For wound care specialists who work in palliative care, providing proper treatment to patients with advanced, life-limiting illnesses can be a delicate balance. It’s common for such patients to suffer from wounds, and along with that comes pain, odor, infection, discomfort and pain.
As the World Health Organization suggests, palliative care affirms life and views death and dying as part of a normal process:
Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.
The bottom line is that our focus must shift from what may be best for the wound to what’s best for our patient. This requires a holistic approach – giving the patient control while facilitating the highest level of independence, dignity, and comfort. Secondary goals may include healing the wound, preventing decline of the wound, providing adequate pain control, preventing infection, managing odor, and controlling exudate.
Dressings & Odor
In palliative care, we often strive to move patients as little as possible due to the discomfort involved. Selecting appropriate dressings to manage the wound or prevent further decline while minimizing repositioning is vital. Managing odor and exudate helps our patients maintain dignity. Here are some main points to consider:
- Exudate is managed by use of absorptive wound care dressing products including specialty absorptive dressings, alginates and foams.
- If the odor comes from high bacterial level causing necrotic tissue on the wound bed, debridement may be needed. The preferred method is autolytic debridement due to its gentle nature.
- Other aids to managing odors include systemic and topical antibiotics, silver dressings, charcoal dressings, topical honey dressings, cadexomer iodine–impregnated dressings, and properly diluted antiseptic solutions along with wound suction devices.
These strategies help enable the patient to socialize with others which is so important to patients and families in palliative care.
Preventing wound complications by preventing infection is paramount. We use basic infection-prevention measures, like good nutrition, wound cleaning, exudate management, and timely dressing changes – if these can be done in accordance with the patient’s wishes.
If healing the wound is a patient goal, traditional treatment approaches (including culturing) are appropriate. Be sure to weigh the benefits of treating the infection against the burden a specific treatment could place on the patient. If wound healing isn’t a goal for your patient, formal diagnosis and treatment of a wound infection isn’t necessarily warranted, especially if it won’t yield benefits.
However, in many cases, bacteria in the wound will cause pain, odor, and high levels of exudate, which are problematic and can reduce quality of life. In this case, you may need to take steps to reduce the bacterial load in the wound. Try such traditional methods as debridement, antiseptics, antibiotics, and various antimicrobial dressings and therapies.
Managing pain is critically important in this patient population. Dressing removal can be the most painful part of wound management, and even the anticipation of a dressing change can cause undue anxiety. The palliative care approach calls for use of long-wear-time dressings to reduce dressing-change frequency. In addition:
- Using contact layers in the wound bed may help if the dressing is adhering to the wound bed and causing pain on dressing removal.
- Minimizing unneeded stimuli to the wound is important; topical lidocaine preparations help by numbing the area locally during dressing changes.
- Pain and anti-anxiety medications may be required.
- Be sure to wait an appropriate amount of time for pain medication to take effect. With parenteral pain medication, wait at least 15 or 30 minutes. With oral medication, wait at least one hour.
What do you think?
Palliative care requires clinical know-how, along with sensitivity and awareness for all those affected by end-of-life conditions. We’d love to hear about your experiences. Does your care setting have specific wound care policies for palliative care patients? Does the staff understand that choosing a palliative care approach is not giving up on the patient? What are your biggest challenges when caring for palliative wound care patients? Please leave your comments or stories below.