What Do We Do When A Patient With A Chronic Ulceration Fails Conservative Therapy And Declines An Amputation?

Chronic ulcerations, especially in patients with systemic disease, are troublesome to say the least. These patients’ visits are often intensive and laborious, taking a toll on both medical and clerical staff. When patients require outside consultations or hospital admission, telephone communications and added paperwork are costly at many levels. For many physicians, the added overhead expense becomes difficult to afford.

Worse yet is the situation in which you have given the patient the very best benefit of conservative care using the team approach and yet the ulcer fails to heal, or even regresses to infection and necrotic change. In some patients, even an aggressive wound care plan can fail and limb loss becomes inevitable.

The ultimate discussion regarding the need for a lower extremity amputation is a tough one and in the specialty of foot and ankle surgery, this type of consultation becomes a fact of life. As a physician and surgeon, experience will bring the maturity that it takes to make a decision to plan for a lower extremity amputation.

But what if the patient simply declines that option? What if he or she has seen the vascular surgeon, the internist, infectious disease physician and other medical specialists who all share the opinion that a lower extremity amputation is the next step in preventing systemic infection, higher morbidity and even mortality? What if the patient just opts to live life with a wound? When do you stop antibiotics? Just how high is too high for the creatinine to climb in the use of antibiotic therapy?

Can you ever stop treating these patients?

Why Wounds Fail To Heal

There are a number of reasons why a patient may fail even the most aggressive wound care regimens.

Poor participation in offloading the limb. (We used to call this noncompliance before our language changed for legal purposes.) This refers to the patients who walk on an ulcerated limb, those who fail to use the custom-molded shoes or braces, or patients who continue to go to work/walk/stand on their feet with complete disregard for their condition.

Lack of patient understanding. This is not the same as a lack of patient education. You can educate a patient until you are blue in the face regarding enhanced glycemic control, exercise, improved hygiene and proactive healthcare to facilitate wound healing. However, there are some patients who truly don’t appreciate the gravity of their condition and accordingly do not behave in a manner that suggests they consider their problem important.

For example, consider the patient who forgets to change the dressing and simply states, “You didn’t tell me I had to keep changing the dressing every day.” There is also the patient who walks on an ulcerated foot and explains that “You never told me I couldn’t walk on my foot, you just said that I shouldn’t.” Also consider the patient who fails to show up for appointments for ulcer care because “I had too much to do and couldn’t get into the office. When I did try to get on the schedule another day, you couldn’t get me in.”

Ignorance and ambivalence. When patients become ambivalent regarding their participation in their wound care, a poor outcome is likely. Some people simply don’t get it and are essentially ignorant about the importance of their own healthcare. Others may be ambivalent and simply don’t think they can do anything to change their condition. They may say things like “It’s just my diabetes. There is nothing that I can do. It has been this way for years. I can’t change how bad my diabetes is.”

Poor circulation. For some patients, their vascular disease is so bad that they can’t heal a wound but they may have just enough collateral circulation to give them some bleeding potential, enough to maintain a stagnant wound. This leads to a wound that just doesn’t get better but isn’t really any worse. X-rays may reveal demineralization of bone but no frank evidence of osteomyelitis is apparent.

Neuropathy. The utter lack of sensation makes it difficult for patients to be connected to their condition. You will hear them say things like:
• “It looks like it should hurt.”
• “It doesn’t hurt. It just looks like the foot is pointing in the wrong direction.”
• “The foot has changed in position but I didn’t notice when it happened.”
• “I didn’t think I had a problem until I noticed drainage on my socks, on the floor, blood stains on the carpet etc.”
• “I began to notice my dog has been licking my foot a lot.”

All of these comments should clue the physician in to the fact that the neuropathy is more important than previously suspected.

Final Words

You don’t have to be a rocket scientist to figure out the complicating factors that can lead to delayed healing or a non-healing wound. However, when you have addressed all of these influencing factors to the best of your ability, what do you do when treatment frankly fails? What if you strongly suggest to patients that they need an amputation but they decline?

What if the plan were to exhaust conservative care and despite numerous surgical debridements, serial courses of oral antibiotics, skin grafting, vacuum-assisted closure and in-home wound care (with or without nursing care in the home), the patient’s wound fails to progress and the patient declines the suggestion of amputation? What if the infectious disease specialist declined the refill for antibiotic coverage since the wound has failed to progress? What if the patient’s renal function is diminishing in the face of prolonged antibiotic coverage? Is there a “standard of care” for the non-healing, chronic ulceration?

When do you say when?

I am interested in your input as I can’t seem to arrive at a perfect answer. I am certain that there are plenty of you who have been practicing far longer than I. Let me know your thoughts as I do not believe this one is answered in any textbook.



Ron Raducanu, DPMsays: October 15, 2013 at 4:21 pm

This is a brilliant blog.

I just don't know what to do with this when it comes around, which it does often in this patient population.

When I see a diabetic amputee with another wound walk into the Wound Care Center with a milkshake in one hand, a Mars bar in the other, poor hygiene and walking on the foot I just partially amputated with a bloody bandage dragging behind them, I feel like hope is lost.

Truthfully, it burnt me out. I did a good bit of wound care for a couple of years and just left it behind. The time, effort, frustration and lack of financial incentive to treat these patients (for a huge variety of reasons) left me totally spent and feeling hopeless.

The few that get better and appreciate your work fueled me for awhile but after doing multiple amputations on the same patient within a one year time frame, it really left me cold and wondering what exactly I was doing. Was I helping them? I couldn't answer that question any longer.

Wound care comes down to the patient alone. The advances made in wound care products and technologies are heroic, but if the patient isn't on board, what good are they?

Sorry for the downer, but I have the utmost respect for those out there who do this day in and day out for years on end. My hats off to all of you.

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Molly Judgesays: October 20, 2013 at 9:10 pm

Ron, I am sure that many people share this sentiment. Wound care is a major portion of what podiatry is meant to do. Our state motto is " Saving lives one limb at a time" and I can see that it is getting harder and harder to stay enthusiastic about that mission. Sometimes, it is easy to help and other times it is a deep dark struggle with the notion that "when to say when" is probably now.

It is my belief with all that is happening in the insurance world that it won't be long before there is actual criteria regarding how much wound care and adjunctive methods can be used for chronic wounds. It would not surprise me that criteria develop regarding whether or not the patient's role in care has been met. These criteria may include values that can be measured such as HgbA1C, number of missed follow-up visits, failure to fill prescriptions in a timely manner, number of missed PCP visits, number of emergency room visits, etc.

Other measurable criteria that will reflect just how well the patient is progressing: number of surgeries, number of grafts, number of wound VAC days/months, emergency room visits for the same wound. These should always be included in the equation when determining when to say when.

When the government secures its role in dictating medicine, the standard of care will be to discuss the amputation as a first line in therapy. That is the ultimate way to reduce the cost of care.

I appreciate your time in considering this blog and preparing a response.

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