Palliative Wound Care

Palliative wound care focuses on relieving pain and suffering and improving the patient's quality of life when the wound no longer responds to, or the patient can no longer tolerate, curative treatment.¹ Where typical wound treatment primarily focuses on bringing a wound to closure, palliative wound care focuses on symptom management, addressing the problems of infection, pain, wound odor, exudate, and decreased quality of life, often, but not always, in end-of-life care. 

Palliative wound patients typically have long-term, potentially life-limiting illnesses of varying etiology that can affect skin integrity.¹ 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), failure-to-thrive, and, in some cases, profound dementia.

Treatments and Interventions

Palliative wound care can take a variety of forms, depending on the symptoms that are being addressed.

Infection. Infection in a chronic wound produces an enhanced and prolonged inflammatory response, which in turn causes more damage to the wound.² Consequently, symptoms that would normally indicate the presence of an infection would be masked as the prolonged inflammatory response also reduces the patient's immune response. 

Depending on the nature of the infection, and the appropriate level of intervention for the patient’s overall medical status, either systemic or local antimicrobials or antibiotics may be used to combat the infection.³ Drainage or palliative-appropriate debridement may be necessary to remove slough and devitalized tissue, as these increase the risk for infection and can affect the efficiency of topical antibiotics. Antimicrobial dressings may be used to help reduce bioburden. A very useful technique for palliative wound care is using non-sharp debridement modalities, such as biologic or enzymatic, which may avoid the pain of surgical debridement, and simplify the administration of topical agents. 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. Pain control in palliation is a primary goal.^2,3 As pain impacts quality of life, patient-focused interventions are key. Dressing removal can be a painful part of the wound management regimen.^4,5 Appropriate analgesia may 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 using dressings that cause minimal trauma upon removal or by gentle irrigation of the wound with warmed normal saline prior to removal.⁵ 

Wound odor. Wound odor, while not technically a barrier to wound health, needs to be taken into account based on the quality of life and psychological effects on the patient. Malodorous wounds can negatively impact a patient's interaction with family and friends, contributing to social isolation.² Wound odor is usually produced by bacteria present in the wound. Limiting the bacterial burden on the wound, managing exudate, implementing appropriate wound cleansing, and applying odor-controlling dressings, such as those containing charcoal or carbon, can all help to reduce wound odor.

Exudate. Exudate presents a particular challenge to consider for patients undergoing palliative wound care.² Proteinases (tissue-destroying enzymes) present in wound exudate damage periwound skin and can enlarge the wound. Absorbent dressings can assist to manage exudate, and can often be used in conjunction with a nonadherent contact layer to minimize dressing change trauma. Since reducing patient discomfort is the priority here, and not faster wound healing, various appropriate methods of keeping the wound dry and stable may be a viable approach with minimal negative impact on the patient.
 
Nutritional support. Patients undergoing palliative wound care may also be facing challenges taking in proper nutrition, whether from certain medications or symptoms of chronic conditions. Encouraging proper nutritional support could help support goals within palliative wound care, including decreasing the risks of skin damage or further healing delays.³ Exact interventions will vary per patient, but a tailored, collaborative approach with nutrition professionals is likely indicated. 

Quality of life, self-confidence, and independence. For patients perhaps experiencing  worsening of their overall health, the psychological implications of reduced independence can be devastating.¹ 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.

References
1.    Woo KY, Krasner DL, Sibbald RG. Pain in people with chronic wounds: Clinical Strategies for decreasing pain and improving quality of life (Chapter 9). In Krasner DL, van Rijswijk L, eds. Chronic Wound Care: The Essentials e-Book. Malvern, PA: HMP; 2018:111-122. 
2.    Woo KY, Krasner DL, Kennedy B, Wardle D, Moir O. Palliative wound care management strategies for palliative patients and their circles of care. Adv Skin Wound Care. 2015; 28(3):130-140. 
3.        Koumaki D, Kostakis G, Boumpoucheropoulos S, Ioannou P, Katoulis AC. A narrative review of management of wounds in palliative care setting. Ann Palliat Med. 2023;12(5):1089-1105. doi:10.21037/apm-23-138
4.    Woo KY. Exploring the effects of pain and stress on wound healing. Adv Skin Wound Care. 2012;25(1):38-44.
5.     Shah JB, Krasner DL. Wound Pain Management, Palliative Wound Care and Psychosocial Issues (Chapter 24). In Shah JB, Milne CT (Editors). (2021). Wound Care Certification Study Guide (Third Edition). Best Publishing Company .