Lower limb amputation. 4: Some ethical considerations

For some people the prospect of amputation may offer an escape from the constant pain, infection and disability which have been part of their lives for many years. However, other may regard death as a preferable option. Denying treatment when the alternative prognosis is death causes much debate among healthcare professionals, families and carers. Ultimately, however, healthcare professionals must listen to the person in need of the amputation. The first article in this series illustrated the care pathway of a vascular patient, the second studied the surgical process of amputation and the third highlighted the importance of the nurse's role in the amputee's physiological, psychological and social care. This article, the last in the series, discusses the issues surrounding the person's decision not to have an amputation.     

Lower limb amputation. 1: indications and treatment

Lower limb amputation is performed predominantly to alleviate acute and chronic limb ischaemia caused by vascular disease, poorly controlled diabetes or, occasionally, infection. Atherosclerosis is the primary cause of chronic arterial ischaemia and the most common reason for amputation. The vascular nurse has an important role in reducing the need for amputation, by providing information on health promotion and illness prevention to patients with vascular insufficiency to halt progression to amputation. This is the first of four articles focusing on lower limb amputation. It examines the indications for lower limb amputation in detail, and briefly outlines other treatment options including revascularization techniques.     

Lower limb amputation in a general hospital: a comparative review

This paper presents the results of a recent review of lower limb amputations carried out in a general hospital, and compares them with those of previous study of similar amputations. Particular attention is paid to the type of amputation-below-knee, through-knee or above-knee--and the associated morbidity, mortality and rehabilitation prospects. There is a need for an active approach to the problems of amputation with emphasis on preoperative preparation of the patient, the operation itself and rehabilitation follow-up in an amputation clinic.     

Lower limb amputation 2: once the decision to amputate has been made

This is the second of four articles on lower limb amputation. The first article (Vol 6(17): 970-7) discussed the indications for amputation and briefly outlined the treatment options that may be tried before the amputation stage is reached. This second article examines the factors that need to be addressed once the decision to amputate has been made. It stresses the importance of preparing the patient and his/her family both psychologically and physiologically for the operation. The techniques and rationale for selecting the optimum level of amputation are then discussed. Finally, the specific levels of lower limb amputation are outlined. The next article in this series will explore the nurse's role in preparing the patient for an amputation, and the final article will address the issues raised when a patient decides that death is preferable to living as an amputee.     

Systemic lupus erythematosus. Part 2: The role of the nurse

The second article in this series of two describes the aims of patient education, and gives an overview of the implementation and evaluation of the patient education programme in the authors' department. It focuses on what patients can do to help prevent lupus flares and how they can develop coping skills in dealing with the day-to-day problems which often face these patients. It highlights the fundamental role of the nurse specialist as a resource in providing patient education and reflects a combined approach in the overall management of patients suffering with systemic lupus erythematosus.     

The role of the laparoscopic nurse practitioner

Since the appointment of the author as laparoscopic nurse practitioner at Milton Keynes Hospital Trust, there have been more cholecystectomy operations, but fewer patients have required open surgery or inpatient admission, with substantial cost savings. The author describes how the role developed and the opportunities it presents for nurses.     

The role of the psychiatric nurse practitioner

Policy, organizational management, and research roles have received little attention in this article because the focus has been on the practice role. It must be noted, however, that psychiatric nurse practitioners often assume these roles. Many psychiatric nurse practitioners have discovered that their expertise in communication and systems assessment prepares them well for policy and management positions. The influence of public and private policy on practice and the lives of mentally ill persons has led psychiatric nurse practitioners to become active in the public policy arena. Similarly, psychiatric nurse practitioners' grounding in practice and training in research allows for participation in planning and conducting studies that will inform policy makers as the mental health reform process continues. The psychiatric nurse practitioner title and role have evolved in response to regulatory desire for consistent titling of advanced practice nurses and community need for practitioners with the skills in assessment, psychotherapy, psychopharmacology, and care management. Nursing academic institutions are working to develop new programs to prepare the psychiatric nurse practitioners of the future in the wide range of skills needed for this role. Practice subspecialties and settings vary, but in all instances the psychiatric nurse practitioner offers a blend of nursing and psychiatric specialty care that, in many cases, is substitutive for that of a psychiatrist. In the current era of health-care reform, fiscal constraint, and burgeoning health-care technology, the practice, research, and policy roles available to and occupied by psychiatric nurse practitioners are many. The primary threat to full actualization of the psychiatric nurse practitioners' potential is that advanced practice nursing will choose to be wedded to anachronistic ideologies regarding nurse practitioners and clinical specialists.     

Lower limb ischaemia in the octogenarian: is limb salvage surgery worthwhile?

Vascular surgeons are being asked to manage vascular disease in an increasingly elderly population, and advanced age may be considered a relative contraindication to limb salvage surgery with an amputation seeming the preferred option. We present a review of 50 patients over the age of 80 years, presenting with ischaemic rest pain, ulceration or gangrene of the lower extremity. Six patients were treated conservatively, four of whom died during the same admission. Only two patients proved suitable for transluminal angioplasty as the sole curative procedure. Twelve patients (24%) underwent primary amputation with a perioperative mortality of 3/12 (25%). Five patients (10%) had an iliac bypass procedure, and 25 patients (50%) were considered suitable for infrainguinal bypass. Of the latter group 14 had femoropopliteal bypasses, and 11 had femorodistal bypasses with an overall perioperative mortality of 3/25 (12%). Mortality at 6 months was high (33%) and was similar in both the grafted and amputation groups. Patients having reconstruction fared well in terms of independent mobility, use of long-term care, and length of hospital stay. Patients over 80 years of age with critical ischaemia should not be denied the opportunity of vascular reconstruction.     

Phantom limb pain and pain interference in adults with lower extremity amputation: The moderating effects of age.

Purpose/Objective: To determine whether the relationship between phantom limb pain severity and pain-related interference was moderated by age and to compare 2 theoretical perspectives used in the literature to account for age-related differences in the experience of chronic pain. Research Method/Design: Analysis of survey data provided by 375 adults with lower extremity amputations who reported phantom limb pain. Results: The relationship between phantom limb pain severity and pain-related interference was shown to be moderated by age (β = -.10, p     

Clinical nurse consultants: defining the role

Pressure ulcers are common among the frail elderly. Reducing the incidence of pressure ulcers requires vigilance on the part of an entire interdisciplinary team; however, gerontology nurses in particular must know how to intervene and assist in maintaining tissue integrity for older adults who are at risk. This article discusses various factors that place individuals at risk for pressure ulceration. Ways to address factors that place patients at particularly high risk for pressure damage are also suggested.     

The role of perceived vulnerability in adjustment to lower extremity amputation: A preliminary investigation.

Objective: To examine the role of feelings of vulnerability in postamputation adjustment problems such as depression and diminished quality of life. Participants: Eighty-four patients with a lower extremity amputation. Setting: Five affiliated prosthetic clinics in Chicago. Main Measures: The Center for Epidemiologic Studies Depression Scale (CES-D), a 3-item quality-of-life measure, and a 2-item vulnerability measure. Participants' prosthetists completed a single-item rating of perceived adjustment. Results: Vulnerability accounted for significant portions of the variance in CES-D scores, quality-of-life ratings, and prosthetists' adjustment ratings. Conclusion: Feelings of vulnerability significantly affect adjustment in persons with amputations, and this impact is not limited to a single domain. Clinicians should assess feelings of vulnerability, the degree to which such feelings are realistic, and any past experiences with victimization. These issues need to be addressed with both individual counseling and community interventions aimed at reducing victimization of individuals with disabilities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Expanded role of the nurse: accountability confusion

Nurses are increasingly taking over the clinical activities once carried out by doctors. In some areas it has now become difficult to distinguish the boundaries between nursing and medical health care. These changes raise important legal issues which will need to be considered by a court when dealing with clinical negligence cases involving the expanded role of the nurse.     

The head nurse role in redesign

As administrators review how best to meet patient's needs and redesign patient care givers' job content, as well as introduce multiskilled workers to the patient care unit, the head nurse role must be reviewed and revamped at the same time. The author describes the experiences of two different institutions in overloading the head nurses with reporting relationships that they were ill-equipped to supervise. The solution in both institutions was the same, and emphasizes the need for interactive planning for these complex and interdependent models.     

The psychiatric clinical nurse specialist/nurse practitioner: an example of a combined role

The purpose of this article is to provide an historical overview of the clinical nurse specialist and nurse practitioner roles in psychiatric nursing. This article is written as a follow-up to that of Dyer, Hammill, Regan-Kubinski, Yurick, & Kobert, (1997), Archives of Psychiatric Nursing, 11, 2-11, in which a new paradigm for delivering comprehensive mental and general health services is conceptualized, i.e., the psychiatric-primary care nurse practitioner role. In this article an alternative model is presented: the psychiatric clinical nurse specialist/nurse practitioner role. Similarities and differences in the two roles are discussed.