Amputation-free Home Management of Infected Lower Extremity Pressure Ulcer through Shared Decision-making: Enhancing the Quality of Life and Highlighting Societal Significance in Home Care

Abstract

Home healthcare is important for allowing patients to live their lives. However, home-care bedridden patients often experience pressure ulcers in the lower extremities, which can lead to life-threatening infections requiring decisions on the need for amputation. We herein report a patient with an infected lower-limb pressure ulcer with a history of spinal injury. The patient, his family, and the home-care physician repeatedly shared decision-making to deliver home-based treatment instead of amputation. Administration of wound dressing, AQUACEL^Ⓡ Ag, led to complete epithelialization. Such shared decision-making and dressing were feasible in a home-care setting and broadened its scope.

Introduction

Home care is of great importance for allowing disabled patients to live as they wish. A healthcare approach that supports home care is of great value to society. Its potential is growing rapidly owing to the development of medical technologies and materials.

However, pressure ulcers on the lower extremities are often experienced by home-care bedridden patients and are a major health issue (1,2). These lesions can develop into osteomyelitis when severe and intractable, leading to sepsis with a 6-month mortality rate as high as 68% (3,4). To control bone infection, amputation of the lower limb is performed empirically as a final treatment, based on the complexity of pressure ulcers (5-7). However, further surgical treatment is accompanied by additional admission periods. Therefore, shared decision-making (SDM) among patients, family members, and healthcare professionals is essential when determining whether patients should receive further surgical treatments or withdraw from treatments to spend their time in peace at home.

As home-care physicians, we experienced a case of SDM with a patient suffering from a severe pressure ulcer in the lower limb, which allowed us to decide not to conduct amputation, thereby resulting in a clinically good outcome.

Case Report

A 79-year-old man with a pressure ulcer on the left ischial area was referred to our home clinic by a plastic surgeon with a complaint of appetite loss, after deciding to receive home visits instead of being admitted to the hospital. Fifty years before receiving home-care, he fell off a roof while working as a carpenter and suffered an L1 compression fracture and spinal cord injury. Since then, he had been bedridden while living with his wife. Sensory and motor loss in the lower limbs persisted after injury. Nineteen years before the present introduction, a pressure injury in his right ischial area developed gas gangrene over the right lower limb. The limb was eventually amputated at the level of the hip joint due to impeded blood flow, presumably because of his heavy smoking history.

From the first visit, the prescription of enteral nutrition products successfully led to the recovery of his appetite. Two months after the first visit, erosion appeared on the left second toe, caused by pressure between it and the third toe. Despite appropriate initial treatment, the erosion gradually worsened to necrosis in the entire second toe accompanied by redness in the dorsal aspect of the foot, suggesting osteomyelitis. Consequently, the patient was referred to a plastic surgeon for amputation of the toe.

Nevertheless, two weeks post-procedure, an erosion in the left plantar emerged due to the bandage over the amputated site, exacerbating into a bedsore that reached the periosteum (Fig. 1A-D). Despite three months of daily cleaning and application of iodine ointment by his wife and visiting nurses, as well as weekly debridement by physicians, granulation growth remained unattained. Given the high risk of osteomyelitis and potentially fatal sepsis, the patient was again referred to the previous plastic surgeon for imaging and consultation regarding future treatment, including possible amputation of the lower limb. Surprisingly, angiographic computed tomography (CT) revealed poor blood flow from the thigh to the periphery, leading to a joint recommendation with another orthopedic surgeon for the same hip joint-level amputation as his right lower limb.

Figure 1.

Redness in the left plantar region with deterioration (A), accompanied by black necrosis two weeks later (B), extending deep to the subcutaneous fat tissue layer another two weeks later (C), and reaching the periosteum another month later (D).

SDM was repeatedly performed to determine treatment plans at home among the patient, his family members, and medical staff. SDM was introduced according to the guidelines provided by several organizations (8,9). First, physicians explained the examination results to the patient. Options for treatment were then provided: undergo hospitalized amputation as suggested by the orthopedic surgeon to achieve infection control or continue home care despite the infection potentially being life-threatening. As the third step of SDM, further decision-making was conducted during the next few consecutive home visits. Conversations were repeated, each lasting more than 30 minutes, to determine what mattered most to the patient. Initially, his daughter, son-in-law, and two granddaughters who lived apart from the patient and his wife recommended limb amputation, as they wanted to spend more time with him. Their feelings stemmed from family ties and having lived together for five years until recently. The patient admitted that prolonging his life was an understandable way of thinking. However, he and his wife eventually expressed the desire to not undergo amputation, based on his prioritizing both his posture and the location where he wished to receive care. His statements as follows were considered by the medical staff to indicate his preparedness, as well as his family members were convinced, to reach his consent to continue home care: “If I have my lower limb amputated at the hip joint, I will have to live the rest of my life on my back, unable to sit up. If that happens, I won't be able to fully enjoy my life, like spending time with my great-grandchildren or enjoying just a small amount of alcohol. That doesn't fit with my view of life. Therefore, I choose not to undergo amputation. I understand that I am risking my life with this decision, but I also choose not to be admitted because I have already suffered more than enough time in hospitals with the amputation of my right lower limb and accompanying events.”

As an alternative treatment after consulting a dermatologist, AQUACEL^Ⓡ Ag, a covering material containing silver ions in HYDROFIBER^Ⓡ, was introduced in combination with iodine ointment in expectation of its specific antimicrobial effect (10), in addition to its general effect on wound dressings that absorb excess exudate. The material costs 3,000 yen (approximately 20 US dollars) for 10 of the 5×5-cm sheets. One sheet was used per day, considering the severity and the considerable amount of exudation. In Japan, insurance coverage for AQUACEL^Ⓡ Ag is limited to bedsores deep up to D3 (depth extending to subcutaneous tissue according to the DESIGN-R scale, a Japanese standard assessment of pressure ulcers) (11). The initial stage of this case corresponded to D4 (depth extending beyond the subcutaneous tissue), which necessitated full payment. The costs for home-visiting nurses were covered by medical insurance according to the reimbursement system for pressure ulcers deeper than D3. Specifically, visiting nurses, as well as physicians, washed the site with tap water, replaced the dressing, and applied ointment on weekdays. During the weekends, no care was planned initially because these days are typically holidays for medical professionals. However, the patient's wife, having worked before as a nurse, voluntarily cared for the site after thorough discussions and medical practice guidance.

The patient was treated with oral antibiotics. One week later, infection control and red granulation growth were observed. Another week after that, oral antibiotics were withdrawn after observing granulation tissue without signs of infection. Two months later, epidermal formation in the left plantar was achieved in the left plantar, signifying the conclusion of the entire treatment (Fig. 2A-D).

Figure 2.

State before treatment (A), followed by achievement of red granulation using AQUACEL^® Ag with iodine ointment one month later (B), partial skin coverage another month later (C), and total skin coverage another month later (D).

Discussion

We encountered a case in which the medical specialist considered amputation of the lower limb appropriate, but the medical team respected the patient's wishes and used AQUACEL^Ⓡ Ag as a non-surgical treatment instead of amputation to achieve full recovery.

Lower limb amputation as a treatment for pressure ulcers with osteomyelitis or intractable ulcers due to severe limb ischemia has been controversial for years. According to a study supporting lower-limb amputation (12), pressure ulcers of clinical stage 4 derived by the Delphi consensus process (based on the depth of the ulcer, ischemia, and presence of infection), which the present case would be classified, had a “high” likelihood of requiring amputation within one year. However, it was reported that the mortality rates for lower limb amputation were 33.7% (at 1 year), 64.4% (at 5 years), and 80.0% (at 10 years) (13), while the amputation-free rate within 1 year was 63%, even in severe cases (14). Of note, we have experienced more than a few cases in which lower limb amputation was performed in consideration of unpredictably large financial and human costs in the future.

In light of such evidence and practice, the present patient chose not to have his lower limb amputated. Two factors support this preference. First, SDM was conducted to clarify and prioritize the patient's values and life purpose. The key elements of SDM under life-threatening conditions are 1) involvement of at least two participants (physician and patient) as parties, 2) bidirectional exchange of information among the parties about existing treatment options with different possible outcomes and uncertainty, and 3) taking steps to build a consensus among the parties about the preferred treatment (15,16). Entering the SDM process is a key competency for all health professionals in support of patient-centered medical practice (16). However, clinicians occasionally hesitate to practice SDM because of limited time (17) and difficulty in explaining the risk to patients or clarifying patients' values (16). As was shown previously among home-visit nurses looking after pediatric patients (18), our case suggested that home-care physicians could also play a critical role in overcoming such barriers to SDM, as could physicians in outpatient or hospital settings, by discussing patients' life purpose during home visits and grasping their desires. However, previous reports point out that 50% of the global population spend only 5 minutes or less with their primary care physicians (19). In contrast, although there are no data available at present, home-care physicians generally spend as long as 10-30 minutes with their patients. According to a previous study, time is an important factor in facilitating SDM (15).

The other factor that supported the patient's desire to continue receiving home care was the use of a covering material. A previous randomized control study showed that pressure injuries with low exudate improved significantly when using AQUACEL^Ⓡ Ag alone compared with povidone-iodine gauze alone (5). The pressure ulcer in our case was presumably more severe than that in the trial, broadening the possibility of non-invasive treatments for severe pressure ulcers in home settings. These findings are in line with an in vitro study that suggested the efficacy of betadine and colloidal silver gel combination against infection (20). However, such treatment effects lack evidence, as it is ethically difficult to conduct clinical trials under life-threatening conditions. As such, more case reports such as ours will be required in the future to expand the possibility of home-based medical care, considering the growing need for such care in super-aging societies, like Japan (21).

Conclusion

Decision-making was shared between a spinal cord injury patient with a foot pressure ulcer reaching the periosteum, his family, and his home-visit clinicians, ultimately coming to the decision not to conduct limb amputation despite specialists' recommendations. Home-based management without hospitalization resulted in recovery using a wound dressing containing silver ions. Home healthcare can play an essential role in supporting patients' decision-making.

The authors state that they have no Conflict of Interest (COI).