Palliative Wound Care In Practice: Improving Patient Comfort and Dignity
by Aletha Tippett MD
What is palliative care relative to wound treatment? In short, it is about humanity, caring and compassion. Today I saw a 90 year-old woman in a nursing home. She had hip and ankle fractures, and developed a sacral ulcer in the hospital. She was in excruciating pain, screaming at every touch. To correct her turned-in hips, she was trussed up in a hip abductor device – she called this “the dragon” – that was both uncomfortable and painful.
On top of all this, the devices were creating wounds on her feet and ankles. She had stage IV coccyx wounds to the bone, an overabundance of tape holding the dressings. The screaming when these were removed was tremendous. The patient had on a diaper and sweat pants — to remove these caused more screaming from the discomfort. Her son had recently insisted that her pain medication be changed from Oxycontin to Vicodin because the former made her too sleepy. The patient was not eating well because of her severe pain.
What is the palliative thing to do in this situation? This 90 year-old woman needs (and deserves) comfort and dignity.
- First, no diaper or pants. Just put the diaper flattened out beneath her and cover her with sheet/blanket or gown.
- Second, no tape for the dressings. Instead, use medicated hydrogel with lidocaine, zinc oxide around the wound, and top the wounds with plastic wrap.
- Third, eliminate all orthopedic devices. She will be more comfortable, and be able to move more without them.
- Fourth, provide static air overlay for flotation and easier positioning and transfer. Her low air loss bed can be replaced with regular foam mattress.
- Fifth, provide air boots for heels that are lightweight and washable.
- Sixth, provide adequate pain relief, starting with Os-Cal with Vitamin D for bone health, methadone 2.5mg qhs for touch-me-not pain, and Oxycodone q 4 hours before dressing changes.
When we were done instituting these changes, the patient was resting comfortably. She was smiling, talking. Her son was included in the care plan and was in agreement, which pleased the patient. Her primary care physician was also involved in the changes and was in agreement. The patient was seen two weeks later in follow-up and her sacral wounds were healing well. The foot and leg wounds were almost gone, her pain was well controlled, and she was smiling. The changes allowed her to be more comfortable, to move better, and to eat better. Beyond helping the patient, this new system of care was easier for her caregivers to provide.
Will her wounds heal? If she lives long enough, yes. Will she be comfortable? Yes. Is her dignity honored? Yes.
This is compassionate, humanitarian care.
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.