Chronic limb-threatening ischaemia and confronting amputation: A Heideggerian derived understanding of Being-with and discourse

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.

Keywords: Being-with; amputation; chronic limb-threatening ischaemia; clinician presence; decision-making; family; hermeneutic Heideggerian phenomenology; revascularisation; treatment options.