Palliative Care Resulting in the Recovery of an İschaemic, Ulcerated Foot With İndications for Amputation: Case Report

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Palliative Care Resulting in the Recovery of an İschaemic, Ulcerated Foot With İndications for Amputation: Case Report


AMPUTASYON ENDIKASYONU OLAN İSKEMIK ÜLSERLI AYAĞIN PALYATIF BAKIM SONUCU İYILEŞMESI:
OLGU SUNUMU
ÖZET
Giriş: Palyatif bakım servisi ve evde sağlık hizmetlerinin koordineli bir şekilde çalışması hastaların takip ve tedavisinde
önemli rol oynamaktadır. Bu olgu sunumu ile seçilmiş hastalarda birimler arasındaki koordinasyonun
tedavideki etkisini göstermeyi amaçladık.
Olgu: Evde sağlık hizmetlerinin evinde ziyaret ettiği 78 yaşında bayan hastanın sağ ayakta 2 yıl devam eden kronik
yarası mevcut. Yara sağ ayak bileği laterale doğru uzanan, 4X5 cm. genişliğinde enfekte görünümlü idi. Amputasyon
kararı verilmesine rağmen hastanın bu durumu reddettiği öğrenildi. Palyatif bakım servisinde 3 haftalık
takip ve tedavisi sonrası yarası düzeldi. Evde sağlık hizmetlerinin kontrolünde olacak şekilde taburcu edildi.
Tartışma: Palyatif bakım destek ihtiyacı olan kronik hastaların hayat kalitesini artırmayı amaçlar. Evde sağlık hizmeti
ile palyatif bakım servisi arasındaki koordinasyonun hastaların takip tedavisindeki başarıyı artırmaktadır.
Anahtar sözcükler: Palyatif bakım, evde sağlık hizmetleri, koordinasyon, yara
ABSTRACT
Aim: The home healthcare services and palliative care services are co-ordinated in our hospital by the Family
Medicine Department. With this case presentation, it was aimed to emphasise the importance of co-ordination of
the palliative care unit with home healthcare services in the treatment and care of selected patients.
Case: A 78-year old female was evaluated by the home healthcare services because of a wound in the left foot
which had not recovered for 2 years and was then admitted to the palliative care unit with an infected wound 4
x 5 cm in the distal of the left ankle extending laterally. Amputation of the injured foot had been recommended
to the patient but she had refused that option. At the end of the 3rd week of palliative care, the foot wound was
seen to have improved and the patient was discharged with follow-ups to be made by home healthcare services.
Discussion: Palliative care is a branch which aims to help patients who are not fully recovered because of a chronic
disease or who require end-of-life support. In the case presented here, a 78-year old female patient was monitored
by home healthcare services but routine dressing changes were not applied and further treatment was required.
The patient was referred to the palliative care unit, was admitted and recovered with the appropriate treatment.
Keywords: Palliative care, home healthcare, coordination, wound
Correspondence:
Assoc. Dr. Ali Ramazan Benli
Karabuk University, Family Medicine, Karabuk,
Turkey
Phone: +90 505 515 23 65
E-mail: dralibenli@gmail.com
Received : May 31, 2017
Revised : August 18, 2017
Accepted : August 19, 2017
Benli AR et al.
ACU Sağlık Bil Derg 2019; 10(2):306-310 307
Palliative care is defined as the care given with a
biopsychosocial approach to improve the quality
of life of patients with life-threatening or serious
diseases (1). In addition to pain management, nutritional
support and care education, psychological and social
support are also provided to the patients when necessary
(2). In our hospital, the home healthcare services and the
palliative care services are co-ordinated by the Family
Medicine Department. Weekly visits were made with all
home healthcare service staff in the region for a training
in the palliative care unit. Thus, the progress of therapy for
patients was kept and provided. The case presented here
emphasises the importance of the co-ordination of palliative
care services with home healthcare services in the
treatment of selected patients.
Case
A 78 -year old female was admitted to the palliative care
unit after consultation with interactive photographs of
a wound on the foot which had been evaluated by the
home healthcare services team. The patient, who had
chronic, ischaemic heart disease and using metoprolol
50 mg/day, amlodipine 10 mg/day, candesartan hydrochlorothiazide
16-12.5 mg/day and acetylsalicylic acid
100 mg/day. Her fasting blood sugar levels were between
100-150 mg/dl and HbA1c was 6.2% and no medication
was being taken for diabetes. She was living alone and in
a good general condition, co-operative and mobile. The
patient could partially manage her own personal care, but
had a wound on the left foot which had persisted for 2
years. The wound of approximately 4 x 5 cm in size in the
distal of the left ankle, extending laterally, was ulcerated,
infected and had discharged (Figure 1). The patient had
been protecting the foot with the suppurating wound in
a plastic bag. Antibiotic therapy had been given sporadically
and dressings had been changed during the home
healthcare services visits by the homecare physician, but
the leakage had not recovered. The patient was then seen
by orthopedics and plastic surgery departments and amputation
was recommended for the wounded foot but
she did not accept it and was referred to the palliative care
unit and hospitalized for advanced wound care.
The laboratory test results were normal and on the
Doppler ultrasound of the venous system, a reflux discharge
was observed at the parvo-popliteal junction
along the valsalvae. On the left arterial colour Doppler ultrasound,
post-stenotic, monophasic discharge was seen
in the distal popliteal artery, slight monophasic discharge
in the tibialis anterior-posterior at ankle level and in the
dorsalis pedis arteries, together with a widespread calcified
plaque. A culture was taken from the wound, then
the infected, necrotic parts were debrided. As empiricial
antibiotic therapy, ampicillin sulbactam 4 x 1 gr was started.
As Pseudomonas aeruginosa proliferation was determined/
detected in the culture, the antibiotic treatment
was continued with levofloxacin 50mg 1 x 1. The wound
dressing was being changed daily. To assist epithelialisation,
Bactigras was applied (Leno/perforated gauze
soaked in soft paraffin containing 0.5% chlorhexidine acetate).
Upon the recommendation of the cardiovascular
surgeon, the patient was administered with ilomedin (iloprost
trometamol) 1 x1 IV in 150ml isotonic over 3 hours.
At the end of 3 weeks, the wound in the foot had recovered
(Figure 2) and the patient was discharged from the
hospital to be followed up by home healthcare services.
Discussion
It is known that with the current increase in life expectancy,
the proportion of elderly in the general population
has increased and these rising numbers are predicted to
Figure 1. Wound before treatment
Palliative Care in İschaemic, Ulcerated Foot
308 ACU Sağlık Bil Derg 2019; 10(2):306-310
continue. This is also associated with an increase in chronic
diseases causing disability and leading to death. In Turkey,
7.3% of the population are aged over 65 years, and of
these, 12.3% are disabled (3). Many patients with chronic
diseases who cannot leave their homes ,because of some
restrictons, require(need) experienced care at home, as
do those with mental or physical disabilites (4). In recent
years, the increasing cost of healthcare has changed the
role of hospitals and the need of health care (for) these
individuals with a labour force outside the family and the
use of technology has become a topic of importance (5,6).
In the case presented here, a 78-year old female patient
was monitored by home healthcare services but routine
dressing changes were not applied and further treatment
was required. The patient , who was referred to the palliative
care unit, was admitted and recovered with the appropriate
treatment. In our hospital, the home healthcare
services and the palliative care unit are co-ordinated by
the Family Medicine Department. Hospitalized patients
in the palliative care unit were evaluated by other home
healthcare services staff in the region for training at weekly
visits . With the case presented here, it was aimed to emphasise
the importance of the co-ordination of palliative
care services with home healthcare services in the treatment
of selected patients.
The management of home healthcare services in Turkey
was published by the Ministry of Health in 2005. Then,
guidelines on the principles and national applications of
home healthcare services came into force in 2010 and in
this context it was aimed to provide an effective, productive,
pleasant and people-centred healthcare service at
homes within a family environment following the principles
of equality and justice for those individuals in need
(7,8). Patients who require monitoring at home because
of disability or who are elderly, bedridden or in similar
circumstances are able to benefit from this service. The
legal regulations were then made for the establishment
of palliative care units in hospitals and the first comprehensive
palliative care centre was opened in Ankara Ulus
State Hospital (1).
Rather than incurring a lengthy hospital stay and for
reasons other than being sick, home healthcare service
is given to meet the care needs of an individual in their
own environment (3). Provision of the necessary longterm
healthcare to these individuals creates problems for
both in-patient institutions that attempting to meet these
needs and for the individuals and their families.
Palliative care is a branch which aims to help patients who
are not fully recovered because of chronic disease or who
require end-of-life support. At the point of starting curative
treatments, symptomatic and relieving approaches
have a significant place within palliative care. The World
Health Organisation (WHO) recommends the integration
of healthcare services at all stages with a weighting given
to primary care. The healthcare system integration of palliative
care is accepted as a significant indicator of end-oflife
care quality (9).
Community-based palliative care, especially together with
the application of healthcare services at home, is associated
with a better symptom control, increased patient satisfaction,
fewer presentations at(admissions to) the hospitals
and lower costs (10-12). Not every family may be able
to care for a terminal stage family member, or if they do
undertake the care, may later experience their own physical
or psychological deterioration. When the patient’s
symptoms cannot be sufficiently controlled (pain, nausea,
Figure 2. Wound after treatment
Benli AR et al.
ACU Sağlık Bil Derg 2019; 10(2):306-310 309
dizziness, vomiting, respiratory problems, discomfort) or
when the patient deteriorates because of inadequate care
at home or there is nobody in the family to provide care
or when the home healthcare service personnel cannot
cope with psychosocial and mental problems of the patient,
the in-patient palliative care institutions, come into
operation (13).
Palliative care service is accepted when there is no possibility
of care to be given/provided at home or the symptoms
related to the disease cannot be brought under
control by the home healthcare services. When the problem
,which has caused the patient to be admitted to the
palliative care unit, is brought under control, the patient
will be/can be discharged to allow a return to a familiar
environment (13).
The collaboration of the palliative care units with the
home healthcare services increases the efficiency of the
service. When there is evidence that close monitoring
of the patient would contribute to the treatment, rather
than remaining at home, the patient can be admitted to a
palliative care unit for a period of time then later it will be
appropriate again to continue with the home healthcare
services. During the period of hospitalisation, training given
to those undertaking the care at homes and increasing
the co-ordination will provide an interactive solution to
the patient’s problems.
In the model applied in Germany, the co-ordination of
the home healthcare services provides the possibility of
hospitalisation when necessary during the course of a disease
or for the treatment of terminal stage patients. The
family physician monitoring the disease is responsible for
making all the necessary interventions for palliative care
when the patient is at home. To meet the knowledge requirements
of healthcare personnel working in the area
of home care, training on palliative care is given within the
service at regular intervals. (13).
The palliative care units in Turkey have been partially
implemented on the model (Table 1) formed in the
guidelines prepared based on examples from around the
world (14). According to this model, education and training
related to treatment and care at home are provided
to relatives of the patient and carers by an experienced
team in patient care at home, and psychosocial support
is provided for the family of the patient. The family physician
plays a role in the follow-up and treatment of the
patients and their families and in the referral to a palliative
care unit or centre according to the course of the disease
and requirements (14).
Table 1. Palliative care model
1. Institutions for in-patient treatment
- Comprehensive palliative care centre (CPCC, 3rd stage)
- Palliative care centre (PCC, 2nd stage)
- Palliative care unit (PCU, 1st stage)
2. Home care programs (HCP, 1st stage)
3. Family physician (FP 1st stage)
4. Hospice
Palliative care and home healthcare services are part of
the structure of the Family Medicine Department at our
university and the/our service is provided in an integrated
manner with other home healthcare service units in the
region. Evaluation of the hospitalised patients in the palliative
care unit, weekly visits with home healthcare service
units and in-service training are provided. Patients that
are seen to be suitable for the services by family physicians
can be referred.
As seen in the case presented in this paper, the importance
must be stressed on the co-ordination of the palliative
care unit and the home healthcare services in respect
of the care and treatment of selected patients. Palliative
care requires a multi-disciplinary and inter-disciplinary
approach. A multi-disciplinary approach to care is essential
and requires units known to the patient, such as
the home healthcare unit or the family physician, within
the team and must include a team leader to co-ordinate
the whole team. The most appropriate discipline for this
is Family Medicine, which demonstrates an integral and
comprehensive biopsychosocial approach to the patient.
Palliative Care in İschaemic, Ulcerated Foot
310 ACU Sağlık Bil Derg 2019; 10(2):306-310
References
1. Benli AR, Erbesler ZA. Differences on comprehension and practice in
palliative care in Turkey. Turkish Journal of Family Practice 2016;20:5-
6. [CrossRef ]
2. Inci F, Oz F. Palliative Care and Death Anxiety. Current Approaches in
Psychiatry. 2012;4:178-87. [CrossRef ]
3. Limnili G, Ozcakar N. The characteristics of applications to home
health care service and expectations. Turkish Journal of Family
Practice 2013;17:13-7. [CrossRef ]
4. Moise P, Schwarzinger M, Um M. Dementia in 9 OECD countries: a
comparative analysis, In: Organisation for Economic Co-operation
and Development, Paris 2004. pp.14
5. Jacobs P, Finlayson G, Faienza B, Brown M, Newson B, MacLean N.
The development of a tool to assess quality of cost estimates. Dis
Manage Health Outcomes 2002;10:127-32.
6. Larsson BW, Larsson G, Carslong SR. Advanced home care:
patients’opinions on quality compared with those of family
members. J Clin Nurs 2004;13:226-33.
7. Memisoglu D, Kalkan B. Governance and innovation in healthcare
services and Turkey. The Journal of Faculty of Economics and
Administrative Sciences 2016;21:645-65.
8. Altuntas M, Yılmazer TT, Guclu YA, Ongel K. Home health care service
and recent applications in Turkey. The Journal of Tepecik Education
and Research Hospital 2010;20:153-8.
9. WHO. Sixty-seventh World Health Assembly, In:Resolutions and
Desicions. Geneva 2014, pp12-8.
10. Brumley R, Enguidanos S, Jamison P, Seitz R, Morgenstern N, Saito
S, et al. Increased Satisfaction with Care and Lower Costs: Results
of a Randomized Trial of In-Home Palliative Care. J Am Geriatr Soc.
2007;55:993-1000. [CrossRef ]
11. Pham B, Krahn M. End-of-life care interventions: an economic
analysis. Ont Health Technol Assess Ser. 2014;14:1-70.
12. Smith S, Brick A, O’Hara S, Normand C. Evidence on the cost and
cost-effectiveness of palliative care: A literature review. Palliative
Med. 2014;28:130-50. [CrossRef ]
13. Bag B. Palliative care practices in Germany’s health system. Turkish
Journal of Oncology 2012;27:142-9. [CrossRef ]
14. Kabalak A, Ozturk H, Erdem AT, Akın S. A comprehensive palliative
care implementation in S.B. Ulus State Hospital. Journal of
Contemporary Medicine 2012;2:122-6.