Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part One -- Diabetic Foot Ulcerations

Gerit Mulder, DPM, MS, David Armstrong, DPM, Susie Seaman, MSN, NP, CETN


Wounds. 2003;15(4) 

In This Article

Abstract and Introduction


Administration of prompt and appropriate care for diabetic foot ulcerations is necessary to reduce complications, which may lead to limb loss. An understanding of standard, appropriate, and advanced care may assist the physician in making the most optimal decision when treating diabetic foot ulcers. An overview of the diabetic foot, its associative problems, considerations when reviewing the diabetic patient, and approaches to treatment are presented in this article. Clinicians are encouraged to review each patient individually to determine their specific needs and to administer the most appropriate care.


There are many variations on the definition and interpretation of the phrase standard of care. Definitions may vary depending on the training of the healthcare providers, including physicians, podiatrists, nurses, physical therapists, and medical assistants. Malpractice insurance companies, lawyers, and medical boards may interpret standard of care differently. Definitions may also be determined by the type of care administered by the majority of healthcare providers within a community.

The legal and professional boards generally believe that standard of care is, "...based on the degree of care, skill, and learning expected of a reasonably prudent healthcare provider in the profession or class to which he or she belongs."[1] While this definition reflects reasonable care, it does not necessarily include the administration of appropriate care.

Appropriate care, although not currently defined in the literature, may be considered as the administration of care by a healthcare provider that addresses the specific needs of the patient and that may be reasonably expected based on the degree, skill, and experience of the profession or class to which the healthcare provider belongs. Appropriate care may not entail the same treatment as standard care. When providing appropriate care, individual consideration is given to each patient and his or her wound etiology.

Advanced care, also not currently defined in the literature, may be considered the use of drugs, devices, or treatment regimens that may be experimental, newly approved, or above and beyond treatment modalities routinely used in the general community for a specific medical problem. Advanced care may sometimes be the only means of rapidly and effectively attaining wound closure.

Universal standards of care are not available for the treatment of chronic ulcers. The American Diabetes Association provides guidelines for the treatment of the diabetic foot but intentionally does not clearly delineate treatment, ostensibly allowing for advances in this area.[2] There are also the American College of Foot and Ankle Surgeons (ACFAS) Guidelines and the American Pharmacuetical Association (APhA) guidelines.[3,4] Recommended guidelines for care of venous ulcers are provided in McGuckin's Venous Ulcer Guideline.[5] These guidelines are for suggested care and may be considered a fair representation of expected treatment. In addition, the Clinical Practice Guideline for the Treatment of Pressure Ulcers is available from the Agency for Healthcare Research and Quality (AHRQ).[6]

This is part one of a two-part series featured in this issue of WOUNDS. Part one focuses on guidelines for the treatment of diabetic ulcers. Part two (Ennis and Meneses), also included in this issue, focuses on treatment of venous ulcers. Extensive publications and guidelines for pressure ulcers may already be found in the medical literature. In this series, standard care versus appropriate care will be presented from a clinical perspective and in context of the specific etiology under review. Advanced treatment modalities, including growth factors and skin replacements, will be discussed and presented with respect to their roles in standard and appropriate care of diabetic foot ulcers.


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