Wound Care in Advanced Illness: Application of Palliative Care Principles

Abstract

1159 EVEN THOUGH Alvarez et al.1 defines palliative wound care as “the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing,” their review article illustrates that these two goals are not mutually exclusive. The paper points out that these strategies intended to provide comfort also lead to healing even in the context of advanced disease. In fact, good palliation, by improving patient care, increases the likelihood of healing the wound. The goals of palliative wound care promote wound healing: controlling pain, managing infection, odor, bleeding, and exudate, and maintaining a good quality of life for the patient and caregiver.2 First, improving mobility is central to preventing/treating pressure ulcers. A primary reason for the lack of mobility, however, is pain. Good pain management improves mobility and thus can lead to decreased pressure on the ulcer, increasing the opportunity for healing.3 Second, management of the infection that causes the odor and exudates is also one of the fundamental tenets to healing a pressure ulcer.4 Third, recent data suggest a relationship between wound healing and psychosocial factors. For example, a national pressure ulcer study showed that administration of an antidepressant correlates positively to pressure ulcer healing.5 Finally, treating the family and caregivers is an integral part of treating the chronic wound.6 Assisting and supporting the caregiver who does the dressing changes improves the wound care. On the flip side of the same coin, curative measures may provide the best palliation for a wound that impairs quality of life. Restoring the blood flow through balloon angioplasty not only provides wound healing but also improves the patients’ pain while salvaging the limb.7 Medicated compression wraps for venous stasis ulcers serve a dual purpose of palliating the discomfort and drainage from the wound and promote healing. Our communication to patients and families should reflect our understanding of this dual purpose of wound management in palliative care. Just as we speak about “hoping for the best and planning for the worse” when breaking bad news,8 so we ought to speak of treatment of the wound as an integration of palliative and curative modalities. The goal is to decrease the burden of the wound, while simultaneously hoping that the interventions will promote healing. Discussion using such a parallel mindset avoids unrealistic expectations. Such unrealistically high expectations may be the reason why pressure ulcers are the number one cause of lawsuits against facilities.9 Effective communication may decrease these lawsuits.10 Like palliative care, wound care is a growing field in which evidence about effective treatments is just beginning to accumulate. As palliative care doctors, we look forward to learning more about how we can integrate this information into our therapeutic arsenal.