Palliative Wound Care

Palliative wound care is an alternative approach that focuses on relieving suffering and improving the patient's quality of life when the wound no longer responds to, or the patient can no longer tolerate, curative treatment. Where typical wound treatment primarily focuses on bringing a wound to closure, palliative care focuses on symptom management, addressing the problems of infection, pain, wound odor, exudate, and decreased quality of life in end-of-life care. Palliative wound patients typically have long-term, potentially life-limiting illnesses of varying etiology that can affect skin integrity. Since "life-limiting" can mean weeks, months, or even years, it is important to set goals that don't exclude the possibility of healing when improving the patient's quality of life. Conditions that may necessitate palliative care include malignant forms of cancer, major organ failure (renal, hepatic, pulmonary, or cardiac), and, in some cases, profound dementia.

Treatments & Interventions
Palliative wound care can take a variety of forms, depending on the symptoms that are being addressed.

Infection

Infection of a chronic palliative wound produces an enhanced and prolonged inflammatory response, which in turn causes more damage to the wound. Consequently, symptoms that would normally indicate the presence of an infection would be masked as the prolonged inflammatory response also reduces the patient's immune response.

Depending on the nature of the infection, either systemic or local antimicrobials or antibiotics may be used to combat the infection. Drainage or palliative debridement may be necessary to remove slough and devitalized tissue, as these increase the risk for infection and can affect the efficiency of topical antibiotics. Antimicrobial dressings, including those that use silver technology, may be used to help reduce bioburden. Antibiotics, whether topical or systemic, should only be used under the explicit direction of a physician/primary care provider. A very useful technique for palliative wound care is the use of maggot debridement therapy for wounds containing necrotic tissue. This debrides the wound and reduces the risk for pain, odor and exudate. It avoids the pain of surgical debridement, and simplifies the administration of topical agents.

In addition to removing a barrier to wound healing, treating the source of infection in palliative wounds can also help mitigate other symptoms such as wound odor, exudate, and pain.

Pain

Pain control in palliation is a primary goal. Pain impacts quality of life; so, pain must always be treated, preferably with an opioid-based agent or topically.

Dressing removal is often the most painful part of the wound management regime. Analgesia should be given systemically or topically before the dressing change procedure begins, with enough time allowed for the analgesic to have the desired effect. Pain can be limited by the use of dressings that are minimally traumatic upon removal and by gentle irrigation of the wound with warmed normal saline prior to removal.

Wound odor

Wound odor, while not technically a barrier to wound health, needs to be taken into account based on the quality of life and psychological effects on the patient. Malodorous wounds can negatively impact the patient's relationship with family and friends, contributing to social isolation. Wound odor is usually produced by bacteria present in the wound. Limiting the bacterial burden on the wound, managing exudate, wound cleansing, and the application of odor controlling dressings, such as those containing charcoal or carbon, can all help to reduce wound odor.

Exudate

Exudate, often present in palliative wounds, presents a particular challenge in wound care. Proteinaises (tissue-destroying enzymes) present in wound exudate damage periwound skin and can enlarge the wound.

Absorbent dressings should be used to manage exudate, and can be used in conjunction with a non-adherent contact layer to minimize dressing change trauma. In cases where the wound bed can be allowed to dry out and the amount of exudate reduced, this may be a preferred alternative. Since reducing patient discomfort is the priority here, and not faster wound healing, keeping the wound dry and stable may be a viable approach with minimal negative impact on the patient.

Nutritional support

As patients become weaker and less alert, they are often unable to maintain oral intake of nutrition. Additionally, certain medications or symptoms of chronic conditions can affect the absorption of nutrients. Without proper nutritional support, the risk of skin damage and delayed healing increases significantly. As a result, the need to encourage the patient to eat and drink frequently can outweigh other dietary restrictions. One approach to increasing nutritional intake is to offer the patient their favorite food or beverage (within reason).

Quality of Life, Self-confidence, and Independence

As a palliative patient's condition worsens, the psychological implications of reduced independence can be devastating. When possible, promoting patient self-care and the continued performance of certain everyday activities can help to improve patient dignity, outlook, and quality of life.

References

Grocott P. Wanted: a theory base for palliative wound care. Wounds UK. 2005;6(1):55-56. https://www.wounds-uk.com/journals/issue/4/article-details/wanted-a-theo.... Accessed May 16, 2019.

Grocott P, David G. The argument for palliative wound care. Wounds UK. 2010;6(1):167-168. https://www.wounds-uk.com/journals/issue/21/article-details/the-argument.... Accessed May 16, 2019.

Hughes RD, Bakos AD, O'Mara A, Kovner CT. Palliative Wound Care at the End of Life. Home Health Care Manage & Pract 2005;17(3):196-202. doi: 10.1177/1084822304271815.

Langemo D, Anderson J, Hanson D, Thompson P, Hunter S. Understanding palliative wound care. Nurs Crit Care. 2008;3(5)56. doi: 10.1097/01.CCN.0000336359.63599.98

Wendelken ME, Markowitz L, Alvarez OM. Case Studies In Palliative Wound Care. Podiatry Today 2009;22(7). http://www.podiatrytoday.com/case-studies-in-palliative-wound-care. Published July 2009. May 16, 2019.

Woo KY, Krasner DL, Kennedy B, Wardle D, Moir O. Palliative wound care management strategies for palliative patients and their circles of care. Advances in Skin & Wound Care. 2015; 28(3):130-140.

Woo KY, Krasner DL, Sibbald RG. Pain in People with Chronic Wounds: Clinical Strategies for Decreasing Pain and Improving Quality of Life (Chapter 9). In Krasner DL, van Rijswijk L, eds. Chronic Wound Care: The Essentials e-Book. Malvern, PA: HMP; 2018:111-122. Downloadable at www.whywoundcare.com/Resources.