbosacral area.137 For each 1 yr increase in a cat’s age, the expected total DJD score increases by an estimated 13.6%. Moreover, there is a dramatic increase in the prevalence and burden of DJD at about 10 yr of age. A diagnosis of feline DJD is based on a thorough history reflecting changes in behavior and lifestyle, physical exam findings, and possible radiographic evidence. Behavioral changes are the most common signs of DJDassociated pain in cats. Feline DJD is usually bilateral, so although cats rarely limp, they are likely to be stiff, have a less fluid gait, become less active (especially at night), and exhibit decreased jumping frequency or jumping height.138 Owners often note that their cats are very stiff going up or down stairs. The cat may resist handling, petting, or stroking of the back or limbs. Showing the owner a list of the common pain-related behaviors caused by DJD is helpful in making the diagnosis (Table 3). It should be assumed that a senior cat has some DJD, and every effort should be made to incorporate gentle handling techniques and padded surfaces for the cat to lie on during the exam. A positive clinical response to analgesics will also indicate the presence of DJD. The first validated clinical metrology tool for the evaluation of feline musculoskeletal pain has now been produced and is available for use in practices.139,140 NSAIDs are the mainstay of pharmacologic treatment for DJD in other species, and there is considerable evidence to support their effectiveness in cats as well.141–145 In the US, however, NSAIDs are not approved for long-term use in cats, and the potential side effects often deter many clinicians from routinely using them in cats. Renal toxicity is always a consideration in the use of NSAIDs; however, one retrospective study found that long-term use of meloxicam did not reduce the lifespan of cats . 7 yr of age with pre-existing, stable chronic kidney disease (CKD) compared to cats without CKD.146 Low-dose meloxicam (i.e., 0.01–0.03 mg/kg per os q 24 hr) is effective in treating arthritic cats and is well-tolerated even in cats with CKD provided their clinical status is stable.145 Meloxicam is effective when administered once q 24 hr and is palatable for most patients, making it easy to administer. In Europe, Australia, and many countries, meloxicam is approved for long-term use in cats at a dose of 0.05 mg/kg q 24 hr. The oral rote of administration and long-term use of meloxicam in cats remain off label in the US. Robenacoxib is a COX-2 selective NSAID approved for surgical pain in cats. It has not been studied for either feline DJD or in older JAAHA.ORG 77 Pain Management Guidelines for Dogs and Cats cats but there is long-term safety data in young cats (i.e., 53 the recommended dosage for 6 mo and 103 the recommended dosage for 6 wk).147,148 Dosing on lean body weight, close monitoring of clinical status (especially appetite), regular laboratory monitoring, and appropriately modifying the treatment plan are recommended for cats receiving NSAIDs.149 NSAIDs should be used with caution on a case-by-case basis in cats with DJD, and cat owners should be advised that in the US, use of NSAIDs for feline DJD is an extralabel indication. Treatment of DJD in cats should focus on environmental modification in addition to pharmacologic therapy. In addition to steps and ramps to facilitate access to favorite elevated areas, additional litter boxes with at least one low side will make access easier. Owners can also provide physical therapy by implementing play times using favorite toys to increase exercise and mobility. When Pain Persists: Hospice and Palliative Care Hospice is designed to provide compassionate comfort and care to patients at the end of their lives and to support their families in the bereavement process. Hospice care for terminally ill patients is recommended when life expectancy is , 6 mo. Palliative care is the active, total care of patients with disease that is not responsive to curative treatment, with pain control being the paramount feature. The goal is achievement of the best quality of life (QOL) for patients and their families. This assumes ongoing assessment of QOL in the terminally ill patient. User-friendly QOL assessment scales are available to help veterinarians, veterinary staff, and owners make proper assessments and decisions at the end of a patient’s life.150 It is generally agreed that the pet’s caregiver is best suited to evaluate QOL, but a team approach emphasizing regular communication (discussed in the next section of these guidelines) is important to provide empathetic support when end-of-life decisions are made. An integrated approach that includes nonpharmacologic modalities is typically best for palliative-care and hospice patients with cancer because it is often associated with features of both acute and chronic pain. In cases of palliative radiation, either a smaller number or lower doses of radiation can make treatment protocols more tolerable to the patient and agreeable to the owner. Environmental modification, physical therapy (e.g., massage, acupuncture, and therapeutic laser), or ultrasound can be useful additions to the pain management plan. Providing nutritional support via feeding tube can be helpful where eating is otherwise difficult or painful. In cases involving hospice and palliative care, it is important to encourage clients to have realistic expectations of the outcomes involving their pets. This includes explanations of probable outcomes and providing the client with end-of-life choices involving the pet. Euthanasia is an option that relieves pain and suffering and should be discussed as a reasonable and humane alternative at some point. Euthanasia may be a topic that the veterinary team initiates if the pet owner does not. A Team Approach and Client