Physician Responded
83 yo male with chf, neuropathy, pad with diabetic foot ulcer update
This is a continuation of a post I posted a week or two ago regarding an 83 yo gentleman I’m the caregiver for. He’s had this foot ulcer on the ball of his foot for at least 4-5 months. I posted a pic of the bandage with a greenish hue which was new at the time. He walks on it all day. Refuses to offload. Doesn’t want treatment. I’ve noticed the blue becoming more prominent. The wound is large but I’m not familiar with them at all. His is the first I’ve seen. He has no symptoms of systematic infection. He does have a little swelling in the foot and leg and a very foul odor (fish and rot). Vitals normal. He has chf, uncontrolled diabetes, PAD and diabetic neuropathy. I guess im trying to gauge this wound as far as how advanced it is and what to expect. Today’s bandage is SO BLUE
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What is your relationship to him/role in his care? Is he competent to make medical decisions? Does he have family or a doctor you can communicate with about this wound?
If he wants to refuse treatment for it that’s his choice (if he’s competent), but he should at least have a doctor explain to him the consequences so he can make an informed decision about it
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u/justsay-inLayperson/not verified as healthcare professional19h agoedited 19h ago
Hi! I am his care companion. He is competent. This is a recurrent diabetic ulcer. He had one in February that went to the bone and had surgery, artery bypass and offloading for three months. I started five months ago and think it probably never healed. He went to the hospital once six weeks ago as the smell took me out! His entire leg was like a balloon. The debrided it once and gave him iv antibiotics. They said they couldn’t rule out bone infection as it was so deep but the xray didn’t pick up on it. He signed an ama and left two days into the antibiotics.
I’ve communicated to his family yes. They say he just doesn’t want anything done with it. It’s really crazy to me- his vitals are all normal, he still smokes many cigarettes a day and seems mostly normal aside from pretty severe congestion from copd and chf. His oxygen sats at 97.
Some people would rather live and die on their own terms and we have to respect that. The alternative of endless hospitalizations and artificially prolonging death is hardly better
I'm 5 years older than you patient;I'm still a smoker and the past few months I've picked up booze again after a 40 year sobriety. I understand why your concerned OP its because you are young and empathetic but this nurse is right. We do know that we've a limited amount of time left. Every day we wake up is a god blessed moment because we do understand that there is a monsterious sized chance we won't wake. I'm lucky, my liver function isn't great.....but it's great for my age. I am going out in the way want to;causing a little mischief and enjoying what life is. Which means candies, booze, tobacco-i mean honestly if I could I'd love to understand why Heroin is so seductive (imma wait till I'm on hospice).
We. Are. Old. We know, we understand, that Death is ecstatically waiting to push our doorbell. Let us live as we wish before that doorbell get rung. I look at the wound and I do worry for bone inclusion cause I fear the pain that would involve for him. But is the treat going to prevent it or maybe cause that pain to be more immediate before relief...is he going to live long enough to go through that? Maybe. Maybe not.
Care fore him. Help him be comfortable as you've made it clear he is able to make conscious educated decisions. They're his regardless of our you feel about it. Let him his choices and stow you're feelings cause it's got nothing to do with you.
Edit: the typos in this thing are horrendous. I tried to fix them. But between the app and the magnification I'm using-i can't seem to get to the most important errors to correct. You've my apologies for how harsh this reads.
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u/ExurotaLayperson/not verified as healthcare professional14h ago
Reads fine and genuine, mate. Thanks for your time.
Hi! Thank you for our response. I’m supportive of his choices 100 percent. After losing my own dad last year, I go back to all the times I said no and fought to save him instead of thinking about HIS pain, sadness and depression of the loss of independence. He wanted hospice and I said no. I thought I could somehow fix everything if I kept pushing. It really sits with me a lot and I’m in therapy for it now. I am overwhelmed with grief and guilt. This man, I draw the line and keep my emotions out of it. I just try to be his friend and help where he requests it. The main thing for me is what to expect. Am I going to walk in and he’s going to be dead? Will there be signs? What can I expect to happen because I’ve never dealt with anything like this before. My daughter died of lung cancer. He had diabetes, too, but he lived with me and it never got to this point because I was very careful with his care.
I do agree with you there. Every day I walk in the door I wonder if he’ll be dead. I definitely don’t want to be the one to find him but hope that eventually he’ll accept some help from prolonged suffering he’ll be forcing himself into.
Or...you'll come in an he will have passed-sith no suffering at all. I hope you aren't the one to find him, it seems youve a big heart filled kindness and compassion so finding him in that will hurt you. I hope you don't, but consider the idea that he might be thinking "Imma pass before that suffering happens". He might be wrong but he also might be right. Which is the hardest aspect of letting people we are caring-its his choice. It may be the wrong one as far as you're concerned but it might be the right choice for him...Speak your words once but accept it's His choice. And accept the pain if him making his choice.
I say this after 20 years telling my kids, "Take me camping and leave me" they're very much older now and understand a little bit better, but as we age we want control over how we go. We don't make the best decisions-its your job to respect that even when your soul is crying out for you to do different for all of the right reasons. You will be making these choices eventually yourself, do you want to be constantly hospitalized, medicated, unconscious, drugged to the point you don't know wtf is going on but you 99 and your kids don't want let go....or do you want be ina good place, knowing the reaper is coming, and wanting to meet him on your own terms?
Edit: I'm really sorry, those typos are worse now. I wish reddits tablet app was better it's so hard to move the curser to where it needs to be to fix things. I also had a blood Mary so maybe I'm failing. Willing to correct if something reads absolutely incomprehensible.
I'm not the person you replied to, but: You're doing fine, I've seen so much worse on reddit! I'm not even a native speaker and I understand you. Don't worry about it. And thank you for your insight!
Awe, you're so sweet. I'm curious as to what your native language is? As I've reread what I wrote twice now (tried to edit it and failed solely because of my tablet, the 150% magnification, and the tablet app is a wee bit wonky) but I could see how maybe German or Spanish native speakers (maybe arabic-simila dialect structures) can deal with the typos. Yet, on the flip side, I was into my first bloody Mary of the night and now my second-the overthinking can be intense when one is two cups in. So you're sweet for writing that comment. I cackle at this point because social insecurity doesn't really go away with age...I just get more of the mindset, "This could be hilarious if I keep doing this..."
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u/ExurotaLayperson/not verified as healthcare professional14h ago
I'm English, people online have staggeringly incompetent literacy online and we're used to it. Nobody can spell, everyone uses words incorrectly. Your comments are almost pristine by internet standards.
This was me with my dad. I just kept hanging on at the expense of his suffering and I regret it every single day. My dad was my best friend and if I could go back I would have changed everything :( we just love our parents so much! The guy I’m caring for I care about- I just don’t want to see him suffer but that’s his choice. He refuses anything that will help him feel better. And I mean everything!
Everything I’ve read about pseudomonas says it smells fruity. This does not! It smells so foul. Like rotten chicken package mixed with fish. It’s so bad.
Will is just continue to get worse visually? Or will it tunnel through the foot and stay this way on the outside? I will not be able to replace bandages for him if it gets much worse.
The hospital warned about five weeks ago that he was facing amputation from the knee down when he had the worst case of cellulitis they’ve seen. The smell was so bad. They debrided it once and started antibiotics but he got agitated with the news that he checked himself out. The smell is very bad now. It’s so hard to stomach. I’m so used to looking at it now I can’t even tell if it’s growing or changing. I take pics to compare. The bright blue bandage this morning was the worst I’ve seen it.
He won’t! He just walks on it all day. I change the bandage for him but it’s so bad and so blue!! The entire bandage was blue today with hints of brown and yellow.
Never seen a bandage turn blue before! What exactly do you mean? Is it an expression of speech or do you literally mean blue and if so how would that occur? Sorry for an obvious question if that is the case!
Thanks for clarifying what you meant! Tbh it looks more green to me in that photograph and not really blue. I am only saying this based on the photograph and just a suggestion and I may be wrong is to get tested for blue-green colour blindness just in case! It seems to be to me at least you are seeing blue quite strongly when you should actually be seeing green, but happy to be corrected!
He was told that he was looking towards amputation from the knee down about six weeks ago and that’s what made him check himself out of the hospital. Fortunately he has zero feeling in his feet, but it’s also a curse for this thing because he just walks on it all day.
My father died of sepsis. He developed an infection from a catheter placement and developed metabolic encephalopathy. It was incredibly painful for him but only when he was moved. If he were lying still he didn’t feel much pain but the hospital physical therapy was pushing him into pt. When I walked in on it and saw him crying in pain I put a stop to it immediately. It did cause confusion however. It was horrible to witness in my dad’s case. But, once morphine was started my dad “woke up” for two days, ate, watched movies and spent time with me and his grandkids for two days before he passed. I am so thankful for that morphine and bringing him home!
I would have been livid! I am glad they started on morphine. If I ever have to deal with such a situation I’ll be saying that they cannot do activities unsupervised by a family member.
Why were they pushing him into PT against his will and do they really force patients to do it even if they are crying, or was the person reprimanded for that?
Did the morphine take away the pain entirely? Did he pass blissfully?
So, the hospital was a horrific event and I filed grievances with them. The doctors were reprimanded and it took firing three to get the right one. But, all that times wasted he wasn’t getting treatment for the sepsis until it was too late. I’ve never seen anyone die before my dad. I was able to bring him home for two days before he passed and they were so good but so sad. It’s the only time he was awake and he thanked me for bringing him home, he was comfortable with no pain and got to see my brother. I can’t say he went blissfully. I was alone with my kids. The hospice team never showed up despite my calling over and over. He had terminal fever and noises I’ve never heard and it was literally the worst six hours of my life when he started to die. But I am so thankful it was short lived. I loved him so much and hope being home and with me and his grandkids brought him peace.
My question is if he doesn't want treatment for a condition that will be fatal if left untreated, is he mentally competent to make that decision and should psychiatry intervene to determine that?
People are allowed to make poor choices. I’ve seen it first hand. Literally DYING and refusing care, all one can do is document and write a damn good narrative.
Generally the psychiatrist will ask them to explain the pros and cons of treatment and non-treatment. If they can explain that, then they have mental capacity to understand what is happening and the consequences. If so, they can refuse any treatment they want.
Thats an age old question. What defines mentally competent and when can we allow ourselves to intervene. Its not always straight forward. We veeeeery rarely force treatment at my department.
It's highly likely this man has chronic limb threatening ischemia (CLTI). The data says his life expectancy will be limited. Despite optimal care/revascularization, there's a decent chance he doesn't make it and even with optimal revascularization he's at a high risk for passing away in a few years with his leg attached from other downstream effects of PAD.
I'm not exactly sure what to say as far as specific advice on either healing this wound / modifying his disease process, but I feel like prognoses are not something that physicians really speak about with their patients and I just would like to state that a wound this bad does not carry a favorable long-term prognosis.
And that's his prerogative. He's an adult who can make his own decisions it sounds like and it clearly seems like he's choosing quality of life (smoking+ good food, etc) over maximizing life with an amputation or quitting smoking. I'm not here to convince you or him otherwise but I'm just here to say that the end may be coming sooner than it may seem on the surface just given the extent of his disease and the comorbid conditions he has
Could the pad, chf and neuropathy possibly be blunting the systemic symptoms? When I took him to the hospital six weeks ago it was so severe but he had no fever and all vitals normal. He had severe cellulitis. Still the same. I’m using optifoam bandages to control the exudate.
TBH mortality at critical ischemia (you mention PAD) is ~25% within first year, ~50-60% after 3.
That’s with treatment.
I completely understand people who choose amputation or nothing. Wound care is cumbersome, painful and needs a lot of care and visits to health services. Means more or less hospitalised from now to the end of life.
Amputation or nothing gives some control and less time in-out of health services.
Yes, he has pad and when he got treatment for a previous diabetic foot ulcer in the same spot in February, he had an artery bypass in that leg. The leg they took an artery from, that foot is permanently purple/red and swollen over the past three months. He had absolutely zero feeling in either foot.
Peripheral Artery Disease (PAD) is basically blocked arteries in your feet from a combination of different factors. So his foot isn’t getting enough blood/oxygen, the poorly oxygenated blood in the area makes the skin appear blue-ish
I hope he meant that literally. If he doesn’t get this amputated and it is not solvable with antibiotics, it likely will eventually end up literally killing him.
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