Peripheral Arterial Disease (PAD) can be successfully managed if it is diagnosed in a timely manner, when it is still in the nascent stage and does not cause significant issues and the patient is compliant with the physician’s recommendations, starting with lifestyle changes. Failure to do so might lead to a myriad of severe complications, including limb amputation.
Lower-limb amputation is, of course, not an inevitable end result of even severe PAD, but is still not uncommon in those patients that have comorbid medical conditions like diabetes, which greatly exacerbates already difficult treatment of some PAD-related issues, i.e. arterial insufficiency ulcers. Also known as ischaemic wounds, they represent 10 to 30% of all types of lower-extremity ulcers and are notoriously difficult and expensive to treat (in comparison with other types of wounds) .
If left untreated or poorly treated, they can progress into gangrene, which is an important component of critical limb ischaemia (CLI) – an advanced stage of PAD (rest pain and tissue loss due to ischaemic wounds and/or gangrene) that has a very poor prognosis. Mortality rates for patients with CLI diagnosis range from 20% in the 6-month period to 50% 5 years after diagnosis [2, 3, 4]. Amputation rates range from 10% to 40% (for a 6-month period after diagnosis) [5, 6].
Another significant cause of lower-limb amputation is, of course, diabetes itself. It is estimated that diabetics are at 15 to 20 times greater risk of amputation in comparison with healthy, non-diabetic patients . Due to other complications associated with diabetes, mortality rates following amputation are even higher than in PAD, ranging from 39% to 80% in the 5-year period after the procedure .
It should also be noted that there is significant comorbidity between diabetes and PAD. Intermittent claudication, the most typical symptom of PAD, is 3.5 times more prevalent in male and 8.6 more prevalent in female diabetics than in non-diabetics (of each respective gender) . And about 50% of patients with CLI are also diabetic . Needless to say, patients with both diseases are at a significantly higher risk of amputation and it is quite likely that clinicians who treat them will have to, in some cases when all other options are exhausted, inform them about the need for an amputation.
How to tell a patient about amputation?
Breaking the news to patients that they are going to lose a limb, especially a leg, limiting their mobility (this particularly impacts individuals who are otherwise physically active), falls into the same bracket as news about cancer diagnosis and prognosis or any other medical conditions with profound negative effects on the patient’s health and well-being. Tact and consideration for the patient’s mental and physical state before telling the patients news of such gravitas is a must. We have therefore prepared a useful list of 6 steps with detailed instructions each physician tasked with this difficult duty should follow to make their job a bit easier.
1. Setting up the interview/preparing for the information reveal
Physicians should mentally rehearse what they are about to say to their patient in regards to the amputation. That includes preparing answers on possible questions that might arise following the reveal of information (still, it is difficult or nearly impossible to prepare oneself for all the possibilities) and how they will respond to the patient’s emotional reactions. Care should be exercised when choosing the appropriate setting and time as both have significant effects on how the patient will respond to the news.
The information should be disclosed in the most confidential/private setting possible under the given circumstances and preferably with the presence of a significant other (if the patient has one), but only if the patient themselves wish that. Don’t rush when conveying to the patient the need for an amputation, take your time and try to make a connection with your patient (maintain eye contact).
2. Assessing how the patient will understand the information
Before actually telling the patient the bad news, the physician should ask the patient what they think about their current medical situation: how serious it is, were they given enough information beforehand to have a reasonably complete and accurate picture of their health. Based on the patient’s feedback the physician can accommodate the amputation news in such a manner that the patient will understand it. This also helps detect the presence of maladaptive coping styles on the part of the patient that would hinder further conversation about the amputation and treatment after the procedure itself.
3. Leading the patient to ask about the diagnosis themselves
In general, the majority of patients will want to hear the full information about their current medical situation and need for drastic measures to save their life, i.e. amputation. This usually reduces the anxiety in physicians who are about to break the news, but that still doesn’t offer an accurate prediction as to how exactly the patient will react when he or she hears the news. The physician should accordingly lead the initial conversation in such a manner as to arouse curiosity in their patient and not force the information on them without proper preparation.
4. Giving the patient necessary information
Even if the patient gives cues that they suspect the news might be bad, it is still recommended that the physician warn them about the nature of the news. This should be done tactfully and at a level of comprehension appropriate for the patient, primarily by explaining the seriousness of their condition using unambiguous, nontechnical terms.
The patient’s reaction on the news about the need for an amputation may vary widely from silence and disbelief to intense emotional outbursts like crying and anger. In the latter cases physicians should offer support and solidarity with the patient through an empathic response. This usually consists of 4 steps. The first one is observing any emotion on the part of the patient, followed by identifying the emotion (the physician might ask the patient, but only if it seems appropriate). The third is identifying the reason for the emotion, as it might not be directly associated with the bad news (asking again might be appropriate). At the end, after the patient has expressed his feelings, the physician should let the patient know that they have connected the emotion with the reason for the emotion by making a connecting statement.
In simple terms, the physician acknowledges the patient’s suffering and fear of what the future will bring, particularly after the procedure – primarily through words (“I understand how you feel. I am sorry the news is not better.”) although a light touch (touching the patient’s arm or hand) might also be appropriate (if the patient is comfortable with this). The purpose of this is also for the patient to calm down sufficiently to be able to resume the conversation with the physician about the details of the procedure, aftercare, use of a wheelchair or a prosthetic leg, etc. Sometimes, it might be necessary to postpone this type of conversation (look at 6. Aftermath management).
6. Aftermath management
Patients who are aware of the seriousness of their medical condition and the need for the procedure and have plans for the future that include activities and life in general without a limb are usually less anxious and uncertain. Physicians should, of course, ask their patient if they are prepared to discuss the aftermath of the procedure, possible complications, the need for continuing management of the medical conditions that resulted in the need for amputation (diabetes, PAD or others) or other non-associated diseases the patient might have.
Breaking bad news, like the need for a limb amputation, to patients is a difficult task, but physicians can prepare themselves by following a few simple steps that are also applicable for conversations about other challenging topics.