Concord Repatriation General Hospital, Sydney, NSW, Australia.
Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.
J Clin Nurs. 2021 Mar;30(5-6):687-700. doi: 10.1111/jocn.15591. Epub 2020 Dec 23.
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.
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.
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.
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.
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.
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.
Understanding of CLTI illness experience. Decisions about revascularisation, amputation or conservative care. End-of-life care for CLTI.
慢性肢体威胁性缺血（CLTI）可能导致截肢和/或死亡，因此需要更深入地了解患者和家属对肢体丧失和临床干预（主动或姑息性）的能力和准备情况。
外科医生建议进行 CLTI 截肢的前期可能是突然的，也可能是漫长的；先前血管重建干预的数量/侵袭性各不相同，肢体丧失和生命末期的考虑因素构成了这一经历。
本项前瞻性、纵向、解释性现象学研究在三个血管外科单位进行，共涉及 19 例 CLTI 病例。参与者在决定截肢时（15 名患者，12 名家属）和截肢后 6 个月（8 名患者，7 名家属）接受了采访。解释学解释使用海德格尔的死亡存在论哲学结构指导了分析。COREQ 清单确保了研究报告的严谨性。
一些参与者无法面对死亡的可能性，通过富有成效的乐观主义或希望获得更多时间来“逃避”（海德格尔对死亡的非真实性定位）。对于其他人来说，对死亡的真实性定位则被理解为：通过选择如何死亡来面对死亡的确定性；由于治疗选择会影响时间，因此死亡时间不确定；死亡的非关系性质，因为只有患者才能体验这段旅程；以及死亡不应被超越，对于一些人来说，截肢和/或死亡可以使自己获得解脱。
用“肢体终点”来表示肢体的无效性是一个有用的标记，强调了 CLTI 的非治愈性质。这可能有助于启动和支持有关生命末期的讨论，以支持姑息治疗计划以及患者和家属对死亡的存在性准备。
死亡构成了 CLTI 的体验。使用“肢体终点”和“生命末期”的术语可以促进以家庭/患者为中心的方法，来处理可能的截肢和其他保守或姑息性策略。
对 CLTI 疾病体验的理解。血管重建、截肢或保守治疗的决策。CLTI 的临终关怀。
