Should patients be kicked for not wanting to be cut?

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I have started this thread as a separate issue from a recent thread "ulcer on medial aspect of bunion"

On the previous thread i noted that treatment to "offload" the ulcer from HV deformity would be to fix the bloody deformity. (obviously there are other things to consider)

Now the final reply was that the patient did not want surgery.

If you had a patient with a longstanding ulcer from a HV deformity who you had been consulting twice a week for the past year, and you suggested surgery and they would not consider.

Would you be willing to discharge them? Controversial i know!:boxing:

 

If the ulcer is not healed in a timely fashion, it is most likely due to poor circulation or continued pressure over the area. Rule out the former and them place the patient in total contact cast (that recommendation alone is enough for patients to seek another practioner and you will not have to discharge them). Once healed, insist upon depth shoes and discharge if not compliant. I would imagine surgery is not required if the patient is compliant.

 

I understand the vast array of treatment modalities available when treating ulcers. My intent was not to debate these, it was merely asking a hypothetical question. That if all conservative therapies had been exhausted and surgery was the only option and your patient refused, would you discharge?

 

If the pt is not willing to go down the surgical route maybe try find out why - do they have a fear of hospitals (has a relative/close friend died in hospital) If the advantages of surgery has been explained has the opposite been explained - with pictures. Just a thought...:drinks

 

Providing there are no co-morbidities, psychological or social issues, or other reasons that would prevent surgical correction of a hallux valgus deformity of this nature - I would question why anyone sane would receive this extremely high frequency of conservative podiatric care, in place of surgery.

Surgery is just another tool, but it has greater risks and consequences if all does not go well.

However, picture the medical equivalent of this. Say - an unstable coronary artery disease with regular angina pectoris ( yes - I know - an ulcerated bunion is not exactly life-threatening). There would be very few physicians who would tolerate this situtation for long without turning to CABG or stenting to 'fix' the situation.

So, providing a suitable period of conservative care has been attempted (eg 3-6 months), then it should be clear to all and sundry that the non-surgical approach will not succeed.

The issue then of patient choice, and your ethical responsibilities is a professional matter aside from the clinical issues. If the patient refuses surgery, despite your advice, with little explanation or justification, then you still have a responsibility to continue care or refer the patient to a colleague with expertise in ongoing conservative care.

There are never any grounds to abandon a patient and leave them without ongoing alternatives for care.

LL

 

To enter the debate:

Patient consent governs what I do. If I had a patient like this who refused the surgical path, then, from my viewpoint, that is final.

The question then becomes whether to discharge the client or keep treating.

As this patient's podiatrist I would consider if the treatment that I am providing is minimising further degeneration of the wound, or not.

If the treatment is minimising degeneration then I would consider it as the new treatment path. The patient would be informed about the new aim of treatment after surgical refusal.

S/he would be informed of complications/costs of this new approach. The patient's consent governs future treatment.

If the treatment is not, then refer on.

From my viewpoint, I think I would have to be flexible enough to accept that the optimal treatment approach is not going to cure/resolve the wound. So long as the patient is informed/educated and consent is ongoing, then maybe some treatment is better than none.

Darren

 

If a simple Silver type bunionectomy would heal the ulcer and help prevent its recurrence, then I see no reason not to insist on foot surgery for the patient. The main reason that podiatrists don't offer surgical correction to these patients is because they don't know how to do the surgery in the first place or haven't seen the great results that these procedures can give patients.

The patient is more at risk of developing osteomyelitis by having recurrent ulcers occur in dirty socks and shoes than from doing a simple bunionectomy to prevent recurrence of the ulcer under sterile conditions in an operating room. Prophylactic surgery is a very valuable option for these patients and will help them save their limbs and will improve their quality of life.

If I had a patient like this, that seemed to unreasonably not want surgery, then depending on the case, I would consider referring them to one of my podiatric colleagues who specializes in chronic wound care. The patient would be told that I don't specialize in these types of cases and would better to be seen by another podiatrist. Since I try to avoid chronic wound care cases (because I am plenty busy taking care of other types of patients and don't particularly like doing this type of work), I have no problem telling my patients that they would be better being treated elsewhere. This is the way that medicine should be done...referring to the medical specialist that is best equipped to handle complex problems that are not in your area of specialization.