Guest Editorial: An Introduction to Palliative Chronic Wound Care

  Palliative wound care — ie, the merging of symptom management into advanced wound care — is a relatively new field. The traditional goal of wound care is to heal or prepare for surgical closure, but techniques and procedures involved can be painful and costly. Palliative wound care requires a different mindset than traditional wound care, yet is based on the same fundamental scientific principles. An all-embracing approach to palliation in wound care involves proper assessment to determine if palliation is appropriate; developing a comprehensive strategy for palliation of various types of wounds — ie, pressure, arterial, malignant, neuropathic, and stasis; exploring alternative treatment modalities, including biotherapy; choosing proper support surfaces to enhance care of the patients and their wounds; consideration of an interdisciplinary approach with nutrition, surgery, and vascular surgery as indicated; and managing symptoms of chronic wounds, especially pain and odor. Even though patients who qualify for palliative wound care may not live long enough to heal a wound, it is inappropriate to ignore wounds or declare them untreatable in patients at the end of life.¹

  An effective palliative wound program can have many benefits, including maximizing functional status and quality of life and (at times) achieving complete wound closure. Successfully incorporating palliative care concepts into the existing healthcare system that focuses so heavily on disease eradication continues to be a challenge, as does integrating palliative concepts throughout the continuum of wound care when the primary goal has always been curative.

  The goals for palliation are different from traditional, healing-oriented care. How long the patient will live, whether he/she has a healable wound, what is appropriate for the patient, and what can be done to provide comfort are primary considerations. Palliative treatment needs to be interdisciplinary and should address the psychosocial as well as physical needs of the patient.² Collaboration and cooperation among physician, nurse, physical therapist, dietitian, social services, surgeon, and others are essential. Even without a goal of wound healing, >50% of wounds improve with good palliative care.³

  Fundamental concerns in palliative care include circulation, nutrition, and immune function. Circulation — ie, bringing oxygen to the tissues — must be a priority. Many treatments (occlusive dressings, compression wraps, and debridement) may be contraindicated. The goal in palliative treatment for ischemic disease is pain relief and prevention of infection, with maintenance of dignity. Often amputation is offered, but it is rarely appropriate in a hospice/palliative care situation. Nutrition is needed to support optimal wound healing, but the clinician always needs to consider what is reasonable for the patient. Immune function often is impaired by patient comorbidities; chronic wounds may take months to heal due to patient age, possible infection, neuropathy, multiple disease states, and medications such as corticosteroids, NSAIDS, and immunosuppressive agents. However, because the body is “programmed” to heal, and skin is preserved above other organs, so even with severe compromise wound healing is possible.⁴

  Prevention and treatment. A major question in palliative wound care, especially in hospice, is whether these wounds can be prevented. In my experience, pressure ulcers, the most prevalent wound, are for the most part preventable. Arterial and stasis ulcers and tumors cannot be prevented. Therefore, correct diagnosis is essential in being able to properly assess and treat wounds.

  Although risk can be assessed to develop individual care plans, all palliative patients are high risk and should be treated the same. The three ingredients of a successful prevention program⁵ include 1) pressure relief/redistribution for bed and chair, 2) pressure relief/redistribution for heels, and 3) lubricating the skin with aggressive emollient therapy.

  Once goals are established, a treatment strategy can be developed that involves wound assessment, patient assessment (including both physiological and psychosocial aspects and the desires of patient and family), and basic tenets of debridement, cleansing, treating infection, controlling pain, promoting granulation, and selecting a dressing. Treatment should be individualized for each patient.

  An example of successful palliative care. A study³ of Cincinnati hospice patients (median age 82 years) treated over a 30-month period following the previously suggested tenets in wound treatment demonstrated good outcomes in the protocol (ironically, deemed “not aggressive enough” by some patients) versus the nonprotocol group, which received standard wound care according to their providing physician. This hospice used a low-tech, high-touch format, providing adequate pressure support/redistribution for bed and chair (static-air preferred, low-air-loss if not available) and used a simple formulary with a medicated hydrogel gauze and zinc oxide ointment for open wounds and betadine for scabbed or ischemic wounds. Maggots were used if debridement was necessary. Pain was controlled as needed with narcotics. No new wound infections occurred, pain relief was notable, odor was reduced, and nearly 50% in the protocol group healed or showed healing before death, compared to 20% in the nonprotocol group.

  In summation, palliative wound care embraces the fundamental scientific principles of evidence-based management, tempered by the reality of the patient’s physical and emotional limitations. The main differences between palliative and curative wound care are the clinical and psychological goals of treatment. The articles in this issue address three crucial considerations relative to palliative care: prevention, pain, and the unavoidability of skin failure. The premier source of palliative wound care information is the 3rd Annual Palliative Wound Care Conference, May 17–19, 2012, in Stevenson, Washington. Visit https://hopeofhealing.org for details.

  The intent of palliation is to provide compassionate care. But really, all wound care should be compassionate. Palliative care providers have much to offer providers of traditional care.

Dr. Tippett is a primary care physician and wound consultant in Cincinnati, OH. She has more than 10 years of wound care experience, eight of which as a hospice physician caring for wounds in patients at the end of life.

This article was not subject to the Ostomy Wound Management peer-review process.

1. Cuddigan J. NPUAP-EPUAP Pressure Ulcer Prevention and Treatment Guidelines (2009). Available at www.npuap.org. Accessed April 24, 2012.

2. Alvarez O, Meehan M, Ennis W, et al. Chronic wounds: palliative management for the frail population. WOUNDS. 2002;14(8 suppl):1–27.

3. Tippett A. Wounds at the end of life. WOUNDS. 2005:17(4):91–98. 

4. Sibbald RG, Krasner DL, Lutz J. SCALE; Skin Changes At Life’s End (SCALE): final consensus statement. Adv Skin Wound Care. 2010;23:225–236.

5. Tippett, A. Reducing the incidence of pressure ulcers in nursing home residents: a prospective 6-year evaluation. Ostomy Wound Manage. 2009;55(11):52–58.