By Gail Rogers Hebert, MS, RN, CWCN, WCC, DWC, OMS, LNHA
The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Setting goals for a patient with a wound doesn’t require wound healing as an endpoint. If you propose this to colleagues who aren’t familiar with the palliative approach to wound care, you may get puzzled looks in return. That’s because the palliative approach to wound care is a fairly new concept.
Clearing up misperceptions about palliative wound care
Certain perceptions of palliative wound care need to be clarified.
- Choosing palliative wound care doesn’t mean you’re giving up on the patient and the wound. Studies show approximately 50% of patients receiving palliative wound care achieve wound healing.
- Palliative care isn’t the same as hospice care. Hospice care is a component of palliative care chosen by patients when their physician determines they’re within 6 months of dying. This prognosis qualifies them for hospice care benefits from Medicare as well as some insurance companies and managed care organizations. Palliative care can occur simultaneously with curative therapies. In contrast, hospice care plans don’t normally include curative therapies. Also, palliative care can be chosen at any time, not just the last few months of life.
- Patients who choose palliative care aren’t indirectly hastening their deaths. In one study, researchers randomized 151 patients into two groups. The control group received standard oncologic care alone; the study group received the same care plus early palliative care. Patients in the early palliative care group had a better quality of life and longer median survival than patients in the standard care group.
Why patients may choose palliative care
As healthcare consumers become more knowledgeable about their options, more are exercising the right to make decisions based on their best interests and belief systems. Palliative wound care is well suited for patients with wounds whose underlying causes don’t respond to treatment, as well as those whose treatment demands are too taxing for their diminishing endurance level.
Some wound care treatments can be painful and distressing for the patient and family to perform—or too expensive for the patient to pay for. As the underlying disease progresses, a move to palliative wound care shifts the focus to maximizing comfort and function for the patient and family, and away from more aggressive healing therapies. It’s time we begin looking at wound care from the patient’s and family’s perspective, and realistically incorporate the patient’s prognosis into goal setting.
When to consider a palliative approach
One article suggests wound care clinicians should ask themselves: Would the patient’s quality of life improve significantly if the wound healed? If the answer is no, palliative wound care should be considered. When patients are coping with serious illness and the many distressing symptoms that may accompany it, standard wound care may impair quality of life—and deserve a lower priority. When proper prioritization takes place, wound care justifiably can be optional, especially when patients are actively dying or wound care causes undue discomfort. In those cases, the need to measure wounds at least weekly can be suspended.
The National Pressure Ulcer Advisory Panel’s white paper titled “Pressure Ulcers in Individuals Receiving Palliative Care” states: “Healing is seldom the goal for these individuals receiving hospice or palliative care, and therefore, there is no purpose to frequently measuring the wound size or deterioration because no plans to intervene will be derived in these measurements.”
Dispelling one last myth
Learning to incorporate a palliative approach to wound care means dispelling one last myth—that palliative wound care is a “do-nothing” approach. Nothing could be further from reality. Clinicians may decide to deprioritize wound care when the patient is actively dying or experiencing pain. But this plan is a conscious decision made by the patient and family in conjunction with clinicians. The decision begins with completing a full wound assessment to determine patient factors and identify signs and symptoms that are having the greatest negative effect on quality of life. That’s where the real work begins.
Editor’s note: “Palliative wound care: Part 2” will provide clinical tips to address the most common issues in managing palliative-care wounds—pain, odor, exudate, bleeding infection, and cosmetic appearance. Look for this article in the March/April issue of Wound Care Advisor.
Selected references
Langemo DK, Black J; National Pressure Ulcer Advisory Panel. Pressure ulcers in individuals receiving palliative care: a National Pressure Ulcer Advisory Panel White Paper. Adv Skin Wound Care. 2010;23(2):59-72.
Letizia M, Uebelhor J, Paddack E. Providing palliative care to seriously ill patients with nonhealing wounds. J Wound Ostomy Continence Nurs. 2010;37(3):277-82.
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-42.
Tippett A. Palliative Wound Care: Merging Symptom Management into Advanced Wound Care Practice. Posted April 27, 2011. http://www.woundsource.com/blog/palliative-wound-care-merging-symptom-management-advanced-wound-care-practice
Tippett A. What is Palliative Wound Care? Posted May 6, 2012. www.woundsource.com/blog/what-palliative-wound-care. Accessed December 2, 2014.
Tippett A, Sherman R, Woo KY, Swezey L, Posthauer ME. Perspectives on Palliative Wound Care: Interprofessional Strategies for the Management of Palliative Wounds. December 2012. https://kestrelhealth.lpages.co/perspectives-on-palliative-wound-care-interprofessional-strategies-for-the-management-of-palliative-wounds-white-paper/. Accessed November 16, 2014.
World Health Organization. WHO Definition of Palliative Care. www.who.int/cancer/palliative/definition/en/. Accessed December 2, 2014.
Gail Rogers Hebert is a clinical instructor with the Wound Care Education Institute in Plainfield, Illinois.
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.
