Outcomes in all of medicine, but especially wound care, go beyond the physical clinical presentation. Accordingly, the panelists discuss unique mental, social and emotional challenges wound care patients may face, and share their experiences and opinions on how best to provide support and care.
What mental, emotional or social challenges do you feel patients with chronic wounds may encounter in relationship to their condition? Why?
Chronic wounds can certainly be a large burden on patients due to the necessary complexity of care, says Jacob Fassman, DPM, FACFAS, CWS. He adds that transportation issues and financial burdens of frequent visits are also very impactful. Both Dr. Fassman and Kazu Suzuki, DPM, CWS identify possible patient embarrassment from malodorous wounds, or needing to ask for help from family and friends as sources of distress and isolation. Both doctors also agree that pain management needs pose a significant challenge for wound care patients.
“Having chronic pain for months or years, let alone undergoing an amputation, can be devastating to one’s mental health,” says Dr. Suzuki.
Citing the work of Beattie and colleagues, Valerie Marmolejo, DPM, MS says a perceived lack of control and loss of self are significant aspects of the psychosocial health ramifications of a diabetic foot ulcer (DFU).1 For example, Fejfarová and Jirkovská note that weightbearing restrictions impact the patient’s ability to perform daily activities, including work-related activities.2 Dr. Marmolejo says this may have a negative impact on a patient’s attitude and self-confidence.1-6
How might these patient challenges pose further treatment challenges for the clinician?
“A key component in treating a patient with a chronic wound is to know that negative emotions will be involved,” says Dr. Marmolejo.
The panelists agree that patients may express these negative emotions in a variety of different manifestations and behaviors. Patients may direct fear and anger at the provider, explains Dr. Marmolejo. She says it is important to understand the underlying reasons for these behaviors and still try to build a positive patient-provider relationship.
Patients with depression may not keep scheduled appointments, which challenges the provider to adequately and promptly address their condition, according to Dr. Suzuki. In addition to appropriate referrals to psychiatric professionals, Dr. Suzuki emphasizes awareness of pain management options.
“I do my best to be proactive about pain counseling and management as there are many pharmacological interventions,” says Dr. Suzuki.
For pain management, he notes that he would have patients start with acetaminophen around the clock (maximum 3,000 mg per day in divided doses) and use narcotic medication (such as tramadol, hydrocodone and oxycodone) for breakthrough pain. Dr. Suzuki says adjunctive pain medication options may include gabapentin, pregabalin (Lyrica®, Pfizer) and duloxetine (Cymbalta, Lilly). He adds that many of his patients also self-medicate with CBD supplements.
When it comes to pain control interventions, Dr. Fassman cautions providers to be aware of unwanted side effects such as somnolence, confusion or even addiction.
Dr. Fassman adds that clinicians should carefully weigh and balance non-clinical issues such as transportation challenges and large or repetitive copays when formulating an appropriate treatment plan that still prioritizes positive outcomes.
What strategies have you employed to prevent or address psychosocial issues during wound treatment?
“I try to be direct and concise with patients who have chronic wounds,” says Dr. Fassman. “I will utilize phrases such as ‘It is essential, Ms. Jones, that you keep your appointment with me next week,’ or ‘It is critical you control your blood sugars in order to heal the wound and prevent you from losing your foot.’”
Dr. Marmolejo relates that taking into account a patient’s psychosocial health is important and begins with a thorough assessment of a patient’s level of education, employment history, history of alcohol, tobacco and drug use, how the patient interacts with his or her social network, the patient’s knowledge and perception of how his or her comorbidities affect health, the patient’s goals of treatment and reasons for previous treatment successes and failures if applicable.1,2,5,7
Dr. Suzuki explains that he strives to be as empathetic and positive as possible during interactions with patients. He adds that close communications with primary care doctors and the patient’s family may also be helpful. Judicious use of antidepressant medications and help from psychiatry colleagues may also be worthwhile, maintains Dr. Suzuki.
Do you have any interesting case examples from this population to share with readers?
Dr. Suzuki shares a case of a woman in her mid-40s with chronic leg wounds over 10 years due to thalassemia (a genetic blood disorder that causes anemia), resulting in multiple hospital admissions. He notes the patient is clinically depressed and only presents for appointments every other week or so. He relates that he sees this in other patients that deal with chronic, lifelong diseases. While some of these patients manage reasonably well, Dr. Suzuki says others experience hopelessness and neglect their medical conditions.
Dr. Fassman relates seeing a recent patient with a chronic, plantar foot ulceration. As an attorney, the patient found it challenging to be able to offload appropriately as he had to be in court and meetings, etc. The patient unfortunately developed a limb-threatening infection, which required hospitalization a few days before a planned vacation out of the country. The patient adamantly expressed he was leaving for his trip “no matter what.”
“I utilized phrases with him such as ‘You have a limb- and potential life-threatening situation if you take a long flight out of the country,’ and ‘It is essential you stay in the hospital where you will have the support and care necessary,’” emphasizes Dr. Fassman. While it took repeated efforts, Dr. Fassman notes the patient did eventually cancel his trip.
A frequent concern she hears from past students, residents and fellows, says Dr. Marmolejo, is how to discuss the situation with a patient when an amputation is required. Taking the potential negative aftermath out of this conversation is a talent honed with time, according to Dr. Marmolejo.
“This conversation can be traumatic for the patient, causing a multitude of emotions, including aggressive and negative ones that may be provider-directed,” notes Dr. Marmolejo. “The provider must learn to give the patient grace, understanding and honesty, and not take the expressed emotions personally. Additionally, one must strive to understand the patient’s perspective and concerns in order to address him or her appropriately, building a relationship with the patient that facilitates the best functional outcome and quality of life.”
Dr. Fassman is a Fellow of the American College of Foot and Ankle Surgeons, and a Certified Wound Care Specialist (CWS). A Diplomate of the American Board of Foot and Ankle Surgery, Dr. Fassman is in private practice in Colorado Springs, Colo.
Dr. Marmolejo is a clinical wound specialist with LifeNet Health and is a medical writer with Scriptum Medica.
Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles, CA. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles, CA. He can be reached at Kazu.Suzuki@cshs.org.
1. Beattie AM, Campbell R, Vedhara K. ‘Whatever I do it’s a lost cause.’ The emotional and behavioural experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers: a qualitative interview study. Health Expect. 2014;17(3):429-439.
2. Fejfarová V, Jirkovská A, Dragomirecká E, et al. Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with diabetes mellitus? J Diabetes Res. 2014:371938. DOI: 10.1155/2014/371938. Available at: https://www.hindawi.com/journals/jdr/2014/371938/. Published March 25, 2014. Accessed April 13, 2020.
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