There is a saying that time heals all wounds, but this is not always the case for pressure ulcers. Those of us who care for patients with pressure ulcers know that some wounds will not heal, and cure becomes an unrealistic goal. Partnering with the patient and family to take a palliative care approach rather than an aggressive plan for healing can potentially reduce suffering, avert painful procedures, and reduce re-hospitalizations.
According to the CDC, chronic disease accounts for the majority of mortality, morbidity, and disability in the United States. As the number of people living with chronic illness rises, it is increasingly recognized that there are limited benefits of curative treatment. This is where palliative care offers an alternative to aggressive wound healing interventions by changing to the focus to wound stabilization, symptom management and patient well-being.
Palliative care is a multidisciplinary approach which focuses on preventing suffering and improving quality of life. It addresses physical, emotional, and psychosocial concerns related to advanced illness while acknowledging that cure is not the primary goal. This approach offers a support system and team approach which integrates psychological and spiritual aspects of care. Palliative care is different from hospice, and is not necessarily directed toward people who are actively dying.
Wound-healing strategies incorporate turning schedules, pressure redistribution devices, nutritional support, pain management, and a variety of dressings and topical applications. Some patients, because of underlying illness or personal preference, cannot tolerate one or more of these measures. For example, turning and positioning is painful for patients with metastatic cancer. Repositioning may be restricted in patients with severe contractures or morbid obesity. Some patients with severe congestive heart failure or tube feedings require the head of their bed elevated which restricts mobility and increases pressure and shear forces on the sacral area.
Wound healing requires nutritional support and debridement which may not be possible in some patients. For example, a patient with a pressure ulcer who is not eating and cannot tolerate adjunctive nutritional measures may have poor prognosis for healing. Some conditions interfere with absorption of nutrients, while others restrict the amount of tube feeding that can be administered. Surgical options are sometimes limited by advanced illness or patient preference. These factors must be taken into consideration when deciding on a palliative approach to wounds.
A palliative care approach to pressure ulcers begins with education of the patient and family regarding rational choices followed by ongoing counseling and psychological support. The values, culture, and lifestyle of the patient must be taken into consideration when setting treatment goals. Feelings of guilt or failure among caregivers must be anticipated and dealt with in a proactive fashion. Treatment involves symptom control for pain, malodor, and exudate, with stabilization of existing wounds while preventing additional wounds and infectious complications if possible.
Medical science and technology have come a long way, yet there are some clinical situations when cure is not a realistic goal. Palliative care offers an alternative that focuses on controlling symptoms while promoting the best quality of life for both the patient and family.
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CMS Tightens Up Pressure Ulcer Classification in Long-Term Care
Determining the Avoidability of Pressure Ulcers
Webinar on Infectious Aspects of Chronic Wounds
See these references for more information on palliative care applied to wounds:
Palliative Wound Care at the End of Life
Palliative Care vs. Restorative/Curative Care for Pressure Ulcers
Factors Associated with Pressure Ulcers in Palliative Home Care
Palliative Care of Pressure Ulcers in Long-Term Care
THANK YOU FOR A GREAT BASIC PRESENTATION OF A VERY COMPLEX ISSUE. I WILL USE IT THIS FALL IN MY PRESENTATION TO PRIMARY CAAE INTERNS AND RESIDENTS AT PLAINVIEW HOSPITAL.