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The Basics of Palliative Wound Care

Despite the ancient history of wound care, the concept of palliative wound care is still relatively new.Terminally-ill individuals are especially vulnerable to the development of chronic wounds. The wound healing process is often impaired due to malnutrition,poor skin circulation, and concomitant comorbidities. As the proportion of the geriatric population continues to grow, there is an increasing need for palliative wound care. [1]

What Is Palliative Wound Care?

Contrary to popular belief,palliative wound care is not a “defeatist” approach to wound management. Active withdrawal of treatment, or giving up hope on recovery is not an attribute of palliative care. However, in contrast to traditional wound care, there is a greater emphasis on the patient's needs, desires, and symptom alleviation. Traditional wound care is often described as being “outcome-driven”which may not always be feasible in terminally-ill patients. While complete healing should be the ultimate goal, having a realistic approach to wound management can help both patients and their healthcare providers.

While a myriad of definition sexists, the majority define palliative wound care as a holistic patient-centered approach that combines principles of palliative care with chronic wound management. [2] Keeping in line with the theme of palliative care, the primary goal of palliative wound care is to improve the quality of life and relieve suffering.

Causes of Delayed Wound Healing in Palliative Care Patients

Several risk factors contribute to the development of chronic wounds in terminally-ill patients. Some of these are listed below:

●     Immobility:a 74% increased risk of pressure ulcer development is seen with immobility. [3]

●     Old age

●     Malnutrition

●     Skin fragility

●     Poor skin circulation [4]

Aims of Palliative Wound Care

Palliative wound care as a concept is often linked to end-of-life situations. This is an in accurate depiction, as patients don't necessarily need to be on their deathbed to benefit from the palliative wound care approach. The central theme of palliative wound care is to minimize discomfort and suffering associated with chronic wounds. Therefore, the concept of palliative wound care can be applied even before a patient's condition is deemed terminal. [5]

Aggressive treatments may be counter intuitive in chronically ill patients and may lead to more suffering and discomfort. Despite an apparent lack of active curative treatment, 50% of wounds experience improvement with palliative treatment. [6] The aims and attributes of palliative wound care are described as follows:

●     Symptomatic relief: chronic wounds are associated with significant pain, odor, and exudate which can be distressing for the patient. Analgesics are prescribed according to the WHO pain ladder to help ease the pain. As odor is often related to bacterial colonization of the wound, debridement, and removal of necrotic tissue can significantly improve symptoms. Alternatively, topical application of metronidazole can be used for effective odor management.

●     Psychological support: Around 30% of people with chronic wounds experience depression. [7] The delayed wound healing process can significantly impact psychological well-being, self-esteem, and quality of life. Moreover, psychological stress can further contribute to delayed wound healing. Strong social and psychological support is a prerequisite of palliative wound care to maximize healing.

●     Multidisciplinary care: Chronic wounds in end-of-life patients are complex, and benefit from a multidisciplinary management approach. Podiatrists, wound care specialists, physiotherapists,psychologists, and other members of the multidisciplinary team can help coordinate care.

●     Patient-centered objectives: the primary aim of palliative wound care is to improve patients’ quality of life.The objectives of the treatment are directed by the patients and the caregiver’s wishes and aim to reduce the physical and emotional burden of disease. Patient's expectations of treatment may not always align with those of the healthcare team so keeping the patient's priorities in perspective can help provide better care. [8]

Role of Podiatrists In Palliative Wound Care

There is a high incidence of pressure ulcers in the lower extremities of palliative patients. Roughly 29% of all deep dermal injuries occur in the foot and ankle region of terminally ill individuals. [9] The disproportionate number of lower limbulcers means patients can greatly benefit from a podiatric consult. Podiatrists are specialized in lower limb anatomy, management, and assessment with a special focus on wound care. In collaboration with palliative care teams,podiatrists can provide specialized wound care that can help improve the patient’s quality of life. [10]

Innovative Wound Care Solutions - Emerging Role Of Telehealth

There is a growing demand for palliative care services, and given geographical restrictions, healthcare might not be equally accessible to everyone. Physical barriers to healthcare access in remote locations is a leading cause of global healthcare inequity. According to research, only 14% of chronically ill patients are currently able to access palliative care. [11]

 Patients requiring palliative wound care are often bed bound and might find frequent visits to the hospital inconvenient. The COVID-19 pandemic has also highlighted the need for innovative wound care solutions for the deserving population. Telehealth offers an alternative wound care delivery model to housebound patients. Wound deterioration can now be prevented through timely telehealth consultations allowing clinicians to better triage at-risk patients.This also allows for a more efficient use of already strained healthcare resources. [12,13] 

REFERENCES

  1. Beers EH. Palliative wound care: Less is more. Surg Clin North Am. 2019;99(5):899–919.
  2. Tippett A. An introduction to palliative chronic wound care. Ostomy Wound Manage. 2012;58(5):6, 8.
  3. Horn SD, Bender SA, Ferguson ML, Smout RJ, Bergstrom N, Taler G, et al. The National  Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents: Pressure ulcer development. J Am Geriatr Soc. 2004;52(3):359–67.
  4. Langemo DK. When the goal is palliative care. Adv Skin Wound Care. 2006;19(3):148–54.
  5. Meghani SH. A concept analysis of palliative care in the United States. J Adv Nurs. 2004;46(2):152–61.
  6. Tippett AW. Wounds at the end of life. Available from: https://scholar.google.com/scholar?cluster=6509945344812163740&hl=en&as_sdt=2005&sciodt=0,5#d=gs_qabs&u=%23p%3DnKK8yMz4V1oJ
  7. Renner R, Erfurt-Berge C. Depression and quality of life in patients with chronic  wounds: ways to measure their influence and their effect on daily life.  Chron Wound Care Manag Res. 2017;4:143–51.
  8. Emmons KR, Lachman VD. Palliative wound care: A concept analysis. J Wound Ostomy Continence Nurs. 2010;37(6):639–44.
  9. Padula WV, Mishra MK, Makic MBF, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis: A cost-effectiveness analysis. Med Care. 2011;49(4):385–92.
  10. Verdin C, Rao N. Exploring the value of a podiatric consult in palliative wound  care. J Palliat Med. 2017;20(1):6.
  11. Muckaden  MA. Palliative care. In: UICC Manual of Clinical Oncology. Oxford: John Wiley & Sons, Ltd.; 2015. p. 174–83.
  12. Ratliff CR, Forch W. Telehealth for wound management in long-term care. Ostomy  Wound Manage. 2005;51(9):40–5.
  13. Bondini CM, Sage S, Wilson BP, Hall MR, Wallis EAR. Modified telehealth for care of chronic wounds during the Coronavirus disease 2019 pandemic: A rapid literature review of alternative care modalities. Int Wound J. 2020;17(6):1960–7.