Proper wound care at the end of life improves patients' psychosocial and physical well-being

Understanding Wound Care in the Hospice and Palliative Setting

Published May 2nd, 2016

In the hospice and palliative care setting, the comfort and care preferences of patients are always the primary foci of care providers. Throughout the span of a patient care, and as terminal illness progress, bodily wounds may occur. Wounds, if left untreated or improperly cared for, impact patients not only physically, but psychosocially as well, and can erode the quality of life that patients enjoy.

Proper wound care provides healing for not only the body, but for the whole person.

By understanding the goals of wound care, the causes of the wounds and their respective treatments, and the effects of effectively treating wounds on a patient’s whole person, we can better understand how the healing practice of wound care serves such a vital role in a non-curative setting.

The Goals of Wound Care in Hospice

Wounds are a common occurrence in patients with terminal illnesses. Of the over 1.6 million patients who receive care from hospice programs across the United States, nearly 1 out of every 3 patients suffer from some form of wound as they near the end of life.

Percentage of Hospice Patients with and without Wounds

With comfort and adherence to patients’ care preferences being the highest priorities, wound care in the hospice and palliative settings is based upon 4 key tenets:

1. Patient-driven Care

The care of a patient’s wounds must be in alignment with the patient’s wishes for their end-of-life care.

2. Management of Wound Symptoms

Though the total healing of the wound may not be possible given a patient’s terminal illness, proper management of wound symptoms — managing the bleeding, malodor, pain, exudate, and progression of wounds, and preventing future wounds — is critical to providing quality wound care.

3. Improvement of Psychosocial Wellness

Wounds not only affect the physical, but the social and emotional well-being of patients, as well. Hospice and palliative care practices must also seek to reinforce a positive body image and guide towards improved psychosocial wellness.

4. Multidisciplinary Team Care

Wounds, and the end-of-life process as a whole, affect the patient’s whole person, as well as the lives of family, friends, and caregivers. Hospice and palliative care organizations must employ a multidisciplinary team of care professionals and various care practices to improve the physical, social, and spiritual well-being of all who are on the end-of-life journey.

In seeking to provide patients with the highest quality of life, wound care in hospice is an evolving practice — one that takes a multidisciplinary, holistic approach for the care of the wound and the relief of patient and family suffering, regardless of whether or not that wound is healable.

Most Common End-of-Life Wounds

Percentage of Common End-of-Life Wounds

The wounds experienced in the hospice and palliative care setting typically fall into a few common categories, each with their own unique characteristics.

Pressure Wounds

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Stages of Pressure Wound - Hide

Pressure wounds, the most common type of wounds found in the palliative care setting, comprise over 50% of the wounds encountered at the end-of-life. Pressure wounds are seen most often in elderly and terminally ill patients as a result skin failure — a naturally occurring process commonly associated with terminal illness wherein the skin begins to break down and die.

Pressure wounds, if left untreated, can advance through 4 stages:

4 stages of pressure wounds and their characteristics:

Stage I: Redness and painful — often darkly pigmented — skin that differs in temperature and texture from the surrounding skin.

Stage II: Partial loss of outer skin, often with a shallow, open wound with a red wound bed.

Stage III: Full thickness outer skin loss. Subcutaneous fat may be visible, but no muscle, bone, or tendon is exposed.

Stage IV: Wound extends deeply, often into muscles or tendons.

Skin Tears

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Arm Skin Tear - Hide

Skin tears are very traumatic wounds that usually occur on the arms and legs of older patients. These wounds are often the result of extreme friction that separates the outer layers of skin from one another, or in more extreme cases, full separation of the layers of skin from the underlying skin structures.

Characteristics of Skin Tears

  • Often actively bleeding

  • Shallow divides between outer layers of the skin

  • May have exudate

  • Usually most present on the hands

Deep Tissue Injuries

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Deep Tissue Injury - Hide

If the underlying soft tissues in a patient’s body are damaged by constant friction, shear, or continued pressure, deep tissue injuries can begin to form. If left unmanaged, deep tissue injuries can progress quickly, causing the surrounding skin to deteriorate rapidly, forming a more advanced wound.

Characteristics of Deep Tissue Injuries

  • Purple or maroon in color

  • Dissimilar feeling to the skin surrounding the wound — squishy or quite firm to the touch

  • Dissimilar in temperature to the skin surrounding the wound — warmer or cooler to the touch

Venous Ulcers

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Venous Ulcer - Hide

Venous ulcers are ulcers that most often occur on the legs of those who have been diagnosed with some form of venous disease.

Characteristics of Venous Ulcers

  • Develop in irregular shapes

  • Shallow

  • Most often form on the lower legs and ankles

  • Usually accompanied by painful swelling

Malignant Wounds

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Malignant Wound - Hide

Malignant wounds form when cancer, growing under the skin, penetrates through the skin and forms a wound. As these wounds and the cancer within them progress, the cancer blocks the oxygen supply to the tiny vessels around the skin, starving the skin in that area of the oxygen it needs.

Characteristics of Malignant Wounds

  • Strong malodor

  • Heavy exudate that crusts

  • Purple or maroon in color

  • Dissimilar in feel to the skin surrounding the wound — squishy or quite firm to the touch

  • Dissimilar in temperature to the skin surrounding the wound — warmer or cooler to the touch

Psychosocial Effects of Wounds

Though wounds affect hospice and palliative care patients on a physical level, with mobility-limiting pain, odor, and exudate, so too do wounds have a negative psychosocial impact on patients.

Social Isolation

Wounds, especially those with exudate and malodor, cause patients to feel ashamed of their body, and feel cut off from friends and family. This feeling of shame typically results in patients isolating themselves from others out of fear of rejection and potentially sensing disgust from others.

Negative Body Image

The presence of wounds, being potentially malodorous or leaky, erodes positivity that a patient may have regarding their body image. Over time, patients can begin to feel and believe that their body is unacceptable to others.

Depression

Often as a result of the negative body image and social isolation, patients with wounds can begin sinking into depression. No longer feeling acceptable in the presence of friends or family, feelings of shame, embarrassment, and self-disgust take root, leading to potentially severe depression.

Common Causes of Wounds

Wounds can form for a variety of reasons. While some wounds may be the result of a patient’s specific terminal illness, there are common factors in the development of wounds at the end of life.

Lack of Movement

Hospice and palliative care patients often, over time, become less mobile as their terminal illness progresses. This increased lack of physical motion causes pressure to build on the patient’s body where the body is making contact with a weight-bearing surface, resulting in the development of a pressure wound.

Friction and Shear

A patient rubbing their heels against the bed linens, sliding their body across the bed to sit up, or any number of frequent, repeated movements against a surface are examples of friction and shear. Both friction and shear cause the skin to be damaged externally and internally.

Inadequate Nutrition

When a patient is still able to receive food and drink, but is not receiving the nutrients they need, the body enters into a state of stress, creating a hypermetabolic state wherein the body’s natural tissue repair mechanisms begin to slow.

In this state, sudden, severe weight loss can occur, reducing the body’s fat. Without a healthy amount of fat, the body’s natural padding for the skin is reduced, giving way to resultant pressure ulcers.

Old Age

As people age, the skin’s natural process of cell restoration slows and the skin naturally begins to become more fragile, thin, dry, and more easily injured. This increased vulnerability to cuts and bruising greatly increases the risk of pressure ulcers forming.

Moisture

Moisture, be it from sweat, waste, or other sources, creates an environment of bacterial growth and increases the permeability of the outer layer of skin, reducing its ability to guard against injury from friction. With a greater chance for injury, paired with increased bacterial growth, the skin is much more easily infected when the presence of constant moisture is a factor.

Treating and Reducing the Risk of Wounds

When treating the wounds of patients who suffer from terminal illness, complete healing of the wound might not always be possible. While pressure wounds might not be able to be completely healed, there are steps taken to help reduce the chance of wound progression and future wound formation.

Repositioning

The patient, in accordance with their wishes and in the best interest of their overall comfort, is repositioned periodically for optimal comfort. Repositioning is often done on a schedule to ensure that pressure isn’t allowed to build for too long of a period on any one portion of the patient’s body.

Protecting pressure-prone areas

While frequent repositioning works well at staving off pressure wounds, improved support and protection on high-friction or high-pressure areas helps reduce the risk of wound formation.

Foam supports or specialty pillows can help position the body in a manner that promotes reduced pressure. Elbow and heel protectors also help cut down on friction against the bedding surface.

Skin care

By maintaining proper skin cleanliness and health, the risk of pressure wounds developing is greatly reduced. Using emollients (non-cosmetic moisturisers) on the skin promotes increase elasticity and prevents dryness — a common occurrence in elderly or terminally ill skin.

Proper management of incontinence

Incontinence, the involuntary loss of urine or feces, if left improperly managed, can lead to excess moisture and bacterial infection. The presence of additional moisture and bacteria can lead to significant weakening of the skin and exacerbation of existing wounds.

By assisting patients with their toileting needs and by providing assistance in cleansing after toileting, the risk of future wound formation is greatly reduced.

Wound Care at the End of Life

In the hospice and palliative care settings, it is often difficult to achieve full healing and closure of wounds as patients begin to draw closer to death. While the complete healing of a wound may not be possible, properly treating wounds and managing wound symptoms provides patients with comfort, a positive body image, and improved psychosocial wellness. Proper wound care provides healing for not only the body, but for the whole person.

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References

  1. Langemo, Diane K., PhD, RN, FAAN, and Joyce Black, PhD, RN, CWCN, CPSN. "Pressure Ulcers in Individuals Receiving Palliative Care." National Pressure Ulcer Advisory Panel. Web. 03 Apr. 2016.
  2. Hughes, Ronda G., PhD, MHS, RN, Alexis D. Bakos, PhD, MPH, RN, Ann O'Mara, PhD, MPH, RN, AOCN, and Christine T. Kovner, PhD, RN, FAAN. "Palliative Wound Care at the End of Life." Agency for Healthcare Research and Quality Archive. United States Department of Health and Human Services. Web. 01 Apr. 2016.
  3. Ferris, Frank D., MD, Ahmad Abdullah Al Khateib, MHA, MSN, Isabelle Fromantin, Linda Hoplamazian, RN, Diane L. Krasner, PhD, RN, CWOCN, CWS, Vincent Maida, BSc, MD, CCFP, Patricia Price, BA,PHD,AFBPsS, CHPsychol, and Louanne Rich-Vanderbij, MSc,BScN,RN,CWCN,COCN. "Palliative Wound Care: Managing Chronic Wounds across Life's Continuum: A Consensus Statement from the International Palliative Wound Care Initiative." Journal of Palliative Medicine, 1 Jan. 2007. Web. 1 Apr. 2016.

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