Providing Quality Wound Care at the End of Life

Abstract

Palliative care concentrates on reducing the severity of disease symptoms rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure. The goal is to prevent and relieve suffering and to improve quality of life for people facing serious, complex illness. Managing pain and other distressing symptoms is an important goal of palliative care. Pain and other symptoms are experienced with wounds. Therefore, excellent evidence-based wound care should be an integral component in excellent evidence-based palliative care. The current literature and clinical practice suggest that wound care in palliative settings is a common and complex issue that negatively impacts patients’ and families’ well-being. Although progress has been made in the assessment and management of wounds, more research is needed.

The National Consensus Project Clinical Guidelines for Quality Palliative Care¹ defines palliative care as the following: “Palliative care expands traditional disease-model medical treatments to include the goals of enhancing quality of life for patient and family, optimizing function, helping with decision making, and providing opportunities for personal growth. As such, it can be delivered concurrently with life-prolonging care or as the main focus of care.” Managing pain and “other distressing symptoms” is an important goal of palliative care. Pain and other symptoms are experienced with wounds. Tippett² states, “…palliative does not mean no care. The intent of palliation is to provide compassionate care.” Therefore, excellent evidence-based wound care should be an integral component in excellent evidence-based palliative care. However, there are few studies found on the prevalence and incidence of wounds at the end of life. Langemo³ found that at least one-third of the nearly 1 million hospice patients in the United States have a wound. Some prevalence rates vary between 30% and 47%, and incidence rates vary from 8% to 17%. In 2005, Tippett⁴ stated that “wounds at the end of life are a problem of tragic proportion for the nearly 1 million hospice patients and millions of other frail, elderly persons living with chronic disease.” Emmons and Lachman⁵ used a concept analysis to define palliative wound care as “a holistic and integrated approach that encompasses 1) symptom management, 2) the improvement of psychosocial well-being, 3) a multidisciplinary team approach, and 4) patient/family driven goals.” Alvarez et al⁶ defined palliative wound care as “the incorporation of strategies that prioritize symptom relief and wound improvement ahead of wound healing (total closure)” that “works in conjunction with curative treatments” and “is much more than pain, exudate or odor management.” Ferris and colleagues and the International Palliative Wound Care Initiative⁷ presented the following definition: “Palliative wound care is the evolving body of knowledge and skills that takes a holistic approach to relieving suffering and improving quality of life for patients and families living with chronic wounds, whether the wound is healable or not.” Tippett² writes that “palliative wound care is the merging of symptom management into advanced wound care.”

End-of-life patient care includes a variety of wound care challenges. Much of current evidence-based wound care practice focuses on the outcome of healing, which may not be an expected or desired outcome at end of life. Patients under hospice care deserve to have symptoms of all types managed, and this should include wound management. This article describes evidence-based assessment and current management of wounds in palliative care and identifies the gaps in research related to palliative wound management.

COMMON TYPES OF PALLIATIVE CARE WOUNDS

Pressure Wounds

Pressure wounds are the most commonly seen wounds in chronically ill and elderly patients. It is defined as a localized injury to the skin and/or underlying tissue that is usually over a bony prominence, as a result of pressure, shear, and/or friction. The intensity of the pressure, the duration of the pressure and tissue tolerance, and intrinsic/extrinsic factors are associated with the development of pressure ulcers.⁸

A study found that approximately 68% of wounds were found to be pressure wounds.⁹ Reported prevalence of pressure ulcers in palliative care settings ranges from 13% to 47%.¹⁰ There are multiple contributing factors to pressure ulcer formation in the chronically ill patient, and one is known as “skin failure.”^11,12 Skin failure is defined as “an acute episode where the skin and subcutaneous tissue die (become necrotic) because of hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems.”¹³ In patients who are diagnosed with skin failure near the end of life, even vigilant care may not prevent skin breakdown.

Table 1 presents the National Pressure Ulcer Advisory Panel’s Revised Stages of Pressure Ulcers. A stage I pressure wound is characterized by intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from that of the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue. A stage I pressure wound may indicate at-risk persons for developing deep tissue injury. Stage II pressure wounds have partial thickness loss of dermis presenting as a shallow open ulcer with a red/ pink wound bed, without slough. These pressure wounds may present as an intact or open/ruptured serum-filled blister or as a shiny or dry shallow ulcer without slough or bruising. Stage III pressure wounds present with full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed or directly palpable. These wounds may include undermining and tunneling, and their depth may vary by anatomical location. Areas of significant adiposity can develop extremely deep stage III ulcers. Stage IV pressure wounds have full thickness tissue loss with exposed or directly palpable bone, tendon, or muscle. Slough or eschar may be present, and stage IV wounds often include undermining and tunneling. The depth of the ulcer may also vary by anatomical location. Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule), making osteomyelitis possible.

TABLE 1: National Pressure Ulcer Advisory Panel’s Stages of Pressure Ulcers¹⁴

Suspected Deep Tissue Injury

Suspected deep tissue injury wounds are described as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared with adjacent tissue. Evolution may be rapid and include a thin blister over a dark wound bed, further evolving to become covered by thin eschar.

Finally, unstageable pressure wounds have full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and, therefore, stage cannot be determined.

Malignant Wounds

Malignant fungating wounds have been defined as an infiltration of a cancer or metastasis into the skin and the afferent blood and lymph vessels in the breast.¹⁵ McManus¹⁶ describes malignant wounds as “invading the epithelium and breaking through the skin surface that may be either ulcerative, forming ulcerative craters, or proliferative, forming raised, cauliflower-like nodules.” Malignant wounds have been reported to be the third most prevalent wound class.⁹ Probst¹⁵ refers to a survey done by Thomas and colleagues that reported a prevalence of fungating wounds of 5% to 10% in cancer patients. Lo¹⁷ also found malignant fungating wounds make up 5% to 10% of all cancers in the Western world. A definite drawback of not knowing the incidence rate of malignant wounds is that it can be difficult to interest wound supply manufacturers to develop any new products for malignant wounds if there is not a significant market.

The characteristics of malignant wounds are varied. Crater-like ulcers and raised nodules may begin with erythematous plaques or areas of alopecia.¹⁸ As the process advances, blood and lymph vessels are disrupted, which causes a buildup of waste, edema, hypoxia, and necrosis. Malignant wounds can grow rapidly and often enlarge within 24 hours. Common symptoms include malodor, exudate, pain, and bleeding. All of these symptoms affect all the dimensions of a patient’s existence, and treatment must be multidimensional in nature.¹⁹

Other Common Wounds

Other common wounds found include skin tears, venous leg ulcers, diabetic foot ulcers, and arterial leg/foot ulcers.⁹ Skin tears are defined as “a traumatic wound occurring principally on the extremities of older adults as a result of friction alone or with shearing and frictional forces that separate the epidermis from the dermis (partial-thickness wound) or a deeper split that separates both the epidermis and the dermis from the underlying structures (full-thickness wound).”¹³ Skin tears were found to be the second most prevalent wound class.⁹

Venous ulcers have been defined as “an ulceration that occurs on the lower limb secondary to underlying venous disease; formerly called stasis ulcers.”¹³ Venous leg ulcers were found to be the fourth most prevalent wound class.⁹ Diabetic ulcers are defined as “a wound occurring most often in the feet of people with diabetes due most commonly to neuropathy and/or peripheral vascular disease.”¹³ Arterial leg/foot ulcers are noted to be “an ulcer that occurs almost exclusively in the distal lower extremity due to in adequate perfusion/ischemia.”

Finally, the Kennedy Terminal Ulcer is another type of pressure ulcer wound that is seen at end of life.²⁰ The Kennedy Terminal Ulcer is noted as a sacral pear-, butterfly-, horseshoe- or sometimes irregular-shaped red/yellow/black ulcer, similar in appearance to an abrasion or blister that may occur suddenly. They emerge larger than other pressure ulcers and are usually more superficial initially and develop rapidly in size and depth.

ASSESSMENT OF PALLIATIVE WOUNDS

Langemo¹⁰ describes a holistic assessment for the prevention and care of pressure wounds in a palliative care patient. In a recent article, Langemo³ describes the use of a risk assessment for palliative care patients with wounds know as the Pressure Sore Risk Assessment Scale for Palliative Care. However, no current literature could be found to support the reliability and validity of this tool.

A consensus statement on Skin Changes at Life’s End was published to explore the issues surrounding skin conditions associated with dying patients.¹³ It contains 10 statements regarding end-of-life skin care (Table 2). These statements address, among other issues, the assessment of risk factors, a total skin assessment, and development of a plan of care.

TABLE 2: Skin Changes at Life’s End (SCALE)¹³

Table 3 presents the Healing Probability Assessment Tool, which provides a list for estimating the probability for any skin wound to successfully respond to aggressive local intervention.^21,22 This tool was developed by the For Recognition of the Adult Immobilized Life program¹² to help providers identify patients with wounds that are unlikely to heal and who, along with family members, would benefit from palliative care. However, current literature regarding the validity and reliability of this tool was not found.

TABLE 3: Healing Probability Assessment Tool²¹

The Braden Scale (Table 4), developed by Barbara Braden,²³ is a validated risk assessment tool for predicting pressure sore risk. Several studies were conducted to assess the psychometrics properties of the scale.^24,25 A recent systematic review examined studies of various risk assessment tools published in Spanish, English, French, and Portuguese to determine which of the many risk assessment tools available demonstrated the best reliability and validity.²⁶ They concluded that the Braden Scale had demonstrated the best reliability and validity indicators in a variety of settings and was a better predictor of pressure ulcers than nursing judgment. However, the Braden Scale has not been clinically evaluated for the palliative care population.

TABLE 4: Braden Scale for Predicting Pressure Sore Risk

The use of a reliable and valid tool provides information to guide the discussion with the patient and family for setting wound care goals. In establishing the goals of care, it must be considered if healing is a realistic goal. If the wound is indeed nonhealing, then the patient and family may agree to a palliative approach.³ Once the goals of care are established, a plan of care can be determined.

MANAGEMENT OF PALLIATIVE WOUND CARE

Wound treatment at the end of life must include advanced clinical knowledge, skills, and technology. Nenna²² states that “the goals of palliation are stabilization of existing wounds, prevention of new wounds if possible and symptom management to improve patient comfort, well-being and quality of life.” She also concludes that “there are no definitive wound protocols for treating dying patient’s wounds, only guidelines.”

The management of symptoms in palliative wound care is critical. It has been suggested that local wound care for malignant wounds must address several key concerns that include hemorrhage, odor, pain, exudate, and superficial infection.²⁷Table 5 presents an adaptation of interventions suggested for wound symptoms. Palm and Altman²⁸ suggest the use of a variety of strategies to treat hemorrhage, which range from pressure and temperature variations (that may result in vasoconstriction) to silver nitrate (readily available, inexpensive, sticks or 10% solution). Afrin is a vasoconstrictor available over the counter, is off label, and when sprayed directly onto the wound bed, helps to control mild to moderate bleeding.²⁹ Epinephrine 1:1000 solution is another topical vasoconstrictor, sprayed onto the wound followed by application of epi-soaked gauze to wound base for several minutes. Gentle cleansing with warmed normal saline can be effective in managing bleeding in wounds.³⁰

TABLE 5: Wound Symptoms (Woo, Palm, Jones, Alexander, Alexander, West, Zip, Merz, Woo, Lusby, Gallegher, Langemo, Tran)

Odor management is another critical aspect of quality palliative wound care. Alexander^18,19,30,31 reported that “of all the symptoms associated with malignant wounds, the offensive smell is often described as the one causing most distress to patients, their caregivers and families.” Metronidazole has been suggested to be the treatment of choice. It is available to be used topically as a gel or cream or gauze can be soaked with intravenous metronidazole solution to use as a compress. Tablets can be ground into a powder and sprinkled onto the wound bed.²⁷ However, research is lacking in the evidence regarding topical or systemic use of metronidazole.³¹ Other odor-reducing treatments that are suggested in the literature but also lack evidence are silver dressings, iodine, activated charcoal, debridement, honey, and others.^{18,27,30–35}

Several studies have reported that pain was the most significant consequence of having a pressure ulcer and affected every aspect of patient’s’ lives.^3,27,36 Three types of pain have been described.³⁷ Noncyclic acute wound pain occurs in a single or infrequent single episode such as during sharp debridement. Cyclic acute wound pain occurs more regularly when the wound is manipulated, and chronic wound pain is persistent and occurs without external stimulation.

Pain management begins with the selection of the dressing. Comfort is enhanced when dressings are selected that need to be changed less frequently. Nonadherent dressings cause less pain because they do not damage the tissues when removed. Pain can also be managed using systemic analgesics or topical anesthetics and analgesics such as 2% lidocaine gel applied to the wound bed.³⁷ Morphine gel has been shown to be beneficial and efficacious, with good outcomes for not only cutaneous ulcers but also esophageal and mucosal damage due to chemo radiotherapy.³⁸ However, there are not enough high-quality studies to recommend the topical route over the systemic route.³⁶

Management of wound exudate is essential for patient confidence and comfort and can also contribute to decreased odor. Increased exudate may lead to maceration of the periwound skin and pain.³⁹ Dressing selection is critically important to control wound exudate. Unfortunately, many of modern dressing products are designed to provide moisture to enhance healing, and this may not be therapeutic for many malignant and palliative wounds that are increasingly moist.

Many wounds are dressed in layers. The primary layer is nonadherent and conforming. The primary dressing should be nonadherent and conforming to vent excess moisture to the secondary dressing. The secondary layer should be highly absorbent, conformable, and as aesthetically pleasing as possible. Hydrocolloid dressings may be useful in wounds with low exudate. Alginate and foam dressings have been found to be highly absorbent and useful as a primary dressing for a wound with moderate to large amounts of exudate. In addition, there are some super-absorbent products based on diaper technology that can be helpful.⁴⁰

Bacteria thrive on wound exudate and moist devitalized tissue, which can cause wound odor.³⁷ Infected wounds can show signs of malodor, exudate, and pain. Many products that are recommended to reduce odor also reduce bacteria levels. Debridement is suggested because eschar or slough material provides growth media for bacteria.²⁷ Topical antimicrobial products are available for superficial wound infections, but no one product is found to be indicated or suitable for all patients. Silver delivery products lack randomized controlled trial evidence but are one of the most popular topical agents. Other antimicrobial agents that are found in current literature include gentamicin sulfate cream/ointment, metronidazole cream/gel, mupirocin 2% cream/ointment, and polymyxin B sulphate.²⁷

CASE SCENARIO

Mrs C is a 77-year-old woman who underwent a left leg arterial bypass graft that became infected postoperatively. The developed infection worsened distally and ultimately required an above-the-knee amputation. The infection did not respond to intravenous antibiotics, and further treatments were also unsuccessful. Mrs C subsequently developed necrotizing fasciitis, and the decision was made to seek hospice care with the goal of comfort at home.

Mrs C presented to hospice on admission with comorbidities of diabetes mellitus, chronic kidney disease, peripheral vascular disease, gastroesophageal reflux disease, and history of cardiovascular accident. Her wounds were dehisced and purulent with exposed bone at the site of the above-the-knee amputation, with likely osteomyelitis. Infection was spreading up the leg to the groin, where there was another open wound site. Her Palliative Performance Scale on admission was 20%. Pain management was the primary goal of care. This was managed with Dilaudid 2 mg every 2 hours as needed and Neurontin 300 mg in the morning and 600 mg at bedtime. Wound exudate and odor were managed with Silvasorb, Dakin solution, abdominal pads, and Kling gauze. Providing emotional support was another important component of the plan of care. Mrs C was visited by the home care hospice nurse and the hospice aide daily for dressing changes and pain management. Three weeks after admission, the wound exudate was decreasing; thus, the plan was changed to xeroform dressing for more comfortable dressing changes. At that time, her Palliative Performance Scale was determined to be 40%. Six weeks after admission, granulation tissue is visible, exudate decreased, and necrotic tissue is beginning to slough. A consult was made to the medical center wound clinic for possible surgical debridement. Seven weeks after admission, Mrs C was discharged from hospice for surgical debridement and closure of the wound at the medical center wound clinic. Mrs C was ultimately fitted for a prosthesis and was ambulatory 3 months later.

IMPLICATIONS FOR PALLIATIVE NURSING AND CONCLUSIONS

The current literature and clinical practice suggest that wound care in palliative settings is a common and complex issue that negatively impacts patients’ and families’ well-being. Although progress has been made in the assessment and management of wounds, more research is needed. Tippett⁴¹ recently wrote, “Palliative wound care is ideal for those wounds in which the underlying etiology does not respond to treatment and or the demands of treatment are beyond the patient’s tolerance or stamina. Palliative principles introduced early into wound care provides the patient and their families options that maximize functional status and quality of life, shifting the priorities from curative to palliative as the progressive nature of the disease demands.” Palliative nurses practicing in all settings should have the basic knowledge necessary to manage palliative wounds. If available, nurses should consult with wound ostomy continence nurses, who are experts and certified to care for wounds. Collaborative work combined with further research will result in better patient outcomes.