Aim: To change concepts is important to change how clinicians and patients conceptualize and act on diabetic foot disease. Different concepts have been introduced for different purposes, e.g., “diabetic foot attack” to emphasize urgency (1), “in remission” to emphasize the high risk of reulceration (2), and “latent diabetic foot disease” to emphasize diabetic foot disease as a single process, encompassing both active and latent phases (3). The aim was to review and discuss conceptualizations of treatment with non-removable offloading devices.
Methods: Review and analysis of literature.
Results: The “forced compliance” concept has been used to denote the use of non-removable offloading devices as a means to secure a high level of compliance/adherence (4). However, this concept may be inappropriate for two reasons. First, the concept has a paternalistic connotation of patients obeying doctors, which is not compatible with viewing patients as partners in decision making. Second, the concept conveys the meaning of doctors as being active (“forcing” compliance) and patients as being passive (being “forced”). Although these connotations are unintended they still may counteract the active and long-term personal responsibility for self-care that we wish to stimulate in our patients. “Ulysses contracts” (originating from Homer’s Odyssey) denote freely made decisions that bind the person in the future. Conceptualizing non-removable offloading devices as Ulysses contracts rather than means to force compliance has two advantages. First, Ulysses contracts emphasize that patients make choices by free will. Second, the “forcing” (i.e., eliminating the alternative to be non-compliant/adherent in the future) does not happen between the doctor and patient, but between the patient’s current and future self. Hence, the patient remains an active and responsible agent during the treatment period which hopefully will spill over into the in remission periods, when removable devices are used and personal responsibility for adherence is crucial.
Conclusions: Ulysses contracts could be a viable way to conceptualize treatment with non-removable offloading devices.