By Aletha Tippett MD
I recently had a patient encounter that reminded me of the difference between palliative and curative wound care. In my role as a hospice medical director with a specialty in wound care, I am often asked to see wounds in our hospice patients. I was asked to see this particular patient because of a wound on her coccyx. I had already approved the nurse’s order of medicated hydrogel covered with a foam dressing, changed every three days. This seemed like a reasonable treatment plan; simple and straightforward. I also gave instructions to provide adequate support surface on her mattress, static air if possible.
The Goals of Palliative Care
When I first met the patient, an elderly woman with end stage dementia, I was struck by how thin she was and how stiff her arms and legs were, and how stiffly she held herself. It was also interesting to see how afraid the patient was of any touch or movement, afraid of falling. The aide helping me was very careful and cautious with the patient, but the patient did not stop her yelling and protesting in fear of falling. The aide and I both held the patient to try to calm her and reassure her. Of course, she had soiled herself, both with urine and stool, and this all needed to be cleaned before she could be examined. We got the patient to lie on her side so her buttocks could be viewed; this was a two person job as the patient was pushing mightily to try to "save herself." There was a foam dressing over the wound, but even though it had been applied earlier that day, it had become unattached inferiorly. This foam dressing was removed with the patient yelling out. The gauze pad under it was removed.
Once examined it was apparent that she had some red erosions at the base of her buttocks and in the midline over her coccyx was a thin full-thickness wound that was dark/black with no ability to visualize the wound bed. Now that I had seen the patient and the difficulties involved in her care, it became obvious to me that this was a palliative opportunity. There was no hope of healing this wound, in fact it was probably a Kennedy ulcer since it appeared suddenly without any known previous injury. Our goals for this patient were to do minimal treatment to minimize handling/touching the patient due to her fear, and to provide as much comfort as possible for her. We also wanted to prevent contamination from urine and stool and have the wound area easy to work with to preserve patient dignity and avoid fear and pain.
Palliative Wound Care Treatment Options
We elected to apply a paste of Balmex (a zinc oxide ointment) mixed with viscous lidocaine to the wound and surrounding area, covered with a piece of Glad Wrap. This was fast, easy, painless, provided comfort for the patient, prevented contamination, and was simple and quick to change, if needed. This dressing could be good for a week. We did not use any more foam dressings or medicated hydrogel dressings, just ointment and plastic wrap. Proper pressure support was still appropriate, as this would help with the patient's comfort.
Overall, this wound treatment approach was more comfortable for our patient and allowed her to die peacefully four days later. This event really crystallized for me what palliative wound care is. We are actively doing a treatment, but our goals are different than curative care. We have no hope of healing this patient's wound, but we want to provide as much comfort as possible, while preserving her dignity. This also allows the caregivers to "do something" which is often important for their feelings of worth and importance and gives them a key role in providing loving care for this patient. Again, the main difference between palliative and curative wound care is the goal of care. Palliative wound care is about controlling the symptoms of the wound, but doing it in a way that also meets palliative goals of comfort and dignity.
About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.