The body with chronic limb‐threatening ischaemia: A phenomenologically derived understanding

Abstract

Aims and Objectives To explore person and family lifeworld narratives of chronic limb‐threatening ischaemia (CLTI) after major amputation has been offered as a treatment option. Background Chronic limb‐threatening ischaemia manifests as ischaemic pain, ulceration and/or gangrene and is receiving heightened attention due to the increasing health system burden from associated complex wounds and hospitalisations for repeat procedures. The patient and family impact of these manifestations is not well‐reported: current studies largely seek to measure treatment outcomes. Patient‐reported outcome measurements need to be developed but should be underpinned by rigorous qualitative research. Design Prospective, longitudinal, qualitative design using interpretive phenomenology. Methods The journeys of 19 people with CLTI were explored via 42 semi‐structured interviews with 14 patient and 13 family participants. The initial interview was conducted soon after the advice of the need for major amputation, and where amputation followed, participants were invited for a second interview 6 months postprocedure. Hermeneutic phenomenological analysis was guided by Merleau‐Ponty's philosophy of embodiment. Results People with embodied CTLI faced an existential crisis due to the catastrophic impact of creeping decay of their flesh and vascular system, relentless pain and a sense of spreading poison from gangrene, infection and drugs, which disrupted the interleaving of the physical and existential body. Consequent to the creeping decay and surgery, participants also experienced shifting body boundaries and an unreliable body. Conclusions The lifeworld of the patient and family living with CTLI is irrevocably altered through the disruption of a spontaneous and reliable body. This shapes subsequent therapeutic relationships and discourse. Relevance to Clinical Practice People facing CLTI require early patient‐ and family‐centred discussions about the possibility for major amputation and its potential to arrest the further decline of the body and to support the body's existential expression.

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

“…CLTI has been understood as enduring a difficult process of dying, often in the context of other diseases and age‐related dysfunction. The unfamiliarity of the body with CLTI (Monaro et al, 2019), and at times the severity, impact and speed of disease progression, could therefore make impending death from CLTI a nonrelational or solo experience as Heidegger explains, ‘With death, Dasein stands before itself in its own most potentiality for being… the possibility of no‐longer being‐able‐to‐be‐there’ (Heidegger, 1927/1996, p. 250). This means that we cannot do death ‘with’ others.…”

“…However, in CLTI, this difficulty is further compounded by the frequently clinically indefinite timeline to death. This is a consequence, once toxaemia is controlled through amputation (Monaro et al, 2019), of the potentially reversible nature of limb‐related ischaemia and/or sepsis. Even a late‐stage CLTI‐related amputation can stabilise and arrest toxaemia‐related deterioration.…”

“…This research method allowed meaning rather than measurement, nonreductionism and acceptance of multiple truths, situational context and an understanding of the experience (Todres & Wheeler, 2001). Details of the method and rigour of the overall study have been discussed in manuscripts previously published (Monaro et al, 2018, 2019), which explored other aspects of the experience of chronic limb‐threatening ischaemia. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al, 2007) (Appendix S1) was used to ensure rigour in research reporting.…”

“…The CLTI experience varies in the number and invasiveness of revascularisation interventions in the lead-in to the recommendation for amputation. Recent phenomenological research exploring experiences that shaped conversations and decisions for people advised to have an amputation-uncovered CLTI as a complex and highly individualised decay of the body that unhinges the physical from the existential body (Monaro et al, 2019).…”

Chronic wound care delivery in wound clinics, community nursing and residential aged care settings: A qualitative analysis using Levine’s Conservation Model

“…Finally, the non‐healable nature of some wounds and patients’ often unrealistic expectations for improvement suggest that more honest conversations are required when wound therapies are futile. In such cases, patients should understand their wound care is palliative, and non‐healing signals the irreversible deterioration of a severely diseased limb (Monaro et al, 2020). That one‐quarter of our participants referred to discussions about amputation supports this notion.…”