Dale, Barbara BSN, RN, CHHN, CWOCN; Emmons, Kevin R. DrNP, RN, CWCN, DAPWCA
Palliative Wound Care: Principles of Care
Palliative care is a term we have become accustomed to hearing since the evolution of hospice care from institutionalization in the 1970s to the modern home-based palliative and hospice care of today. The World Health Organization (2002) defines palliative care as:
An approach that improves the quality of life of patients and their families facing the problems 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. (p. 84)
Palliative wound care is generally understood as wound care provided without the aim of complete wound healing. However, palliative wound care in the home healthcare setting involves much more than merely dismissing or omitting any goal directed toward healing. A common misconception among some healthcare providers is that palliative care does not include curative goals. This misconception implies that healthcare providers will not provide any care directed at healing end points and may include the omission of care all together. Palliative care and palliative wound care are not exclusive to hospice care at the end of life; rather, palliative care principles can be applied throughout the life span with a focus on symptom management and not excluding the possibility of healing end points (Emmons & Lachman, 2010).
In today's home healthcare and hospice setting, patients are coming home from the hospital more acutely ill than ever before with more chronic diseases that are being treated more aggressively (The Joint Commission, 2011). In 2008, 14% of home healthcare patients aged 65 years and older received wound care of some type (Jones et al., 2012). It is inevitable that home healthcare nurses will encounter persons with wounds. It is also likely that these persons may require care that addresses symptoms management in the presence of severe physiologic compromise. It is reasonable then to consider the application of palliative wound care principles while not omitting goals of healing end points. These types of encounters demonstrate a need for evidence-based practice guidelines and practical clinical care pathways. However, literature in this area is severely limited. Moreover, the evidence-based research is nearly nonexistent for specific topical palliative wound treatment options in the home setting (Langemo, 2012; National Consensus Project for Quality Palliative Care, 2009). The purpose of this article, first of a two-part series, is to explore the principles of palliative care.
What is Palliative Care?
Palliative care is symptomatic care and not disease-focused. It is patient oriented with shared decision making. Palliative care takes a holistic “approach” to alleviate bothersome symptoms based on patient needs, desires, and patient-set goals. This type of care can be provided at any time and is not always provided just at the end of life (Institute for Clinical Systems Improvement, 2011; National Consensus Project for Quality Palliative Care, 2009). Palliative care can be a beneficial option when a patient is in a specific disease trajectory, recovering from a severe illness, at the end of life, and if within patient/family preferences for care (Resnick, 2012). For example, a patient with congestive heart failure and venous insufficiency with ulcerations may not want the standard compression therapy because it exacerbates his/her shortness of breath. A patient with debilitating rheumatoid arthritis may have a pressure ulcer on his or her coccyx and refuse optimal treatment if it involves frequent turning or being positioned in a manner that increases pain in the joints. A cancer patient at the end of life may be hesitant of daily wound care to a necrotic of fungating wound if it increases his or her pain. In these scenarios, palliative care approaches are beneficial as they aim is to improve quality of life by alleviating or managing the symptoms that are bothersome to the patient. “Palliative care can occur simultaneously with curative therapies, or may be the sole focus of care” (Institute for Clinical Systems Improvement, 2011). To best care for patients in these situations, home healthcare and hospice nurses must collaborate with the patient, physician, and family members to develop a palliative plan of care that meets the patient's goals and preferences and may continue to evolve throughout the trajectory of care.
Understanding Healing in the Face of Illness
Although healing may actually be possible, it can give the patient and family a sense of relief to shift goals from healing to symptom relief. Home healthcare staff can use healing probability tools to help determine probability of wounds to heal and to gain a better understanding of some circumstances or situations that may impede healing. The For Recognition of the Adult Immobilized Life (called FRAIL) healing probability assessment tool can assist nurses in the beginning stage of developing a plan of care (FRAIL, 2002). The tool lists factors that commonly impact wound healing. The more factors that a patient has, the less likely the chances are for complete wound healing. Armed with this information, the nurse can help facilitate the discussion of palliation over curative treatment if necessary.
Palliative Wound Care
Patients receiving palliative care may experience many types of wounds. Maida, Ennis, and Corban (2012) report the most common wounds seen in persons with advanced illness are pressure ulcers, skin tears, malignant wounds, venous leg ulcers, diabetes-related foot ulcers, and arterial leg/foot ulcers. Persons with advanced illness may be more susceptible to developing new wounds secondary to a compromised health status. Traditional evidence-based wound care may or may not be appropriate in this population, as it focuses on healing as the primary goal or outcome. To achieve wound healing with traditional wound care, the home healthcare nurse must control or eliminate causative factors (etiology), provide systemic support to reduce existing or potential cofactors (systemic), and maintain a local wound environment that promotes healing (topical) (Bolton, 2007; Levine et al., 2013). In many cases, controlling or eliminating causative factors may not be possible or may be delayed because of complex conditions that often accompany home healthcare patients. Conditions may include lower extremity arterial disease, malignant wounds that failed treatment, significant protein-calorie malnutrition, and so on. In these cases, it is suggested that principles of palliative wound care be implemented. Palliative wound care is a holistic integrated approach of care that addresses symptoms management, is interdisciplinary/multidisciplinary, is driven by patient and family goals, and addresses a patient's psychosocial well-being (Emmons & Lachman, 2010). Using this approach, the home healthcare nurse can integrate the concept of palliative wound care into the plan of care considering each of the areas (Table 1).
Starting With Patient Self-Report
When determining goals and appropriate interventions to meet those goals, this is the first question that needs to be asked: What about the wound is bothering you the most? What symptom or symptoms have the most effect on your day-to-day well-being? It is essential that clinicians ask the patient what their values, preferences, and concerns are. Sometimes, the priorities of patient or family are different from those of the clinicians. Open communication provides an environment where every one's concerns can be addressed and encourages the patient and family to be active participants in developing a plan of care. Common wound-related complaints reported include wound pain, pain with dressing dressings, odor, amount of exudate, bleeding, itching, and appearance (Emmons & Lachman, 2010; Kalemikerakis et al., 2012; Letizia et al., 2010; Woo et al., 2013). Using specific items in Table 1, the home healthcare nurse can address most aspects that may have an impact on the patient's quality of life.
Developing a plan for symptom management should be patient driven and have achievable goals. It is imperative to explore what the patient and caregiver experience is and then prioritize symptoms based on what is most bothersome and what can be realistically managed. Some considerations and questions are listed below.
* Is the patient or caregiver able to verbalize what the most debilitating symptom is at this time? If not, can the home healthcare nurse identify it by patient behavior, caregiver report, or nursing assessment?
* Does the patient avoid going out in public because of a fear of others noticing an odor or appearance?
* Does the patient complain of increased pain during dressing changes or when the wound is too dry or too moist?
* Does the amount of drainage impact daily living?
* Is the patient concerned with bleeding, itching, or any other symptoms?
Asking these questions of yourself and also directing these types of questions to the patient and family can help facilitate the development of a patient-specific plan of care and ultimately guides interventions and strategies to improve the patient experience. Exploring the patient's experience with the wound allows an open discussion. Sometimes, it may be beneficial to list these common symptoms and have the patient rate them in order of what is most bothersome and what is least bothersome. Patient-reported goals or end points may include the wound getting smaller or complete healing. In these cases, the nurse and patient can list what is achievable in the short term and what is the long-term goal. An example would to include a hospice patient with a stage IV pressure ulcer with heavy drainage, odor, and periwound pain. The patient identifies that he or she wants the wound to heal and wants to get rid of the odor. Since you have already identified the large amount of drainage, you can discuss that the focus of wound care for the short term will be the reduction of odor and drainage, as they may be achieved first and is part of the healing process. Clarify that healing may not occur in the near future, but it will still be listed as a goal further down on the priority list. Defining success is another technique to help the patient and family understand the healing process. Success in wound care is not merely defined as complete healing. Rather, discuss success as effectively managing each goal that has been identified as problematic.
Having access to needed referrals is also an important aspect of care. If the patient is contracted or has difficulty ambulating, a physical or occupational therapy referral could provide necessary resources to improve care. This is also true of other services such as dietitians or nutritionists, psychologists, specialty physicians, and so on. Other fields of expertise should be used when available to collectively provide the best possible care.
Developing Wound Care Protocols
In healthcare's outcome-driven market, some home health agencies (HHAs) use some type of wound care protocols. Development and utilization of wound care protocols enables a HHA to put research-based evidence into practice, standardizes care between staff by reducing variation in treatment, and leads to positive wound healing outcomes. Comprehensive wound management includes systemic support and topical wound interventions (Sibbald et al., 2011). Some protocols include all aspects of wound healing, such as etiology, systemic, and topical, and others focus primarily on topical care. Protocols are usually developed and based on the HHA's specific product formulary. The protocols serve the nursing staff as an interventional guide based on specific wound etiologies. A palliative protocol may have many of the same statements as a healing protocol, but it should contain alternatives that address the symptoms most frequently reported by palliative wound care patients including pain, odor, and exudate management (Lo et al., 2012). In effect, an appropriate palliative wound care protocol would include an approach that would balance the benefit with the burden (see Case Study) (Hughes et al., 2005). Development of topical wound care protocols for palliative wound care could facilitate a more effective and smooth transition to meet patient goals of care and to improve quality of life. Adjunctively, use of a symptom management chart can steer the development of the plan of care with appropriate interventions in situations in which a wound may fall within several wound categories, out of the realm of available protocols, or under no specific protocol. The symptom chart can facilitate the nursing plan of care to focus on a specific symptom(s) most bothersome to the patient without narrowing the plan of care to one type of wound and/or restricting interventions.
Home healthcare nurses face special challenges in providing wound care and are often faced with the difficulty of patients who may not have the capacity to heal. In these patients, especially among those at the end of life, it is essential that the home care nurse understands principles of palliative wound care. Excellent palliative wound care is a holistic approach that requires the home healthcare nurses to be an active member in developing the most effective plan of care.
Case Study: Balancing Burden With Quality Care
Mrs. M is a 93-year-old woman and was recently discharged home from the acute care hospital. As an inpatient, she underwent several surgeries for heart valve replacement; however, these attempts were complicated by numerous infections and prolonged ventilator support, and subsequently the original problems have not been completely resolved. The cardiac surgeons have told Mrs. M and her husband that additional surgeries are not an option. After several meeting with the hospital staff, Mrs. M and her husband are considering hospice care, but they are unable to make a decision.
While hospitalized, Mrs. M sustained a hospital-acquired pressure ulcer measuring 7 cm 10.5 cm 3 cm. The wound has been documented as Stage IV pressure ulcer with 40% yellow tissue and 60% red tissue with moderate serosanguineous drainage. It is documented that exposed muscle has been covered over in granulation tissue. There are no signs of infection. The discharge instructions indicate that hospital recommends Mrs. M followed up with surgery for surgical debridement of the wound and topical care as wet-to-dry gauze dressings twice daily. Mrs. M and her husband express concerns about having surgery especially after it was difficult for her to wean off of the ventilator the last time. Mrs. M also complains of pain with each dressing change and fluid leaking from the dressings onto her bed.
As the home healthcare nurse, what would be the best course of action? While considering hospice care and her complex history, do the patient and her husband have the option not to continue with surgery? Asking the patient and family to list their concerns with the wound can provide other priorities such as pain control, extended wear time dressings, drainage management, and other noninvasive forms of debridement.
In this case, the patient and family identified that pain control and limiting the amount of dressing changes was a priority while not giving up the hope of healing in the future. The nurse spoke with the primary care provider, who agreed with the plan of placing an absorptive dressing such as a silver alginate lightly on the wound and covering it with a foam dressing. Dressing changes were completed every 3 days. This dressing selection provided an absorptive dressing while also optimizing an environment to facilitate the body to remove dead tissues called autolysis. The silver in the dressing reduced topical bacteria, thereby preventing infection and odor. As her overall health worsened, the patient and her husband decided that Mrs. M would receive home hospice care. Dressing changes were extended to every 5 days with the same results. Mrs. M's husband called the home care agency to say thank you and that she died peacefully at home with the pressure ulcer, but with all of her symptoms effectively managed.
This case illustrates that although wound healing was not achieved, there was success in managing symptoms and improving quality of life. Initial therapy recommendations of surgery and frequent dressing changes did not account for patient and family preferences. Prioritizing patient goals while not abandoning healing created a realistic plan of care with achievable goals.
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