Chronic limb‐threatening ischaemia and reframing the meaning of ‘end’

Abstract

Introduction The possibility of amputation and/or death from chronic limb‐threatening ischaemia (CLTI) is real, and deeper understandings of the person and family's capacity and preparedness for limb loss and clinical interventions (active or palliative) are required. Background The lead‐in period to the surgeon's recommendation for amputation for CLTI may be sudden or protracted; the number/invasiveness of previous revascularisation interventions varies, and limb loss and end‐of‐life considerations frame the experience. Method This prospective, longitudinal, interpretative phenomenological study in three vascular surgical units involved 19 CLTI journeys. Participants were interviewed when making decisions about amputation (15 patients, 12 family members) and, where applicable, 6‐months postamputation (8 patients, 7 family members). Hermeneutic interpretation using Heidegger's philosophical construct of Being‐towards‐death guided the analysis. The COREQ checklist ensured rigour in research reporting. Findings Some participants were unable to face the possibility of death and metaphorically ‘fled’, either through productive optimism or through hoping for more time (Heidegger's inauthentic positioning towards death). For others, authentic positionings of Being‐towards‐death were understood as: the confrontation of the certainty of their death by making choices about how to die; the indefiniteness of death where treatment choices influenced timing, yet the time for death remained unknown; the nonrelational nature of death, as the journey could only be lived by the person; and death as not to be outstripped, where for some, there was a freeing of oneself for amputation and/or death. Discussion The term ‘end of limb’ to denote the futility of the limb is a useful marker that emphasises the noncurative nature of CLTI. This may help to instigate and support discussions about end of life to support palliation care planning and the person and family's existential preparation for death. Conclusion Death frames the experience of CLTI. Using ‘end‐of‐limb’ and ‘end‐of‐life’ terminology may facilitate a family/patient‐centred approach to possible amputation and other conservative or palliative strategies. Relevance to Clinical Practice Understanding of CLTI illness experience. Decisions about revascularisation, amputation or conservative care. End‐of‐life care for CLTI.

Chronic limb‐threatening ischaemia and confronting amputation: A Heideggerian derived understanding of Being‐with and discourse

“…Unfortunately, these discussions may occur in ‘chaotic’ vascular surgical units where multiple stakeholders, cultural and linguistic diversity and information overload can make it hard for patients and families to receive the information they need from busy clinicians (Monaro et al, 2018). The relentless pain, declining body function (Monaro et al, 2020; Quon et al, 2011; Senra et al, 2012) and the person's authentic positioning to their own death (Monaro et al, 2021) lead to an existential crisis that may either facilitate or obstruct meaningful conversations about palliative treatment options like amputation. The person's cognitive capacity to participate in treatment discussions is a further barrier (Monaro, 2018; Quon et al, 2011), and while decisions may be made suddenly for some due to critical deterioration, for others, a decision to engage in amputation may evolve over years (Quon et al, 2011).…”