t is theoretically true that most wounds can be closed. However, the processes required to achieve that goal may be inconsistent with the overall objectives (priorities) of patients with advanced disease and diminishing health. Wounds that remain unresponsive to therapies that treat both the cause and complications of the wound should be reassessed in the context of the entire patient. A frail patient who presents with a chronic wound should trigger a complete assessment of overall goals of care and consideration of palliative measures. It is a great challenge to incorporate palliative care concepts into our healthcare system, which focuses predominantly on disease eradication and associates palliative care options with “giving up.” Palliative care goals work in tandem with those aimed at complete wound closure, addressing objectives focused on quality-of-life issues for both the patient and family. Today, we know that palliative wound care approaches are simply the natural evolution of treatment options developed as a result of advancements in modern medicine. We have learned that palliative wound care principles, if introduced early in the treatment protocol, can accommodate both patient and family needs, shifting priorities as the progressive nature of the disease demands.
In developing this first Palliative Wound Management section for WOUNDS, my goals were 1) to better define the population of patients with wounds who have a degree of frailty where symptom management outweighs a curative treatment plan or who are at the end of life; 2) to highlight the importance of non-closure endpoints, such as wound stabilization and improvement; and 3) to identify current gaps in products and services supportive of palliative care strategies. In addition, this section needed to be a compilation of manuscripts that not only supported the concepts of palliative wound care but also improved our understanding about this patient population and its wound care needs.
In the first article, Reifsnyder and Magee examined retrospective data of home hospice patients to study the incidence and prevalence of pressure ulcers. Four home hospice programs (all in the northeast United States) participated in this survey. Prevention and management algorithms were uniform throughout. Data for 980 patients were examined during a 3-month study period in 2003. An incidence of 10% and a prevalence of 27% were reported. As expected, cancer was the most frequent diagnosis, followed by dementia and cardiovascular disease. However, patients diagnosed with dementia were disproportionately affected by pressure ulcer development, since nearly two-thirds (62.6%) of the sample population had cancer, but only 9% had dementia.
In the article by Meehan, the institutionalized and immobile frail patient is discussed. This article provokes thought about the complexity of the problem and the need to better define the population of patients with chronic wounds who are at the end of life. Meehan points out that patients with advanced dementia who do not have terminal cancer diagnoses are frequently ignored for palliative care.
The importance of wound odor is underestimated. There is no doubt that wound odor causes social embarrassment and has a negative psychological impact. In the study of metronidazole use on malodorous wounds by Kalinski et al., all 16 patients had favorable responses, and nearly two-thirds experienced complete odor elimination within 24 hours. This contribution adds credibility to the study of wound care endpoints that do not lead to complete wound closure.
In “Wounds at the End of Life,” Tippett writes, “Understanding the magnitude and scope of the problem [wounds at the end of life] can provide a basis for developing palliative treatments and influencing public policy.” Tippett discusses the challenge of defining palliative wound care to a hospice patient population and delivering that care within the per diem of hospice reimbursement. Wound prevalence among the studied population (hospice patients in the home and nursing home setting) was 35% total, 17.5% with pressure ulcers, 7% with lower leg (vascular) wounds, and 10.5% with miscellaneous chronic wounds.
Ennis and Meneses report on healing rates over 6 months of practice at a newly created subacute wound unit. They report that 68.4% of their inpatients markedly improve (>50% wound closure) or completely heal. Of that subset, 77.4% healed, and 22.5% markedly improved. Of the subset that healed, 63.9% healed by secondary intention, and 36.1% healed by surgical closure. One relevant issue evident from this work is that wound improvement and/or wound stabilization can be reliably measured and useful to the clinician to better balance palliative and curative goals. Another point expressed in this article is that palliative wound care provided in this subacute setting can work in tandem with curative care, as many of the same advanced wound care products were useful for both palliative and curative groups. |
