PAGE 128 JOURNAL OF VASCULAR NURSING DECEMBER 2016

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Limb loss: The unspoken psychological

aspect
Jasmiry Bennett, MS, RN, APRN, ACNP-BC

In the United States, health care providers have diagnosed 29.1 million people with diabetes. Uncontrolled diabetes is
the main reason for limb loss. This review addresses the lack of psychological support after limb loss. Few scholarly sour-
ces analyze the psychological aspects of limb loss before and after amputation. These sources report that patients do not
have a clear understanding of their disease process and that patients often report a lack of empathy and communication
from health care providers. There is no standardization of postoperative care instructions causing great confusion and
increasing anxiety for both the patient and the caregivers. Individuals with limb amputation express increased depression
and body image disturbance along with social embarrassment after amputation. Postoperatively, patients report a
decrease in resources once discharged home. Some studies suggest psychiatric consultation preamputation and postam-
putation. The literature also suggests increased communication between the patient undergoing amputation and their
health care provider preoperatively and postoperatively. (J Vasc Nurs 2016;34:128-130)

The diagnosis of diabetes is detrimental and can lead BACKGROUND

to multifaceted health problems. According to the American
Amputees report a lack of preparedness when the plan of
Diabetes Association,1 in 2012, the population in the United
amputation was discussed with their health care provider.3
States diagnosed with diabetes is 29.1 million with 8.1
Emotional and spiritual components associated with limb loss
million that remain undiagnosed. Diabetes is one of the
should be considered; however, they are not.4 Bateup discovers
main causes of lower extremity amputation. Accounting for
there is no specific information given to the patient on grief
an estimated 54% of the amputation, Advanced Amputee
and loss after limb amputation. People with diabetes lack psycho-
Solution2 states that the percentage increased by 24% over
logical support and are at higher risk for psychological distress.5
the past several years. Uncontrolled diabetes leads to poor cir-
Nicolucci et al6 affirm the lack of interdisciplinary coordination
culation and nonhealing wounds. If diabetes is not addressed,
for this population. The researchers state that psychiatry should
then patients may experience limb loss. The psychological
be involved in treatment programs for every loss of limb patients.
component of amputation from diabetes is not very well stud-
The loss of a limb is comparable with the loss of a loved one.
ied. There is a need for increased awareness from the health
In this situation, the patient undergoes the stages of grief. Spiess
care provider to account for the psychological component of
et al7 state the amputee undergoes denial, anger, bargaining,
limb loss.
depression, and acceptance. Most amputees linger in the depres-
The increased rate of amputation due to diabetic complica-
sion stage. The addition of a psychiatrist to the interdisciplinary
tions is on a steady incline. As a nurse practitioner in vascular
team is speculated to prepare and assist the patient through the
surgery for 10 years, I have noted that when a patient undergoes
grieving process.7 According to Delea et al,8 patients report
amputation, surgeons and hospital employees do not have a
that psychological support in conjunction with medical manage-
standard protocol for treatment. In addition, retention of infor-
ment allows a smooth transition through the amputation process.
mation is limited, whereas the patient goes through emotional
Limited sources discuss the psychological effects of limb
changes so rapidly. Short hospitalization does not allow for
loss; those sources that do report similar findings. The literature
the adjustment of a loss of limb. Pastoral care along with psy-
also reports a lack of empathy from health care providers, body
chiatric evaluation is not considered when a decision for ampu-
image disturbance, social maladjustment, and lack of resources.9
tation is made. This manuscript will focus on the gaps
addressing the psychological aspect of the individual with dia-
betes after limb loss. LITERATURE REVIEW
The literature review was based primarily on qualitative liter-
ature. Phenomenologic studies conducted by Livingstone et al10
From the Texas Christian University, Dallas, Texas. and Delea et al8 via a series of one-on-one interviews and ques-
tionnaires taking account of the person’s lived experiences after
Corresponding author: Jasmiry Bennett, MS, RN, APRN,
amputation. Grounded theory was used in one study conducted
ACNP-BC, Texas Christian University, 2800 S., University Drive,
Fort Worth, TX 76129 (E-mail: jasmirybennett@yahoo.com). by Livingstone et al10 to assess social processes and the partici-
pants’ mechanism of adjusting to bereavement after limb loss. A
1062-0303/$36.00 single quantitative study conducted by McDonald et al3 used
Copyright Ó 2016 by the Society for Vascular Nursing, Inc. validated tools to measure body image disturbances, anxiety,
http://dx.doi.org/10.1016/j.jvn.2016.06.001 depression, and quality of life questionnaires with participants
who underwent amputation.
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Livingstone et al10 interviewed one female and four males
(n = 5) who were diagnosed with diabetes and had amputation
of a limb. The researcher conducted audio-recorded interviews
with each participant that lasted for 30–45 minutes. The partici-
pants were asked the same questions during the interview. The
researchers decoded and categorized findings from the interviews
into three categories reflecting similarities between participants’
experiences: (1) imposed powerlessness, (2) adaptive function-
ality, and (3) endurance leading to a path of perpetual resilience.
Imposed powerlessness was reflected as participants’ reports
of lack of education and knowledge deficit regarding their dis-
ease process.10 One participant stated, ‘‘I do not think people un-
derstand the complications with diabetes’’ (p. 23). The second
category, adaptive functionality, was described as the physical as-
pects of an amputation. The researchers noted that participants
described the feeling of helplessness and inability to ‘‘do the
jobs’’ they were able before amputation. After amputation, the
participants required assistance with basic activities of daily
living such as bathing, dressing, and walking. Participants report
a lack of sufficient home care services on discharge. At last,
endurance was described by the researchers as the mechanism
that the patients use to adapt and accept their new way of life
after amputation. The participants describe feelings of ‘‘turmoil’’
and ‘‘fear,’’ whereas others state they felt a lack of confidence
with mobility and social embarrassment.10 Limitations to this
study are a small sample size and minimal variation in geograph-
ical location.
Another qualitative study conducted by Delea et al8 obtained
diabetic participants with active foot disease or amputation
(n = 10) from the Prosthetic, Orthotic, and Limb Absence Reha-
bilitation Center. There was only one patient with active foot dis-
ease, and the other nine participants had lower extremity
amputation. The researchers collected data through question-
naires and audio-recorded one-on-one interviews. Researchers
found ‘‘a need for supportive interaction with health care profes-
sionals.’’ Most participants express that they would prefer
emotional support alongside medical management of their condi-
tion.8 The researchers also report differences in education; some
participants were experts in the disease process, whereas others
report a lack of understanding with their disease process. Educa-
tion and postoperative expectations should be standardized for all
patients to ensure that everyone receives the same information.8
Participants reported discrepancies with incisional care in-
structed from providers. Geographic disparities and access to
health care is reported. Participants stated that they are dis-
charged home without adequate supply or resources along with
a reduction in supportive home care services.8 A limitation to
this study is small sample size. It was limited to Caucasian males,
and therefore did not account for females or other ethnic back-
grounds. Overall, the participants’ request for empathy, social
support, and streamlined care instructions preoperatively and
postoperatively may offer benefit for their postamputation
recovery.
A quantitative study conducted by McDonald et al3 compares
rates of depression and conceptions of body image in diabetic pa-
tients with and without amputation. The researchers recruited
their participants through diabetes and amputee associations.
There were 240 diabetic patients without amputation and 50
diabetic with amputation. Researchers collected data using the
PAGE 129
Hospital Anxiety Depression Scale, a validated tool to measure
anxiety and depression.3 In addition, the researchers used another
validated tool the World Health Organization Quality of Life
Brief to assess the patients’ quality of life by administering ques-
tionnaires to participants. A third validated tool, Body Image
Disturbance Questionnaire was administered to assess body im-
age disturbances via body dissatisfaction, distress, or dysfunc-
tion.3 There was no statistical difference between comparison
groups on demographics, or medical and lifestyle variables
(P = 0.185).3 Statistical analysis review of depression was statis-
tically significant in the diabetic population with amputation
(P = 0.011). Patients with amputation were more likely to expe-
rience higher levels of depression along with greater body image
disturbances.3 A sample of convenience is one limitation of this
study as the results may not be reproducible. The participants in
this study are mainly males increasing the possibility of gender
bias and limited generalization of findings.
GAPS IN CARE
In synthesizing, the cited body of evidence study participants
frequently requested information regarding dressing changes, ac-
tivities of daily living, mobility, and incisional care after lower
extremity amputation. Standardization of postoperative care in-
struction was another complaint noted in the literature.8 Partici-
pants voice concerns about inconsistencies in information
regarding dressing changes, care of the amputation site, and their
health care providers’ lack of compassion. Dissimilarities in the
standard of practice created chaos for the psychologically fragile
participants. Review of the literature reveals the lack of standard-
ization for incision care at the amputation site. The literature
review demonstrates a gap in communication between health
care providers and their patients regarding care of an amputation
due to diabetes.10 Participants often report a reduction in home
care services and a lack of support once home.8
The patient who undergoes amputation is shown to have body
image disturbances and experience challenges with social adjust-
ments. Individuals express a need for spiritual guidance during
the amputation process in conjunction with medication therapy.4
Addressing religious beliefs, communication, and supportive
care before and after limb loss may provide transition through
the grieving process, decrease the incidence of depression, and
increase social adaptation.4,10 Researchers need to conduct
further studies examining the role of body image disturbances
and physical deterioration and its impact on psychosocial
outcomes after amputation.3
RECOMMENDATIONS
There is little research reviewing the psychological effects of
limb loss in patients with diabetes. Variation among health care
providers in postoperative care after limb loss causes confusion
and increased anxiety for the patient. Participants in the reviewed
studies also report a lack of communication between providers
and their caregiver. Livingstone et al10 suggest the process of
psychological healing should be discussed with the patient before
amputation for enhancement of physical well being. Communi-
cation among health care providers is essential for consistency
in the plan of care for the patient and their caregivers.
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According to participants in the reviewed studies, health care
providers portray nonchalance and lose site of the psychological
aspect of patients who undergo this procedure. A multidisci-
plinary approach in conjunction with fluid communication is
imperative for successful passage through the grievance process
for diabetic patients undergoing amputation. Further research is
vital in influencing practice changes and factoring the psycholog-
ical aspect of limb loss.
CONCLUSIONS
The loss of a limb is a life-changing event. Uncontrolled dia-
betes in conjunction with poor wound healing is the number one
culprit of limb loss. As the length of hospital stay grows shorter;
clearer discharge incisional care for patients and their caregivers
is essential. Preventive care is optimal in avoidance of limb loss;
however, at times amputation is inevitable.11 Diabetes manage-
ment is imperative to avoid future detrimental events such as
limb loss. Patient education on diabetes control should be
stressed, as most participants in the reviewed studies were un-
aware of the possibilities of limb loss due to diabetes. A multidis-
ciplinary approach with the inclusion of a psychiatrist and
pastoral care facilitates a smoother transition through the griev-
ance process. Providers may view an amputation as ‘‘just another
surgery,’’ however, to the patient, it is a deleterious loss. Most pa-
tients report a lack of provider compassion. Sensitivity courses
should be offered to health care providers who care for this pa-
tient population. Standardization of postoperative care along
with communication among health care providers, patients and
their families and referral to support groups such as Amputee
Coalition is essential for successful transition to a new lifestyle.
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