Palliative wound care is an alternative approach that focuses on relieving suffering and improving the patient's quality of life when their wound no longer responds to, or the patient can no longer tolerate, curative treatment. Where typical wound treatment primarily focuses on bringing a wound to closure, palliative care focuses on symptom management, addressing the problems of infection, pain, wound odor, exudate, and decreased self-confidence in end-of-life care. Palliative wound patients typically have long-term, potentially life-limiting illnesses of varying etiology that can affect skin integrity. Since "life-limiting" can mean weeks, months, or even years, it is important to set goals that don't exclude the possibility of healing when improving the patient's quality of life. Conditions that may necessitate palliative care include malignant forms of cancer, major organ failure (renal, hepatic, pulmonary, or cardiac), and, in some cases, profound dementia.
Treatments & Interventions
Palliative wound care can take a variety of forms, depending on the symptoms that are being addressed.
Infection of a chronic palliative wound produces an enhanced and prolonged inflammatory response, which in turn causes more damage to the wound. Consequently, symptoms that would normally indicate the presence of an infection would be masked as the prolong inflammatory response also reduces the patient's immune response.
Depending on the nature of the infection, either systemic or local antibiotics may be used to combat the infection. Drainage or debridement may be necessary to remove slough and devitalized tissue, as these slow wound healing and can affect the efficiency of topical antibiotics. Antimicrobial dressings, including those that use silver technology, may be used to help reduce bioburden. Antibiotics, whether topical or systemic, should only be used under the explicit direction of a physician. A very useful technique for palliative wound care is the use of maggot debridement therapy for infected wounds. This debrides the wound and eliminates infection, and promotes wound healing. It avoids the pain of any surgical debridement, and simplifies the administration of any antibiotics by eliminating the need for any.
In addition to removing a barrier to wound healing, treating the source of infection in palliative wounds can also help mitigate other symptoms such as wound odor, exudate, and pain.
Pain inhibits wound healing, whether curative or palliative. Pain must always be treated, preferably with an opioid based agent. Pain control in palliation is a primary goal.
Dressing removal is often the most painful part of the wound management regime. Analgesia should be given systemically or topically before the dressing change procedure begins, with enough time allowed for the analgesic to have the desired effect. Pain can be limited by the use of dressings that are minimally traumatic upon removal and by gentle irrigation of the wound with warmed normal saline prior to removal.
Wound odor, while not technically a barrier to healing and wound health, needs to be taken into account based on the psychological effects on the patient. Malodorous wounds can negatively impact the patient's relationship with family and friends, contributing to social isolation. Wound odor is produced by bacteria present in the wound. Limiting the bacterial burden on the wound, managing exudate, and the application of odor controlling dressing such as those containing charcoal or carbon can all help to reduce wound odor.
While moist wound healing has been well-received in recent years as an effective method of wound management for certain types of wound, chronic palliative wounds present a particular challenge. Proteinaises (tissue-destroying enzymes) present in wound exudate damage periwound skin and can enlarge the wound. Absorbent dressings should be used to manage heavy levels of exudate, and can be used in conjunction with a non-adherent contact layer to minimize dressing change trauma. However, in cases where the wound bed can be allowed to dry out and the amount of exudate reduced, this may be a preferred alternative to moist wound healing. Since reducing patient discomfort is the priority here, and not faster wound healing, dry wound healing may be a viable approach with minimal negative impact on the patient.
As patients become weaker and less alert, they are often unable to maintain oral intake of nutrition. Additionally, certain medications or symptoms of chronic conditions can affect the absorption of nutrients. Without proper nutritional support, the risk of skin damage and delayed healing increases significantly. As a result, the need to encourage the patient to eat and drink frequently can outweigh other dietary restrictions. One approach to increasing nutritional intake is to offer the patient their favorite food or beverage (within reason).
Self-confidence and independence
As a patient's condition worsens, the psychological implications of reduced independence can be devestating. When possible, promoting patient self-care and the continued performance of certain everyday activities can help to improve patient dignity, outlook, and quality of life.
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