Palliative Care for Our Diabetic Amputees: Should this be a Standard of Care?

There are many opportunities to deliver palliative care with patients who have wounds.

First, wounds can be painful and we spend great effort in attempting to control pain related to the care of wounds. Second, we have wounds that are not expected to heal over some short time span; for these patients we practice utilizing a chronic disease model where the speed of how quickly we cure them is not the priority. Third, we take care of patients whose wounds are secondary to an underlying disease process which is not specifically under our control, as with fungating cancerous wounds.

When we think of patients with cancer who have significant disease burden, the thought of a palliative approach to the care of those patients is not surprising and is probably a standard of care at some point and at some level. However, in our wound centers, we have patients who have expected life spans less than many commonly encountered malignancies and we do not formalize palliative discussions with those patients: these are the patients at risk for an amputation or who have had amputations.

The Danish scientific article related to the diabetic foot[1] was just published which revealed that the time from first amputation to death was 2.5 years. The five-year mortality was 43% in those patients with amputations with type 1 diabetes and 52% in those patients with type 2 diabetes. These mortality numbers are comparable to many forms of cancer. The wound care community should include palliative care discussions for any patients who have had amputations or are at risk for impending amputation. The situation indeed is very grave when you look at the statistics.

Our wound centers are filled with clinicians from multiple specialties, many of which do not have training in palliative care. Referral to or association with palliative care programs (in some cases hospices) that offer their expertise would be of great benefit to our patients. Palliative discussions with all patients with diabetes and amputations should probably be a standard of care rather than an exception to the rule. It is easy to also extend these services to patients with multiple chronic diseases who presented to the wound center with an end-stage process including those with atherosclerotic disease of the peripheral arteries.

© 2016 Scott Matthew Bolhack, MD, MBA, CMD, CWS, FACP, FAAP

[1] The diabetic foot and a multidisciplinary team setting. Number of amputations below ankle level and mortality. Wilbek TE, et al. Exp Clin endocrinol Diabetes. 2016