by Karen Zulkowski DNS, RN, CWS
As health care professionals we always want to heal our patients and make them better. This may not always be possible. We need to understand that not letting the pressure ulcer or wound we are treating get worse sometimes has to be the realistic goal.
Families and the public equate the development of a pressure ulcer with poor care which is why this is such a litigious area. As a result, both fear of litigation and our desire to heal any medical problems is sometimes the motivation for aggressive treatment. However, we need to stop and ask, what is wrong with this picture?
Skin is the largest organ and its health is dependent on the other organs functioning properly. When a person has renal failure, respiratory and cardiac compromise, and poor nutrition, a pressure ulcer may be unavoidable and certainly if one develops it will not easily heal. Yet, in examining medical records, there is rarely any patient or family education about treatment options or plan of care. Should we be aggressive in treating all patients? When is palliative care best?
We need to consider the palliative care option and do a better job of educating the public, the patient and the family on how much we do to prevent pressure ulcers, and that not all can pressure ulcers be avoided. We recognize and discuss the Kennedy terminal ulcer among ourselves, but not with the people outside of medical care.
Sarah Palin talked about “death panels”, but in reality there needs to be treatment with reason. Spending health care dollars for aggressive treatment or treatment that won’t change outcomes is not the answer. In the 2009 55(9) issue of Ostomy/Wound Management, Nancy Collins and Nancy Spaulding-Albright discussed the evidence for tube feeding and concluded that while enteral nutrition has a role in medical care, it is not a cure-all. The same is true for pressure ulcers. We need to recognize that we cannot prevent or cure all pressure ulcers. Continuing to treat frail patients aggressively is expensive and painful for the patient.
On the flip side, palliate/comfort care does not mean no care. I have seen hospice patients' wounds treated inadequately. Using modern dressings, even if healing is not possible, may still be appropriate. This is especially true if the wound is painful, and there is excessive exudate or odor. My own mother died from lung cancer several years ago. At the end, her cancer pain was well controlled but the stage II pressure ulcer on her coccyx was very painful. I tried many things, but a cold gel dressing worked best. I cooled the dressing in the freezer and when her pressure ulcer started to hurt, I put a cold one on it. Certainly this is an off label use, but it worked. My point is not to recommend gel pads for cancer patients, but to recognize that conservative treatment may improve quality of life.
How does care planning change for palliative care and how do you talk to the family? That topic will be discussed next month.
About The Author
Karen Zulkowski DNS, RN, CWS is an Associate Professor with Montana State University-Bozeman, teaches an online wound course for Excelsior College, and is a consultant for Mountain Pacific Quality Improvement Organization. She has served as a Research Consultant with Billings Clinic Center on Aging, and was the Associate Director for Yale University’s Program for the Advancement of Chronic 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.