Case 71: Supportive Boot Therapy in Elderly Incapacitated Patient until Death

This 79 year old lady was admitted to the Bryn Mawr Hospital on April 2nd, 1993 on the service of her family doctor with a "blue warm tender right foot". She had a history of recurrent congestive heart failure, atrial fibrillation, coronary bypass surgery (1992), carotid artery stenosis, and a right femoral-popliteal bypass (Jan 22, 1993). She was followed by a neurologist for global ischemic encephalopathy and by her vascular surgeon who anticipated amputation of her right leg. She was given heparin and antibiotics for a week without benefit. She remained without pulses below her femoral arteries at the groin. She was lethargic and in pain. Leg amputation was considered. It was recognized that she might not survive the procedure. Again, if she did survive the procedure, there was question as to whether and how fast she could heal the amputation site. Finally, if she did heal, she was obviously a poor candidate for a prosthesis and rehabilitation. What to do? She was referred for boot therapy on April 10th, 1993.

The distal half of her foot was ruborous and her first toe was purple and blistering.

On the plantar view, both the first and second toes appeared to be lost.

She tolerated the boot well. Her pain diminished. It was hoped she might autoamputate her first toe. With her foot crisis controlled, she was transferred to the Nursing home for long term care and boot treatment. She died a week later. Her death certificate listed acute pulmonary edema, chronic congestive heart failure, generalized arteriosclerotic cardiovascular disease, arteriosclerotic heart disease and peripheral arteriosclerosis obliterans as causes of death.

Comments: This lady obviously might have been referred for therapy sooner. She was not treated long enough to determine if her leg might actually have been salvaged. She is included here as she is an example of a class of patients we are not infrequently asked to serve: those patients who are too sick for other therapies. In many of these patients, we have been able to provide pain relief and to maintain leg function and patient independence until death. The treatment may seem fruitless to some... but rarely to the patient or family. The cost of the treatments is balanced in part by diminished needs for nursing care and other medicines. Again, some of these patients may surprise all and thrive on the treatments and go home to independent living.