A palliative approach to care can be employed in managing complex chronic wounds that fail to heal despite optimal treatment. Palliation being the comprehensive care provided to individuals with life-limiting diseases or incurable advanced chronic conditions that focuses on relieving symptom burden and improving a patient’s quality of life rather than curative treatments.
Healing as a goal of wound care may not be feasible when medical interventions are ineffective, or when the patient is unable to physically tolerate wound therapies.
Non-healing wounds include malignant lesions, though they are more often wounds associated with conditions such as advanced peripheral vascular disease, diabetes, musculoskeletal disease and neuropathic disorders.
Examples of such wounds may be gangrenous foot ulcers where amputation is declined, arterial leg ulcers with failed revascularisation attempts and sacral pressure injuries in patients with motor neurone disease on continuous positive air pressure therapy where positioning is limited.
Patients presenting with these types of chronic palliative wounds may not necessarily be at the end of life, but it is imperative to recognise that these wounds significantly impact their life expectancy, activities of daily living and quality of life.
Conversely, patients in palliative care can develop wounds as a natural consequence of disease progression, often due to comorbidities and complex symptoms such as malnutrition, dehydration, immobility and incontinence heightening susceptibility to skin injury.
A 2019 review of the Silverchain Community Specialist Palliative Care Service found pressure injuries and skin tears were the most common wound. A percentage of the superficial skin injuries were found to heal in this palliative population contrary to general consensus, while the deeper wounds typically did not. It is important to recognise that just because a patient is for palliation does not mean that their wounds are not healable.
A comprehensive assessment is fundamental and encompasses the wound, the individual, and the physical and psychosocial healing environment.
The wound presentation guides the clinician in choosing products to manage exudate and malodour, support the need for debridement, provide antimicrobial treatments and, if possible, facilitate healing. Determining the underlying wound aetiology can prevent further injury to the wound and potentially optimise wound interventions and outcomes.
Management of underlying comorbid conditions and addressing functional and nutritional deficits reduce the impact of systemic confounders on healing, and further guides targeted therapies.
The person’s environment, support systems, and personal desires and goals of care are also crucial considerations that shape the wound management plan. Access to resources, equipment, assistive devices, and formal or informal caregiver support can substantially affect outcomes.
At assessment, if most of the patient’s intrinsic and extrinsic factors can be identified and addressed, the wound may be responsive to standard evidence-based wound care interventions even if the patient is palliated.
An example is a skin tear on the arm of an end-stage heart failure patient that is treated with appropriate cleansing, silicone dressing, and protective strategies that allow for healing.
However, suppose the same patient subsequently develops a venous leg ulcer that precludes the use of compression therapy due to its impact on cardiac function. In that case, it presents significant obstacles to wound healing and may not be achievable as a goal. Wound palliation for the leg ulcer may become the best approach, while healing remains the goal for the skin tear.
Rather than focusing solely on the wound, the clinician must adopt a holistic approach to align the wound management plan with the patient’s anticipated clinical trajectory, values and care goals determining if healing is unachievable.
Careful consideration of the patient’s prognosis, their quality of life and treatment preferences are essential particularly if the patient is transitioning to a palliative care approach. Strategies that focus on symptom control and addressing quality of life issues instead of wound closure predominate.
Informing patients of the risks and benefits of potential treatment options is crucial, however the practitioner needs to ensure they do not overburden or offer unreasonable hope. All healthcare providers, the patient and their significant others must discuss and agree on the palliative plan of care to avoid conflict and confusion. Open, honest and empathetic communication with the patient and their family is essential to ensure shared understanding and agreement on the care approach.
Key messages
- Not all wounds are able to be healed
- A holistic assessment of the patient determines the goal of care and management plan
- A multidisciplinary, patient centred, palliative approach should be adopted for unhealable wounds.
– References available on request
Author competing interests – nil
ED: The author is a nurse practitioner with Silverchain.