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Atkins E, Kellar I, Birmpili P, Boyle JR, Pherwani AD, Chetter I, Cromwell DA. Patient experience of the process to diagnosis of chronic limb-threatening ischaemia: A qualitative study. J Foot Ankle Res 2024; 17:e12042. [PMID: 39020478 DOI: 10.1002/jfa2.12042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 06/27/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION Delays exist at each stage of the chronic limb-threatening ischaemia (CLTI) care pathway, but there is little known about patient factors influencing delay to diagnosis of CLTI. This study explores the experiences and perceptions of patients recently diagnosed with CLTI. METHODS A qualitative interview study was conducted. Sixteen participants underwent semi-structured interviews. Reflexive thematic analysis was performed on the data, aiming to understand factors which can influence delay in the CLTI care pathway. RESULTS Five interrelated themes were developed: CLTI is a devastating condition; Reluctance to ask for help; When we are empowered we get better care; Luck plays a role in the process to diagnosis; and Vascular units can do better, comprising sub-themes of information transfer-consider communication and arterial versus non-arterial centres-proximity isn't everything. CONCLUSIONS The five themes generated from the interview data describe factors relevant to delay given meaning by participants who have lived experience of CLTI. Theme content should be noted by clinicians, commissioners and providers looking to improve care pathways for patients with CLTI. The importance of awareness for the public, patients and clinicians linked ideas in some themes and interventions to raise awareness should be considered.
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Affiliation(s)
- Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | | | - Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Jonathan R Boyle
- Department of Vascular Surgery, Cambridge University Hospitals NHS Trust and Department of Surgery, University of Cambridge, Cambridge, UK
| | - Arun D Pherwani
- Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Wagner JN. Pain and temporality: a merleau-pontyian approach. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:321-331. [PMID: 38760624 PMCID: PMC11310234 DOI: 10.1007/s11019-024-10205-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/19/2024]
Abstract
Chronic pain is a common disorder with enormous sociomedical importance. A major part of primary and secondary costs of illness is caused by the various pain syndromes. Nociception - the sensory perception of a painful stimulus - is a complex process relying on an intricate system of anatomical, neurophysiological and biochemical networks. This applies even more so to pain - the state of experiencing a nociceptive event, of interpreting it in terms of meaning for the affected individual and of suffering a range of emotions it elicits. This intricacy renders it obvious, that the empirical medical sciences alone cannot explain all aspects of pain. Hence, it has also become a focus of phenomenological research. One aspect of these investigations is the interaction of pain and the perception of the lived body's spatiality. The focus of this article will build on these concepts to develop a construct of the alteration of temporality caused by chronic pain and the effects this spells out for the affected subject. To this end, I will primarily draw on Merleau-Ponty's ideas of the lived body as well as on theories of enactivism and embodiment. I will also point out parallels to neuroscientific data, thereby demonstrating the proximity of phenomenology and neuroscience. A possible partial solution to the pain dilemma may be derived from psychology: techniques relying on cognitive behavioural intervention, awareness training, and existential analysis may provide alleviation to patients suffering from chronic pain.
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Affiliation(s)
- Judith N Wagner
- Faculty of Humanities, Department of Philosophy, Charles University, Prague, Czech Republic.
- Evangelisches Klinikum Gelsenkirchen, Teaching Hospital University Duisburg-Essen, Munckelstrasse 27, 45879, Gelsenkirchen, Germany.
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Shan LL, Telianidis S, Westcott MJ, Debono D, Davies AH, Choong PF. Patient perspectives of quality of life in chronic limb-threatening ischemia: a qualitative study. ANZ J Surg 2024; 94:429-437. [PMID: 38012083 DOI: 10.1111/ans.18791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Quality of life (QOL) is an outcome that matters to patients with chronic limb-threatening ischemia (CLTI). However, we identified the lack of and need for a CLTI-specific QOL instrument. Our group is developing this instrument which requires a deep understanding of patient perspectives of QOL in CLTI. METHODS Qualitative inquiry with patient and public involvement was performed in accordance with the Standards for Reporting Qualitative Research. Reflexive thematic analysis of semi-structured interviews was conducted within a constructivist-interpretivist research paradigm. Data were organized and managed in NVivo. Techniques to enhance trustworthiness included maintaining an audit trail, member checking, mentoring, and peer-debriefing. Patient and the public were consulted for feedback on codes, themes, and thematic maps. RESULTS Thirteen participants (median age: 74 years, range: 43-90 years) with a variety of patient demographics were interviewed. Four themes were developed on QOL in CLTI: (i) 'independence as key to life satisfaction', (ii) 'change in identity when continuity is needed', (iii) 'coping with intractable disease', and (iv) 'not wanting to be alone'. Member checking with patient and public involvement confirmed the relevance and centrality of these themes to the lived experiences of patients with CLTI. CONCLUSIONS The thematic outputs contribute important insights into what QOL truly means to patients with CLTI and what matters for their QOL. The content validity of the new CLTI-specific QOL instrument is improved by giving patients voice. This study highlights the value of qualitative inquiry and patient and public involvement in vascular surgical research.
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Affiliation(s)
- Leonard L Shan
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stacey Telianidis
- Department of Vascular Surgery, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Mark J Westcott
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah Debono
- Centre for Health Services Management, School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Alun H Davies
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Peter F Choong
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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Monaro S, West S, Gullick J. Making decisions about amputation for chronic limb threatening ischaemia. JOURNAL OF VASCULAR NURSING 2024; 42:65-73. [PMID: 38555180 DOI: 10.1016/j.jvn.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/19/2023] [Accepted: 11/27/2023] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Chronic limb threatening ischaemia causes pain, loss of function and complex wounds, necessitating urgent interventions. While growing options for minimally invasive revascularisation make operating on frail and older persons safer, the challenge is knowing when to stop this option and offer amputation. Decisions about amputation are difficult for the person, or for the family who act as substitute decision-makers. Timely treatment decisions are important to optimise clinical outcomes but do not always align with outcomes that are acceptable to patients. AIM To provide a philosophically-based understanding of patient/family experiences of making decisions for chronic limb threatening ischaemia. METHODS Longitudinal qualitative study using Heideggerian phenomenology. Patient and family participants were recruited from three sites. Semi-structured interviews occurred at two time points: soon after advice to consider major amputation, and for those who experienced amputation, six-months post-operatively. The COnsolidated criteria for REporting Qualitative studies (COREQ) checklist guided this report. FINDINGS Variable timelines, disease progression, and interventions were encountered prior to confronting the possibility of amputation. Decision-making was interpreted as an initial irresoluteness (neglecting or renouncing decisions). For most, this was eventually followed by a resoluteness where participants either turned away or towards amputation, according to one's preferred mode of suffering, and thus owning the decision to turn. Those who opted for amputation often experienced better-than-anticipated outcomes. CONCLUSION Patients and families had difficulty making decisions about amputation. Clinicians may have been complicit in the neglecting and renouncing of decisions and have an important role in sharing decision-making through their authentic discourse. IMPLICATIONS Chronic limb threatening ischaemia requires complex discussions to support decisions and shared decision-making requires clinician presence and engagement in discourse. Patients and family members benefit from more time to experience and process the phenomenon as they move towards owning their decision about amputation.
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Affiliation(s)
- Susan Monaro
- Vascular Clinical Nurse Consultant, Concord Repatriation General Hospital, Clinical Senior Lecturer, Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, New South Wales, Australia.
| | - Sandra West
- Associate Professor, Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Australia
| | - Janice Gullick
- Associate Professor, Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Australia
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Monaro S, West S, Gullick J. Chronic limb-threatening ischaemia and confronting amputation: A Heideggerian derived understanding of Being-with and discourse. J Clin Nurs 2023; 32:6559-6573. [PMID: 36788640 DOI: 10.1111/jocn.16644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/14/2023] [Accepted: 01/23/2023] [Indexed: 02/16/2023]
Abstract
AIMS AND OBJECTIVES To explore the notion of Being-with and authentic discourse for people making decisions about major amputation. BACKGROUND Chronic limb-threatening ischaemia is a devastating disease with a high burden of pain and complex wounds. Patients may deteriorate suddenly after multiple revascularisation procedures and, amputation is offered when further reperfusion is considered futile. Delayed decisions about amputation have negative consequences for patients, families and health systems, yet little attention is given to training clinicians for the sophisticated communication required. Clinicians need to engage in authentic discourse about amputation to create shared meaning and facilitate decision-making. DESIGN Qualitative study using hermeneutic Heideggerian phenomenology. METHODS Twelve patients offered major amputation, and 13 family participants from three vascular units in Australia engaged in 42 semi-structured interviews, representing 19 cases of chronic limb-threatening ischaemia. Hermeneutic phenomenology using the Heideggerian tenet of Being-with as an analytic framework, a philosophically based understanding of Being-with and Discourse related to treatment discussions and decisions was derived. The research was reported in accordance with the COREQ checklist. FINDINGS Effective discourse between the person and family was hampered by changed circumstances of Being-with, characterised by guilt, and a retreat from discourse through deficient discourse and filtering information. Clinician Being-with was hampered by discourse that was deficient, poorly delivered, discordant and disconnected through a lack of empathetic listening. There were also examples of enhanced clinician Being-with that made room for more constructive discourse and more timely decisions about amputation. CONCLUSIONS Heidegger's construct of Being-with provides a useful framework to reveal the role of authentic discourse in improving patient and family experience and decisions about treatment. NO PATIENT OR PUBLIC CONTRIBUTION This study did not engage consumers other than as patient and carer participants. RELEVANCE TO CLINICAL PRACTICE Decisions about amputation are often difficult for patients or family members who may be substitute decision-makers. A better understanding of the experience may assist clinicians in their interactions with patients and families.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Sandra West
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Janice Gullick
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
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Schober TL, Abrahamsen C. Patient perspectives on major lower limb amputation – A qualitative systematic review. Int J Orthop Trauma Nurs 2022; 46:100958. [DOI: 10.1016/j.ijotn.2022.100958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/29/2022]
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Monaro S, Pinkova J, Ko N, Stromsmoe N, Gullick J. Chronic wound care delivery in wound clinics, community nursing and residential aged care settings: A qualitative analysis using Levine's Conservation Model. J Clin Nurs 2021; 30:1295-1311. [PMID: 33506537 DOI: 10.1111/jocn.15674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/21/2020] [Accepted: 12/13/2020] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To explore patient experience of chronic wound care across diverse models of outpatient wound care delivery. BACKGROUND Chronic wounds represent a significant personal, family and healthcare system burden. Evidence suggests specialist wound clinics are more effective and less expensive, however, most outpatient wound care is delivered by general community nurses. There is little understanding of how patients experience diverse models of wound care delivery and the subsequent impact on their capacity to adapt to imbalances in their internal/external environment. DESIGN Descriptive, qualitative study. METHODS Eighteen patients with chronic wounds from three wound services were engaged in semi-structured interviews. Initial inductive analysis was refined deductively using Levine's Conservation Model. RESULTS Chronic wounds lead to imbalances and subsequent adaptions in energy conservation and personal, social and structural integrity. Nursing process and wound care system responses suggest specialist wound clinics provide access to the right person and care at the right time, with less care variation. The community nursing model is most effective with a small team of nurses and a documented care plan, with specialist wound nurse oversight. Residential aged care facilities emerged as important sites for wound care delivery revealing higher variance in care and less specialist wound oversight. CONCLUSIONS The application of Levine's conservation model provides a theoretical understanding and important insights into the patient experience of nurse and system elements across diverse models of wound care delivery. Specialist oversight by expert wound nurses with the capacity for medical specialist referral is the cornerstone of good wound care. A frequently reviewed wound care plan and skill development for nurses in primary, aged care and community settings are vital. RELEVANCE TO CLINICAL PRACTICE Shared care between specialist and primary care should include evidence-based pain assessment, clear referral pathways, collaborative relationships, telehealth capacity, patient-held wound plans and upskilling of frontline clinicians.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Sydney, NSW, Australia.,Faculty of Medicine & Health, Susan Wakil School of Nursing & Midwifery, University of Sydney, Camperdown, NSW, Australia
| | - Jana Pinkova
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Natalie Ko
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | | | - Janice Gullick
- Faculty of Medicine & Health, Susan Wakil School of Nursing & Midwifery, University of Sydney, Camperdown, NSW, Australia
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Monaro S, West S, Gullick J. Chronic limb-threatening ischaemia and reframing the meaning of 'end'. J Clin Nurs 2020; 30:687-700. [PMID: 33290625 DOI: 10.1111/jocn.15591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The possibility of amputation and/or death from chronic limb-threatening ischaemia (CLTI) is real, and deeper understandings of the person and family's capacity and preparedness for limb loss and clinical interventions (active or palliative) are required. BACKGROUND The lead-in period to the surgeon's recommendation for amputation for CLTI may be sudden or protracted; the number/invasiveness of previous revascularisation interventions varies, and limb loss and end-of-life considerations frame the experience. METHOD This prospective, longitudinal, interpretative phenomenological study in three vascular surgical units involved 19 CLTI journeys. Participants were interviewed when making decisions about amputation (15 patients, 12 family members) and, where applicable, 6-months postamputation (8 patients, 7 family members). Hermeneutic interpretation using Heidegger's philosophical construct of Being-towards-death guided the analysis. The COREQ checklist ensured rigour in research reporting. FINDINGS Some participants were unable to face the possibility of death and metaphorically 'fled', either through productive optimism or through hoping for more time (Heidegger's inauthentic positioning towards death). For others, authentic positionings of Being-towards-death were understood as: the confrontation of the certainty of their death by making choices about how to die; the indefiniteness of death where treatment choices influenced timing, yet the time for death remained unknown; the nonrelational nature of death, as the journey could only be lived by the person; and death as not to be outstripped, where for some, there was a freeing of oneself for amputation and/or death. DISCUSSION The term 'end of limb' to denote the futility of the limb is a useful marker that emphasises the noncurative nature of CLTI. This may help to instigate and support discussions about end of life to support palliation care planning and the person and family's existential preparation for death. CONCLUSION Death frames the experience of CLTI. Using 'end-of-limb' and 'end-of-life' terminology may facilitate a family/patient-centred approach to possible amputation and other conservative or palliative strategies. RELEVANCE TO CLINICAL PRACTICE Understanding of CLTI illness experience. Decisions about revascularisation, amputation or conservative care. End-of-life care for CLTI.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
| | - Sandra West
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
| | - Janice Gullick
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
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