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Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA |
As podiatric physicians, we spend a lot of time trying to save the limbs of unfortunate souls who've gotten themselves into dire straits. Sadly, sometimes, despite everything we do, some patients' limbs just cannot be saved. Where should we draw the line? Is there a point where we should just stop and let nature take its course?
 Recently, in a confluence of events, I had several patients in the hospital with terrible limbs. I found myself in the unfortunate situation of having to tell the medicine service that a couple of these patients would do better with limb amputations. (Oddly, all of them had incredibly poor vascular supply combined with significant pedal involvement.) What made a couple of these situations worse was that other consulting services disagreed with my recommendations.
One of the patients was a very elderly gentleman who had dry gangrene involving a large portion of one of his feet. A very sick man, he was diabetic, on renal dialysis, demented, and no longer ambulatory. Additionally, the patient had minimal arterial perfusion to his foot. Given the patient's frailty, severe comorbidities, nonambulatory status, and predicted short remaining life expectancy, I recommended a below knee amputation.
What was I thinking? Why not try to do everything possible to save the patient's limb? Why give up so easily? My simple answer is that I live in the real world where academic answers don't always end up with the best patient results.
With that in mind, here's my thought process for determining how aggressively to treat a patient in the real world.
Considerations in How Aggressively to Treat Limb Salvage Cases
- Is the patient likely to benefit from my intervention for a reasonable amount of time?
- Is there an appropriate alternative?
- Does the patient want the proposed intervention?
- Are the risks of the treatment outweighed by the benefits?
These questions are applicable to all treatment decisions regardless of the situation. It doesn't have to be as high stakes as limb amputation. Let's take a clinical example. Say you're seeing a 40-year-old, 200-pound man with a complaint that you've diagnosed as hallux rigidus. After failed nonsurgical treatment, the patient has requested surgical intervention. For the sake of discussion, let's say you've chosen two options: fusion versus implant arthroplasty. Looking at the questions above, you might answer no to question 2, since the alternative treatments have been tried. You've already answered yes to question 3, since the patient is requesting surgery. Questions 1 and 4 are related in the sense that you are weighing benefits in light of the patient's specific situation. You know that a 40-year-old, 200-pound male is likely to destroy a great toe implant in a short period of time. You know he may in fact benefit from this, but for too short a time period and will likely need revision in a very short time. The benefits of the procedure don't last long enough to outweigh the risks. You might then consider the fusion procedure over the implant arthroplasty.
There's nothing foolproof about this calculation. I once spent a full year trying to save a patient's leg that had previously had a Charcot arthropathy after an ankle fracture. I had initially offered the patient an amputation, but she wanted to fight. I weighed question #3 to such a high extent that my patient and I violated question #4. In hindsight the risks had not outweighed the benefits.
Now, getting back to my original patient. My recommendation for limb amputation boiled down to answering no to question 1. This patient would have to undergo revascularization first. Assuming that was successful, the next step would be an open transmetatarsal amputation and debridement of the large heel wound. Given the rest of the patient's medical history, I knew his limb healing timeline would be extended with all of the inconveniences and trials that would go along with it. Was limb salvage possible? A guarded yes was my answer. But this would take up a significant portion of the remaining life of the patient. What benefits did the patient achieve? Likely very few. However, the patient and his family wanted to try, and the other doctors agreed with them. I was overruled.
Sometimes – despite our desire to keep fighting – we just have to say enough is enough. It's never an easy decision, but having a system or method in which to approach this difficult subject makes the decision at least possible. Consider these four questions the next time you are confronted with a difficult patient care decision.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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