End-of-life care following leg amputation in patients with peripheral artery disease or diabetes

Abstract

Background:The aim was to characterize end-of-life care in patients who have had a leg amputated for peripheral artery disease (PAD) or diabetes.Methods: This was a population-based retrospective cohort study of patients with PAD or diabetes who died in Ontario, Canada, between 2011 and 2017. Those who had a leg amputation within 3 years of death were compared with a control cohort of deceased patients with PAD or diabetes, but without leg amputation. The patients were identified from linked health records within the single-payer healthcare system. Place and cause of death, as well as health services and costs within 90 days of death, were compared between the amputee and control cohorts. Among amputees, multivariable regression models were used to characterize the association between receipt of home palliative care and in-hospital death, as well as time spent in hospital at the end of life.Results: Compared with 213 300 controls, 3113 amputees were less likely to die at home (15⋅5 versus 24⋅9 per cent; P < 0⋅001) and spent a greater number of their last 90 days of life in hospital (median 19 versus 8 days; P < 0⋅001). Amputees also had higher end-of-life healthcare costs across all sectors. However, receipt of palliative care was less frequent among amputees than controls (inpatient: 13⋅4 versus 16⋅8 per cent, P < 0⋅001; home: 14⋅5 versus 23⋅8 per cent, P < 0⋅001). Among amputees, receipt of home palliative care was associated with a lower likelihood of in-hospital death (odds ratio 0⋅49, 95 per cent c.i. 0⋅40 to 0⋅60) and fewer days in hospital (rate ratio 0⋅84, 0⋅76 to 0⋅93). Conclusion: Palliative care is underused after amputation in patients with PAD or diabetes, and could contribute to reducing in-hospital death and time spent in hospital at the end of life. Reference 1 Campbell WB. Non-intervention and palliative care in vascular patients. Br J Surg 2002; 87: 1601.

Underutilization of Palliative Care for Patients with Advanced Peripheral Arterial Disease

“…Wilson and colleagues performed a single center study at their academic medical center that looked at 111 patients that died on the vascular service. 14 15 Compared with those who did not undergo an amputation, amputees with PAD or diabetes were less likely to have palliative care evaluation both on the inpatient and outpatient setting. Among amputees that died, only 13-14% had a palliative care consultation.…”

“…Specifically for vascular patients, a single study showed that after major amputation, home palliative care was associated with less time in the hospital prior to death and lower rates of in-hospital death. 15 Finally, palliative care consultation provides caregiver and family access to vital resources and support. Ultimately, is important to recognize that palliative care services can provide a myriad of patient benefits and are not equivalent to transition to hospice.…”

Chronic limb‐threatening ischaemia and reframing the meaning of ‘end’

“…While some vascular specialists (Campbell, 2000; Ketteler & Maxfield, 2009; Nehler et al, 2003) have advocated for more research into vascular palliative care, there has been little research since these publications, and the control of ischaemic pain remains extremely difficult as the doses of drugs required often bring unacceptable side effects (Woelk, 2012). de Mestral et al’s (2020) recent paper does demonstrate, however, that palliative care is underused after amputation and could contribute to reducing in‐hospital death and time spent in hospital at the end of life. More importantly, if we could establish that end of life was improved through palliative care, it would be a humane approach to caring for the whole person, regardless of whether amputation was performed.…”

“…While there is an immense amount of end‐of‐life research exploring dying from cancer and more recently cardiovascular and renovascular failure (Moens et al, 2014), very little literature addressing death from peripheral vascular disease is available (Ketteler & Maxfield, 2009; de Mestral et al, 2020). The end‐stage of lower extremity peripheral artery disease (PAD), recently re‐named and re‐defined as chronic limb‐threatening ischaemia (CLTI) (Rundback et al, 2017), is an increasingly prevalent, debilitating condition associated with rest pain and tissue loss and a high risk of major amputation and associated adverse outcomes (Conte et al, 2019; Rundback et al, 2017).…”

Amputation Pain Management

“…Around a third of these patients have persistent depression and anxiety after their amputation [6]. Financially, it is noted that amputees have higher healthcare costs and if the amputation was related to vascular disease higher mortality [7].…”