Inappropriate amputation requests by mikesanye

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JULIE A. PARSONS, Ph.D.
WALTER ARMIN BROWN, M.D.
ALAN D. SIROTA, Ph.D.




Inappropriate amputation requests
Most patients    experience    considerable    distress   when    decision should be based entirely on medical grounds.
faced with the loss of a limb.' We recently provided                 When informed that amputation was not indicated, the
psychiatric consultation    for two patients       who were       patient became increasingly angry and complained to the
demanding leg amputations in the absence           of clinical    psychiatric consultant, the surgeon, and his congressman
indications. This report, which as far as we      know is the     that he was not receiving adequate care from the Veterans
                                                                  Administration. Both the psychiatric consultant and sur
first to describe such patients, documents        our experi
                                                                  geon visited the patient, listened to his expressions of
ence in assessing and managing this clinical dilemma.             irritation and disappointment, and tried to convey their
                                                                  awareness of his distress. The surgeon discussed the pa
CaseI                                                             tient's medical condition with him in considerable detail.
A 43-year-old single man was hospitalized for the fifth time      Soon thereafter the patient seemed less angry and asked to
at a university-affiliated Veterans Administration medical        be discharged.
center for treatment of recurrent venous stasis ulcers of the        Following discharge he was seen weekly by a social
left leg, which had consistently healed during previous           worker for vocational counseling and exploration of how his
hospitalizations. Psychiatric consultation was requested          loneliness contributed to his adjustment problems. Several
because the patient repeatedly demanded a leg amputation,         weeks later he was no longer voicing complaints regarding
in spite of medical and surgical consultants' statements that     his leg and was actively seeking work. When his father died
his condition did not warrant such a procedure.                   a short time later, the patient experienced an uncomplicated
   The patient was employed and had worked at various odd         grief reaction.
jobs prior to his leg difficulties. He had a history of alcohol
abuse, but had been sober for the past five years. Describ        Case2
                            he maintained that he had no close
ing himself as a “¿loner,―
                                                                  A 44-year-old divorced man with a history of multiple
relationships. He expressed considerable admiration for his
                                                                  hospitalizations for venous stasis ulcers and chronic pain in
father, who had recently undergone a leg amputation, and
                                                                  both legs was again hospitalized for exacerbation of his
reported that two other male relatives had also had leg
                                                                  symptoms. Shortly after admission, he began to demand
                                                    The
amputations and were getting along “¿great.― patient
                                                                  amputation of his left leg against surgical advice. Psychiat
showed no evidence of psychotic thinking, hallucinations,
                                                                  nc consultation was requested to determine the probable
affective disorder, or cognitive deficits. He expressed a
                                                                  psychological effects of amputation.
great deal of hostility toward the surgical staff and also
                                                                     Before his leg difficulties, the patient had been a machin
expressed some unhappiness with his inability to meet job
                                                                  ist. Numerous efforts at vocational rehabilitation had been
demands and form lasting relationships.
                                                                  unsuccessful, and currently he did not have a paying job but
   The psychiatric consultant recommended that the sur
                                                                  worked daily as a hospital volunteer. Although abstinent for
geon discuss indications for amputation and alternate
                                                                  the three years before this hospitalization, he had a history
treatment modalities with the patient in detail, and that the
                                                                  of alcohol abuse.
                                                                     Problems associated with leg ulcers had led to hospital
                                                                  ization during a substantial part of the past five years. He
From the Brown University Program in Medicine and the             was described by the staff as a “¿known hospital abuser.―
Providence Veterans A dministraiion Medical Center. Reprint          He showed no evidence of psychotic thinking, hallucina
requests to Dr. Brown, Veterans Administration Medical            tions, affective disorder, or cognitive deficits. He com
Center, Davis Park, Providence, RI 02908.                         plained of unremitting leg pain, but was repeatedly ob


822                                                                                                        PSYCFIOSOMATICS
served wheeling himself throughout the hospital in a             alert the physician to the necessity for psychological
wheelchair, running errands, and visiting friends. Consis        evaluation and specific management approaches. Some
tently refusing to cooperate with prescribed therapy, he         ofthese approaches are applicable to any inappropriate
insisted that he was unable to commute to the hospital for       request for surgery. It also should be noted that patients
rehabilitation therapy, kept his legs in a dependent position,   who are driven by a desire for amputation may attempt
and picked at his ulcers and refused topical medication for      to increase     the likelihood      of an amputation           through
them. At one point, he tied a tourniquet around his leg.
                                                                 active or passive means. Such patients may present to
   Although the surgical staff agreed that the patient's con
dition did not warrant amputation, there was some con            the physician with unexplained inadequate healing of
troversy over whether the procedure might provide psycho         the extremities,     rather than a demand for amputation.
logical benefit and facilitate rehabilitation. The psychiatric   When patients        who demand an amputation     are en
consultant suggested that psychological or rehabilitation        countered, we recommend the following steps:
benefits would not be expected to follow amputation and            1. A thorough psychiatric evaluation should be con
recommended that the patient's reasons for requesting            ducted, including assessment of the patient's expecta
amputation be further addressed in psychotherapy, with a         tions regarding the effects of amputation, beliefs about
focus on his over-dependence on the hospital system.             what life will be like without an amputation, and the
   The patient's ulcers healed during his hospitalization and    potential for secondary gain. Such evaluation may
he was informed of the decision not to amputate. Angry at
                                                                 identify misconceptions correctable with education.
first at the psychiatric consultant, he nevertheless accepted
                                                                    2. The direct care staff should be cautioned not to
the offer of follow-up psychotherapy.
                                                                 challenge the validity ofthe patient's complaints; doing
                                                                 so alienates the patient and makes overall care difficult.
Discussion                                                          3. The decision to amputate should be based entirely
Psychiatric evaluation suggested some possible deter             on standard medical grounds. Patients seeking ampu
minants of the inappropriate demands for amputation.             tation may make irrational demands and exhibit in
As do many surgical candidates,      these patients held the     gratitude and hostility, evoking anger in their physi
expectation of secondary gain (increased disability              cians. The physician aware of his or her reaction to the
payments or continued dependency on the hospital).               patient will be less likely to have it interfere with a
Menninger@and other investigators,@'4in discussing the           medical decision. When the amputation        is not medi
surgery-prone patient, point to the dependency needs             cally indicated, the physician must also be careful not to
of these patients and the opportunity that surgery               give in to the patient's intense pleas and demands.
provides to receive solicitude and attention and to                4. If an amputation is not indicated, the surgeon
avoid adult responsibilities.                                    should carefully explain the rationale for the decision,
   The patient in Case 1 anticipated moving into his             the alternative treatments, and the prognosis. The pa
father's home following amputation, and becoming                 tient should be given an opportunity to ask questions
more like him. This patient also viewed amputation as            and express concerns. Such a discussion early in the
normal and nonstressful     because of the high incidence        course of the illness may circumvent              the inappropriate
of amputations among relatives. DeVaul and Faillace5             demand for amputation in the first place.
and Wahl and Golde& found that the family members                   5. Finally, psychiatric         treatment     should     be recom
of surgery-prone patients tended to have repeated                mended if psychiatric evaluation reveals problems in
surgery   themselves.   Wahl    and Golden3      further   ob    dicating the need for such treatment. Included among
served that the type of surgery these patients had was           such problems would be persistent, unrealistic demands
sometimes similar to that experienced by their parents.          for amputation.                                                          0
   Thus, in apparent motivation and family back
ground, the patients in Cases 1 and 2 are in some ways           REFERENCES
similar to surgery-prone, or polysurgery, patients. But          1. Friedmann LW: The psychological rehabilitation of the amputee. Spring
                                                                    field, Ill, Charles C Thomas, 1978.
perhaps underlying the request for amputation in par             2. Menninger KA: Polysurgery and polysurgical addiction. Psychoanal 0
ticular was the belief that their ulcers would ultimately           3:173-199, 1934.
lead to amputation. The fear of this procedure may                WahI
                                                                 3.          JS:            ofthe        patient:
                                                                     CW,Golden Thepsychodynamics polysurgical
                                                                    Report of sixteen patients. Psychosomatics 8:65-72, 1966.
have led to attempts to control the time and circum              4. Devaul RA, Faillace LA: Surgery-proneness: A review and clinical assess
                                                                    ment. Psychosomatics 21:295-299, 1980.
stance of what they saw as an inevitable outcome.                5. DeVaulRA, Faillace LA: Persistent pain and illness insistence: A medical
   A patient's insistent demand for amputation should               profile of proneness to surgery. Am J Surg 135:828-833, 1978.



SEPTEMBER     1981 . VOL 22 . NO 9                                                                                                      823

								
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