Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part Two -- Venous Ulcerations

William J. Ennis, DO, MBA, FACOS, Patricio Meneses, PhD


Wounds. 2003;15(4) 

In This Article


An attempt has been made in this paper to review the physiology of venous ulcers and treatment options. Literature has been cited heavily throughout the body of the report in an attempt to provide an evidence-based review. Standard of care consists of compression therapy and moist wound healing. This protocol should be followed strictly and reevaluated in two to four weeks. If there is no significant improvement then the clinician needs to address the individual needs of the patient and reevaluate the appropriateness of care. In recalcitrant cases, advanced therapeutic options may be required. The use of skin grafting, venous surgery, bioengineered tissues, growth factors, and modalities may turn out to be cost effective if they can significantly reduce the overall time to healing and eliminate the long treatment programs currently used by many clinicians. Quality of life and work return also may be improved by proposing a more aggressive approach to the venous ulcer patient. It is important to note that standard of care may not be adequate and, in some cases, may be inappropriate. Guidelines and standard-of-care papers are being developed and implemented at a rapid pace. From a legal point of view, it must be clear whether a guideline was developed to improve quality of care or whether other concerns and considerations were the basis for the project.[166] There is not yet clear consensus on whether guidelines will be used as the standard of care or will simply be another piece of evidence that a jury would use to determine the outcome of a medical liability litigation.[167] In order for guidelines to develop legal standing as standard of care, tort reform would be needed. State legislatures would need to unify the medical standard of care and the legal standard of care.[168] Statutes would then recognize the guideline as defining the appropriate standard of care without, possibly, the need for expert testimony.[168] At this time, there is still much confusion, and the clinician, therefore, needs to be aware of the guidelines that apply to the clinical situation but must be cognizant of the fact that some patients will require guideline modifications and deviations. Identifying those patients will, therefore, be the challenge we all face.