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Palliative Wound Care: Closing the Gap
Advances in modern medicine have improved life expectancy. The US national estimated life expectancy in 2019 was 78.8 years of age.1 One downside to this increased longevity is the greater risk of developing chronic systemic diseases. As a result, patients live with multiple comorbidities, and many take numerous medications. The Centers for Disease Control and Prevention (CDC) reported that the five leading causes of death in 2019 in persons 65 or older are: heart disease; malignant neoplasms; respiratory diseases; cerebrovascular disease; Alzheimer’s disease; and diabetes.1
Chronic wounds associated with these disease conditions are also of increased prevalence. Although not typically problematic in healthy patients, advancing age, paired with numerous underlying conditions, such as heart disease and metabolic syndromes, systemic stresses, and malnutrition, predispose patients to developing nonhealing wounds.
A 2018 retrospective analysis identified that approximately 8.2 million Medicare beneficiaries developed wounds, both with and without infections.2 The estimated cost to Medicare for acute and chronic wound treatment ranged from $28.1 billion to $96.8 billion.2 The 2018 National Hospice and Palliative Care Organization report indicated that 1.55 million Medicare beneficiaries received hospice services in that year.3 The study also noted that this figure represented an increase of 4 percent compared to the previous calendar year..3 While cancer (29.6 percent) was the leading diagnosis among Medicare hospice patients, circulatory/heart disease (17.4 percent) and dementia (15.6 percent) followed closely behind.3 The organization highlighted that home care accounted for the majority of care provided, with the figure coming in at 98.2 percent.3
Despite these statistics, there is often a gap in hospice coverage in this patient population. Medicare only covers hospice care if and when a patient’s primary care physician determines death is imminent. Consider the following scenario: Martha is 96 years old and still lives in her home of over 70 years. She has had slowly progressing breast cancer for two years, along with type-2 diabetes and coronary artery disease. Despite these serious health conditions, Martha’s doctors did not feel she was near death, therefore her Medicare policy would not cover hospice care. As a result of her advanced disease states, Martha eventually developed a nonhealing foot wound that went undetected until it resulted in infection, eventually leading to hospitalization and amputation. Had Martha been enrolled in a palliative care plan, this outcome may very well have been preventable.
What is Palliative Wound Care?
The World Health Organization (WHO) defines palliative care as the active care of a patient whose disease state is not responsive to curative treatment.4 In the traditional wound care model, the focus is on providing aggressive therapies to obtain wound closure or complete healing. In the palliative wound care pathway, the focus shifts toward providing patient comfort and dignity, preventing wound infection and deterioration, averting hospitalizations, and improving overall patient quality of life. Evidence shows that palliative care increases patients’ overall satisfaction with the care they receive.5 Palliative care also decreases the need for trips to the emergency department and hospitalizations, thus, reduces health care costs. In a study of home-bound, terminally ill patients, the average daily cost of care for those receiving palliative services was $95.30 versus $212.80 in the group not receiving palliative care.5
When to Employ Palliative Care
Utilizing the evidence-based, fatigue, resistance, aerobic capacity, illnesses, and loss of weight (FRAIL) model’s Healing Probability Assessment Tool can be a helpful guide to elicit data related to potential for wound healing.6 Variables identified by this tool can establish real-world criteria that indicate the need for palliative wound care (see table below). One should note that the more factors present, the less likely the patient is to heal and the more one should consider palliative care. Additionally, we should not overlook psychosocial well-being. Nonhealing wounds are a considerable cause of emotional distress and isolation for patients and their families due to wound-related stigma.
The importance of ongoing communication with the patient, family, and other caregivers is paramount. Addressing the concerns of both the patient and their family members while providing support and encouragement is key. Discussions with the patient and the family should emphasize that nonhealing wounds are often a result of advanced age paired with declining overall health and do not necessarily constitute negligence on the part of the patient, family, or the caregiver. It is also essential to set reasonable goals and expectations. This open dialogue can help lessen the patients’ feelings of blame, isolation, and depression.
In order to facilitate patient understanding, one should lay out their options for treatment in a way that is easy to comprehend. The author’s experience has shown that informed consent forms are a useful tool. The document should detail the reasons for enrollment into a long-term care or palliative care pathway, the purpose of the program, and set specific goals of care. Addressing these fundamental concerns and taking into account the patient’s perspective allows for a personalized approach to palliative care. Patient engagement will also increase adherence to treatment protocols, thus improving patient outcomes.
Key Components of Palliative Wound Management
Although the primary goal of palliative wound care is not necessarily wound healing, it does not mean that these wounds will never heal; it just may take longer to do so. Wound care clinicians should focus on increasing patient quality of life. Performing a complete wound assessment at each visit is essential in determining the appropriate treatment plan.
Studies have shown that controlling wound odor, pain, exudate, and the above-mentioned patient education can be key to mitigating feelings of depression.7 Dressing selection should consider limiting the frequency of dressing changes. Choosing highly absorbent, long-wearing dressings is paramount. The old wound care adage, “drainage dictates dressing decisions,” is something clinicians should keep in mind when selecting dressing materials. Estimating the volume of wound exudate is crucial in choosing the appropriate dressing. Managing exudate is vital in preventing periwound maceration, controlling odor, minimizing infection, and decreasing pain. Skin protectants containing zinc or polymer acrylate may also be applied during dressing changes to decrease the potential for skin damage.
Using materials that help to optimize the wound bed is also important. Many factors can contribute to wound malodor, including bacterial colonization, necrotic tissue, uncontrolled exudate, and malignancy. Dressings that contain activated charcoal can aid in odor reduction. If one determines that bacterial colonization is the source of wound odor, topical dressings consisting of impregnated silver can reduce bacterial burden, thus aiding in odor reduction.8 Conservative methods of debridement to remove necrotic or devitalized tissue such as autolytic or enzymatic can be an effective alternative to sharp debridement have utility in palliative wound care. Leptospermum honey dressings reduce inflammation and aid in autolytic debridement of necrotic tissue.9
Pain management is another crucial component of an approach to the palliative wound care patient. Consider premedication with over-the-counter pain relievers prior to scheduled dressing changes. Topical anesthetic agents such as EMLA cream or lidocaine gel can also be valuable to aid patient anxiety and concern. Using saline or sterile water to moisten the dressing prior to removal can facilitate dressing removal. Biomaterials that control exudate, protect the periwound, limit odor, and decrease pain should have primary consideration.
Key Additional Concerns
Maximizing the mobility and functionality of palliative care patients so they may continue to perform their activities of daily living is a vital part of helping them maintain their independence. Non-ambulatory patients will require pressure management as part of their treatment regimen. The use of devices such as foam, water, or gel products reduces static pressure and is the most cost-effective.10 On the other hand, devices such as mattress overlays, floatation therapy beds, and low air-loss mattresses can reduce or eliminate external loads.10 Patients who used foam, water or gel devices with continued deterioration of pressure-related injuries may qualify for more advanced device reimbursement.10
In addition, recognizing nutritional deficiencies in the palliative patient population can be a simple yet powerful way to support the care of these patients. Macronutrients play a vital role in wound healing. Proper nutrition is something that every wound care clinician should discuss with their palliative care patients. Caloric needs increase during wound healing, and estimates suggest patients should consume 30 to 35kcal/kg daily.11 Protein acts as an essential building block for tissue repair. Dietary protein provides amino acids that are essential in cellular metabolism. The body is in constant need of protein to support new cell growth.11 Therefore, sufficient protein intake is vital in patients with open wounds. Patients should be encouraged to include a high protein food source at every meal, and those with wounds should consume roughly 1.2 to 1.5kg of protein per kg body weight daily.11
Fats provide vital fuel necessary for wound healing. Dietary fats break down to produce ATP, providing energy that supports cellular function, therefore sparing protein for wound healing. Fat intake also assists in absorbing fat-soluble nutrients such as vitamin A, Omega-6, and Omega-3 fatty acids.11 Fatty acids are needed to synthesize prostaglandins.11 Without adequate quantities of two essential fatty Omega-6 fatty acids, linoleic and arachidonic, prostaglandin synthesis will be negatively affected and decrease the body’s ability to mount an immune response to bacteria and other antigens.11 Carbohydrates provide abundant energy necessary for cellular proliferation, fibroblast migration, and leukocyte activity. Carbohydrates stimulate insulin production needed for anabolic activities during the proliferative phase of wound healing.11 Carbohydrate intake should be monitored in persons with diabetes since increased intake can result in hyperglycemia, reducing granulocyte function.11
In Conclusion
The principles of palliative wound care become more important as our population ages. Clinicians see patients with complex wounds due to multiple comorbidities and local factors. Maintaining high-quality wound care is essential when a patient becomes enrolled in a palliative care pathway. Managing both wound symptoms and addressing psychosocial patient concerns will minimize the negative impact of living with a chronic wound and can increase patient quality of life.
Unfortunately, access to advanced wound care is a significant barrier challenging the very patients that would benefit the most. There is a growing need for alternative models of care such as home visits, telemedicine, and concierge medicine to support patients aging in place and allow them to maintain their quality of life for as long as possible.
Dr. Cole is the Director of Wound Care Research at Kent State University College of Podiatric Medicine and the Director of Professional Development and Clinical Education for Woundtech. She is board certified by the American Board of Foot and Ankle Surgery and the American Board of Wound Management. Dr. Cole is a Fellow of the Academy of Physicians in Wound Healing.
References
1. Kenneth D, Kochanek MA, Xu J, Arias E. Mortality in the United States, 2019. NCHS Data Brief, No. 395. Available at: https://www.cdc.gov/nchs/data/databriefs/db395-H.pdf Published December 2020. Accessed March 3, 2022.
2. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health. 2018;21(1):27–32.
3. NHPCO releases new facts and figures report on hospice care in America. NHPCO Website. Available at: https://www.nhpco.org/hospice-facts-figures/. Published August 17, 2020. Accessed March 3, 2022.
4. Fleck CA. Ethical wound management for the palliative patient. Extended Care Product News. 2005;100(4):38-46.
5. Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000
6. FRAIL Palliative Wound Care. Healing probability assessment tool. 2009. Available at: http://www.frailcare.org/images/Palliative. Accessed March 3, 2022.
7. Yan R, Strandlund K, Ci H, Huang Y, Zhang,Y, Zhang Y. Analysis of factors influencing anxiety and depression among hospitalized patients with chronic wounds. Adv Skin Wound Care. 2021;34(12):638-644.
8. White RJ, Cutting K, Kingsley A. Topical antimicrobials in the control of wound bioburden. Ostomy Wound Manage. 2006;52(8):26-58.
9. Günes UY, Eser I. Effectiveness of a honey dressing for healing pressure ulcers. J Wound Ostomy Continence Nurs. 2007;34:184-189.
10. Centers for Medicare and Medicaid Services. Pressure reducing support surfaces. Available at: http://www.ngsmedicare.com . Accessed March 3, 2022.
11. Quain A, Khardori N, Nutrition in wound care management: a comprehensive overview. Wounds. 2015;27(12):327-335.
