Palliative Care Plays Important Role in Wound Care

Abstract

Pressure ulcer management calls for more than just treating the wound. Palliative care can help address pain and discomfort, and it can improve quality of life. Yet patients and practitioners alike often avoid important conversations because they think palliative care means giving up or giving in. Especially when it isn’t likely that the wound will heal, said Jeffrey Levine, MD, CMD, “The toughest thing is the conversation. You’re handing over the bad news that healing isn’t expected, and we need to set aside hopes that the wound will heal and the patient will go home and get back to their old life. That is usually not only because of the wound but also from other comorbid conditions as well. Nonetheless, we have to help the patient function at the highest possible level and live with minimum pain and maximum comfort. “When you examine wounds, you don’t look at the hole in the patient; you look at the whole patient,“ he said, a quote he attributed to Elizabeth Ayello, RN, PhD. “That is so wise. We need goals of care that address the whole, individual patient within an ethical and spiritual framework.” Some family members may resist palliative care for their loved one and insist on aggressive treatments instead. “Some want everything possible done. They construe anything else as negative and unacceptable,” Dr. Levine said. At least one study has suggested that uninformed relatives are more likely to insist on aggressive interventions — such as feeding tubes or hospital admission for antibiotic or other treatment — than those who have knowledge about risks and benefits. When patients have pressure ulcers and other conditions due to serious or terminal illness and increasing frailty, there is a point at which comfort rather than cure is an appropriate goal. Open communication with patients and families can help them understand this. “Particularly when death is approaching, people may panic and question themselves and their decisions,” he said. “We need to provide patients and families with reinforcement to initiate the best, most effective palliative care and help see them through stormy times. “When there is a wound and we don’t expect it to heal, we have decisions to make. There are expensive, advanced, heroic, complex treatments. But if we know the wound won’t heal and that these interventions aren’t likely to be safe or effective, there is no sense in subjecting the patient to them,” said Dr. Levine. He shared a story: “I recently saw a patient in her 90s who had a malodorous eschar and was in severe pain. In a younger, healthier person, I would say ‘debride it right away.’ But just turning her over caused her terrible pain. We reached the decision with her family to use a topical antiseptic to minimize pain and prevent infection.” Individualizing palliative care is especially key for non-pharmacologic interventions to address issues such as pain, anxiety, or depression, he said. “You have to know each patient and what interventions and activities are most likely to be beneficial. For example, I was just on a hospice floor where musicians were going from floor to floor playing classical music. For those who enjoy this, it can be very comforting and enjoyable. Other people really respond to pet therapy, although I wouldn’t advise bringing animals around someone with a wound.” For these individuals, staff should consider alternatives such as plush toy animals or movies or picture books featuring animals. “We need to keep in mind that quality of life is subjective based on the patient’s perspective. To you or me, a person who has dementia and is bed-bound and uncommunicative may seem to have a poor quality of life. But he or she may have close family relationships and get immense pleasure from their children and grandchildren. Or they may listen to music via headphones and get enjoyment from that,” Dr. Levine said. “We need to keep this in mind when we consider what is best for each person.” Dr. Levine is one of the speakers on “Overview of the New AMDA Clinical Practice Guideline for Pressure Ulcers,” set for Friday, March 18, 1:30–3:00 pm, during AMDA’s 2016 annual conference in Orlando, FL. He will participate in a panel with Art Stone, DPM, Paul Takahashi, MD, CMD, Janet McKee, RD, MS, Nancy Overstreet, DNP, GNP, Gary Brandeis MD, and Karl Steinberg, MD, CMD. Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for AMDA and other organizations.