Facilities have long struggled to find the appropriate balance related to treating wounds for the patient on palliative care. It can often be very challenging determining the best way to treat the wound that most likely will not heal. Harmony (HHI) offers the following advice to assist the facility with this challenge:
The first step is understanding the definitions of Palliative Care and Hospice.
Palliative Care: Focused on relief of pain symptoms faced by patients with serious illness. Palliative care can be provided along with curative care. Goal is to improve Quality of Life.
Treatment is conservative and curative
Hospice Care: A component of palliative care. Curative treatment is no longer beneficial or desired. The goal is to improve the Quality of Life. It is important to remember that choosing Hospice does not mean that the patient chooses death, rather it is a choice of living life to the fullest with what time is left.
Treatment is conservative, not curative
- Assess the wound: Assessment must be holistic. Review all factors that impact wound healing including systemic, psychosocial and environmental. Evaluate the following:
- Social support
- Overall prognosis and diagnosis
- Life expectancy
- Type of wound
- Clinical characteristics of wound including measurements
- Wound measurements need to be completed at least weekly unless the patient is actively dying
- Know the Goal: When reviewing treatment options, it is critical to identify what the goal is. Input from the patient, family, MD and SW can make this process easier. Most likely, the goal will be controlling pain associated with the wound rather than expecting it to heal.
- Maintaining a stable wound – relieve symptoms, pain, odor, bleeding, drainage and infection
- Prevent new breakdown and infection
- Maximize patient mobility and function to improve quality of life
- Do what is best for the patient, not the wound
- Treatment Planning: Know the primary and secondary goals. Know the patients’ advanced directives. The following are some options in treating common issues:
- Odor – can be embarrassing, may decrease appetite, may cause social isolation. Interventions include:
- Debride dead tissue – choices include autolytic (least painful, more gentle. Does not harm healthy tissue. For non-infected wounds), mechanical (can be painful, can damage healthy tissue), sharp (painful, effective with wound that have large areas of necrosis), enzymatic (does not harm healthy tissue, works quickly) and bio-surgical (medical maggot therapy, very effective but costly).
- Antimicrobial dressings – decreases odor in infected wounds
- Charcoal dressing – absorbs odor
- Bacteria Control: More bacteria in a wound results in increased complications and discomfort. Treatment options include:
- Topical antiseptics – such as Dakin’s Solution properly diluted to ¼ strength
- Topical antibiotics – used only for active infection and for short durations
- Topical antibacterial dressings – silver dressings can be very effective
- Drainage control: Some moisture in the wound bed is important to both promote healing and control discomfort. When there is too much moisture, it results in damage to surrounding skin and increased pain. Treatment options include:
- Hydrocolliods and composite dressings – for light drainage
- Foam (for example, Allevyn) – for light to moderate drainage
- Calcium Alginate – for moderate to heavy drainage
- Hydrofiber dressing (for example, Aquacil) – for heavy drainage
- Bleeding: caused by increased bacteria load. Decrease the bacteria levels in the wound.
- Wound Pain: The key is to remember that pain is whatever the patient says it is. Interventions include:
- Non- pharmacological: Offloading, pressure relieving devices, splinting, bed cradles, lift sheets for mobility, transfer aids etc..
- Psychological: offer reassurance, hand holding, soft lights, music, quiet room, acknowledge the pain.
- Pharmacological: Follow the appropriate analgesic ladder
- Phase 1: Mild to moderate: Treat with non-opioid analgesic
- Phase 2: Moderate to severe: Phase 1 plus codeine
- Severe: Phase 1 plus morphine
- Dressing changes: Use wound care gel or lidocaine gel, soak dressing prior to removal, minimize number of changes, use dressings with minimal adhesive, allow patient to participate in dressing change, protect surrounding tissue (use skin prep type product). Think outside the box when choosing ways to adhere the dressing. Often, dressings can be secured without the use of tape.
The most important thing to remember when developing the plan of care for these challenging wounds is putting the patient and/or family wishes first.