Wound Care: Moving Toward HealingPage 10 of 13

8. Advanced, Palliative, and Hospice Care

Advanced therapies include skin grafts, sharp debridement, compression therapy, and hyperbaric oxygen therapy. A referral to other wound care experts can lead to new ideas and options for the patient of which you may have not been aware of or have accidently overlooked. Collaboration with other professionals cannot be stressed enough for our wound care patients. Referral to a wound, ostomy and continence (WOC) nurse has also shown to increase positive patient outcomes through cross collaboration.

Negative Pressure Wound Therapy (NPWD)

A device offering negative pressure wound therapy (NPWT) can be utilized on various types of wounds. The purpose of the device is to prevent infection, increase healing rates, promote skin growth stimulation, reduce edema, and help draw the edges of a wound together to promote closure. A negative pressure device will allow the wound to heal from the bottom up in an effective manner. The clinician must check with the facility to review the manufacturer guidelines of NPWT, depending on which device is available.

Wound Care Centers

Referrals to the wound care center should never be overlooked. The more collaborative is the approach in wound care, the more the patient is likely to heal and enjoy an increased quality of life. Wound care center referrals and/or vascular referrals can decrease risk of readmission and infection as well as provide an additional specialist to assess the patient and provide education. Referrals can be used when: the wounds are stagnate, they increase in size, there is possibility of infection, there is patient noncompliance, and advanced therapies are required that are not available in home care or assisted living.

Palliative and Hospice Care

With the patient population living longer, we need to be vigilant in starting the end-of-life discussions with physicians as there is deterioration in the patient. These discussions with patient and caregivers, when necessary, can be the very difficult. Many skin changes appears at life’s end, and caregivers are not always ready to accept changes to their loved one. When dealing with skin changes to the body, caregivers can be very aggressive in insisting a very small red mark is a tragedy, when in fact the reality is the patient’s heart is beginning to fail.

For caregivers, it is easier to notice changes on the skin because it is a visible organ. When the patient experiences heart or respiratory issues, the caregiver may not seem as concerned because those organs are “invisible.” As trained healthcare professionals, we know a skin injury is not as critical as heart and respiratory failure unless the skin is the source of infection or sepsis. Truth be told, “No one is concerned about a toe if the heart and lungs are not working properly.”

It is important to determine the plan of care with the patient, physician, and caregiver because this will determine whether aggressive or palliative wound treatments are suggested and will dictate what wound products are used. Having a patient on palliative care or hospice care guides treatment goals simply to prevent infection and provide comfort. If the internal organs of the patient’s body are not functioning properly a wound will not heal. In palliative and hospice care, we work toward preventing infections, treating odor, and controlling drainage. Skin changes at life’s end can result from compromised tissue perfusion, decreased tolerance to external insults, severe malnutrition, anemia, hypotension, and vasopressors.

In treating the wounds of palliative patients, position them for comfort and document whether the patient cannot be turned due to pain. Discuss the goals with the patient, caregivers, and physician. In tissue with poor perfusion, the ability to tolerate pressure becomes limited. Repositioning either more or less often may assist in obtaining comfort. Pain management during palliative care requires close work with the physician to assist in patient comfort during life transition.

At the end of life, skin has less blood supply because the body is directing blood toward the vital organs (heart, lungs, and brain)—meaning less oxygen reaches the skin and there is a decrease in perfusion that will lead to increased risk of breakdown. The most common place for skin breakdown near the end of life is seen directly above the buttocks. Some of these wounds may not be preventable even with the best quality care. The patient pain level and quality of life dictates wound care goals, with the objective to keep the patient comfortable and respect their wishes.

Palliative or hospice care should never be a last-minute conversation. As our society is living longer, these discussions can and should occur before there is an increase in suffering. Of course, we all want a physician who will do everything to heal and correct the situation. These conversations are crucial to have when developing a plan of care for the patient to ensure the plan aligns with the wishes of the patient. The clinician will do what is possible to promote comfort and ease into the next transition of life no matter what comes. These decisions are the patient’s and the caregiver should respect their wishes and carry out the request.