by Holly Hovan MSN, APRN-ACNS-BC, CWOCN-AP
by Aletha Tippett MD
In considering this question as to whether amputation can be palliative, let’s keep clear that these are two separate subjects that sometimes interact. It is key to always keep our goals in mind. What is the goal in palliative care? The goals are to provide comfort, relieve pain, prevent infection, and improve or maintain quality of life. These goals are always to be in concert with the desires and wishes of the individual patient.
Is limb salvage automatically a palliative endeavor? Not necessarily. It depends on the patient and their desires/needs and the reason to consider amputation. Let’s consider several cases:
Case A. A 90 year old woman with advanced dementia, chairbound, has a wound on her lower leg that does not respond to various treatments. Treatment is further complicated by the patient not understanding what is happening and frequently undoing or otherwise interfering with the wound dressings. This wound and treatments cause the patient discomfort. Ultimately the patient is taken for an AKA that heals nicely. The patient is not aware that she has lost her leg and she remains chairbound, very comfortable with no further discomfort from dressing changes.
Was this amputation palliative? I think the answer is yes. The patient’s quality of life was improved.
Case B. A 59 year old with diabetes has an infected heel ulcer with infection deep to the calcaneus. The patient stated she never wanted an amputation and she would do anything to save her leg. She was being treated at home and even started maggot therapy on her heel. She had to go to the hospital to get a blood transfusion, but once there she was seen by surgeons who removed her maggots and amputated her leg.
Was this amputation palliative? I think the answer is no. Amputation may have gotten rid of the infected heel, but for this ambulatory, active patient who did not want an amputation, limb salvage efforts would have been palliative for her.
Case C. An 85 year old man is in hospice for end stage cardiac disease. He has painful ulcers on his right lower leg due to his peripheral arterial disease. The family states they were told he needed the leg amputated. The hospice doctor told them that amputation would not change his disease, may hasten his death, and would leave him with other problems—he may still have pain and his amputation stump might not heal. He only has a short time to live, so the hospice doctor suggested to keep him comfortable with pain medications and topical treatments to prevent infection in his wounds. The family agreed to no amputation.
Was not amputating a palliative decision? I think the answer is yes. The hospice doctor was correct. Amputation for this patient would not help him. Treating his pain, painting his ulcers with betadine, and keeping him comfortable would be a palliative response.
Reasons to amputate a person’s leg that are given are: pain, infection, malignancy, trauma, ischemia, gangrene and non-healing wounds. Some of these, such as a malignancy or trauma, where a limb is destroyed, do require amputation. But all the others can be treated with limb salvaging techniques, in concert with patient desires and needs. Saving a limb can mean saving a life. For more information on this topic, download the presentation here [PowerPoint].
About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.