Tag Archives: palliative wound care

Palliative wound care: Part 2

This approach brings patient-centered care to life.

 By Gail Rogers Hebert, MS, RN, CWCN, WCC, DWC, OMS, LNHA

Editor’s note: This article is the second in a two-part series on palliative wound care. For the first part, click here.

By preventing and relieving suffering, palliative care improves the quality of life for patients facing problems associated with life-threatening illness. This care approach emphasizes early identification, impeccable assessment, and treatment of pain and other issues—physical, psychosocial, and spiritual.

When relieving distressing symptoms takes higher priority than healing the wound, the patient may choose palliative  wound care after consulting with the medical team. Addressing such issues as pain, odor, exudate, bleeding, infection, and cosmetic appearance, this treatment approach couples the elements of traditional wound care with symptom management. When delivered correctly, it brings patient-centered care to life.

Addressing pain

Many wound care patients have ongoing pain. Dressing removal can be the most painful part of wound management. If pain intensifies with each dressing change, the palliative-care approach may call for use of nonadherent long-weartime dressings to reduce dressing-change frequency. Minimizing unneeded stimuli to the wound also is important; topical lidocaine preparations help by numbing the area locally during dressing changes.

Try to schedule dressing changes for a time when patients feel their best, if possible. Before you start, offer pain medication; wait until it reaches maximal effectiveness before assessing whether the patient is ready to begin the procedure. Also consider using music, relaxation, position changes, meditation, guided imagery, and transcutaneous electrical nerve stimulation. If the patient has dis-comfort during the dressing change, call frequent time-outs: Stop the procedure and ask if the patient would like a break. If so, don’t resume activity until the patient consents.

Reducing odor

When unpleasant wound odor reduces quality of life, odor management becomes a palliative-care goal. Wound odor can embarrass the patient, causing depression and self-imposed isolation. Family members may feel guilty if they can’t approach the bedside owing to overpowering wound odors. Wound odor also may decrease the patient’s appetite, which impedes the palliative-care goal of providing adequate nutrition.

Because odor commonly results from bacteria in necrotic tissue, consider wound debridement if it’s consistent with the patient’s overall plan of care. Autolytic methods commonly are used because they’re gentle and easy to implement with moisture-retentive dressing products. Other aids to managing odors include systemic and topical antibiotics, silver dressings, charcoal dressings, topical honey dressings, cadexomer iodine–impregnated dressings, and properly diluted antiseptic solutions.

If wound odor permeates the patient’s room, consider placing essential oils, kitty litter, or coffee beans nearby. Also consider using scented candles and having  visitors place methylated preparations under their noses to mask the smell. These strategies help enable the patient to socialize with others.

Decreasing wound exudate

High exudate levels can pose challenges for both palliative wound care patients and clinicians. Consider using absorbent dressing products, such as foams, alginates, and specialty dressings. The goal is to manage exudate to keep excess moisture off surrounding skin, where it could cause further breakdown.

If exudate volume is high enough to necessitate frequent dressing changes or if odor control is needed, consider pouching the wound. Negative-pressure wound therapy (NPWT) helps contain the drainage if all other wound factors are consistent with use of this therapy. Pouching and NPWT help manage odor because these closed systems don’t allow  exudate to contact room air, except during equipment or dressing changes.

Unlike traditional wound care treatment, a palliative-care approach may avoid moist wound healing for dry and scabbed areas. Although moist wound healing is widely accepted to expedite healing, when the patient’s prognosis is limited and the wound can be managed without further complications, healing  takes lower priority, and scabbed areas can be left open to air with no dressing.

Managing bleeding

In malignant wounds, bleeding may result from the effects of cancer cells on blood vessels. Tissue becomes friable and more susceptible to local trauma. Bleeding also may result from overall health conditions, including abnormal platelet function.

For minor bleeding, calcium alginate dressings (typically used to absorb exudate) can help trigger the coagulation cascade. Also consider such products as absorbable gelatin powders, collagens, and vasoconstrictors. Chemical cauterization with silver nitrate may be required, as well as suturing of involved vessels and laser therapy.

Preventing and managing infection

Preventing wound infection is an important goal for all wound care patients. Use basic infection-prevention measures— good nutrition, wound cleaning, exudate management, and timely dressing changes—if these can be done in alignment with the patient’s wishes. If healing is a palliative-care goal for a patient with a wound infection, traditional treatment approaches (including culturing) are appropriate.  Be sure to weigh the benefits of treating the infection against the burden the treatments could place on the patient.

If wound healing isn’t a goal for your patient, formal diagnosis and treatment of a wound infection isn’t necessarily warranted. If treating it won’t yield benefits and the patient can be maintained comfortably, the infection may not require active treatment.

However, in many cases, bacteria in the wound cause pain, odor, and high levels of exudate, which are problematic and reduce quality of life. In this case, to meet palliative-care goals you may need to take steps to reduce the bioburden. Try such traditional methods as debridement, antiseptics, antibiotics, and various antimicrobial dressings and therapies.

Improving cosmetic wound appearance

Most patients don’t want others to see their wounds. If the wound is on the head, neck, or other highly visible area, this poses a challenge. Patients may be embarrassed and not want to frighten others by their appearance. A major challenge in palliative care is to dress the wound in an inconspicuous way that protects patients’ dignity and supports their desire for socialization. One way to do this is to avoid bulky dressings in favor of lower-profile, more streamlined dressings.

Creating symmetry with dressings is important, too. Dressing just one side of the body immediately draws the observer’s eye to that side because of the asymmetry. So when feasible, use dressings to  build up both sides of the body to restore symmetry and make the wound less noticeable. Also, dressings come in various skin tones to blend better against the skin; choose the most appropriate tone for your patient. And try to use clothing creatively to cover the wound.

Palliative wound care embodies the best of patient-centered care by focusing on what’s best for the patient—even if that’s not what’s best for the wound. Aggressively managing the most distressing symptoms of chronic wounds helps maximize patients’ quality of life.

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. www.woundsource.com/blog/palliative-wound-care-merging-symptommanagement-advanced-wound-care-practice

Tippett A. What is Palliative Wound Care? Posted May 6, 2012. www.woundsource.com/blog/whatpalliative-wound-care.

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. www.woundsource.com/whitepaper/perspectivespalliative-wound-careinterprofessional-strategiesmanagement-palliative-wou.

Woo KY, Sibbald RG. Local wound care for malignant and palliative wounds. Adv Skin Wound Care. 2010;23(9):417-28.

Gail Rogers Hebert is a clinical instructor with the Wound Care Education Institute in Plainfield, Illinois.

Palliative wound care: Part 1

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. www.woundsource.com/blog/

palliative-wound-care-merging-symptom-management

-advanced-wound-care-practice. Accessed December 2, 2014.

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. www.woundsource.com/whitepaper/perspectives-palliative-wound-care-interprofessional-strategies-management-palliative-wou. 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.