Case Studies In Palliative Wound Care
There may be instances when advanced therapies are contraindicated in elderly patients. In other instances, elderly patients with multiple comorbidities may be wary of the risks of surgical intervention for lower extremity wounds. Accordingly, these authors offer a variety of case studies that illustrate fundamental principles of palliative wound care.
The demographics of the American population are shifting dramatically toward a majority of people being over the age of 65. There are currently more than 35 million Americans age 65 and over, which is almost 15 percent of the United States population. This number is expected to increase to 70 million (20 percent of all Americans) by the year 2030 and to almost 80 million by 2050. In contrast, the population under age 65 will increase only 7 percent by 2050.1
An increasing number of adult children are taking on the responsibility for the care of their frail elderly parents or other close relatives. The application of palliative care concepts provides frail patients and their families with options that may maximize the patient’s functional status.
Palliative care aims to relieve suffering and improve the patient’s quality of life. It may complement and enhance disease-modifying therapy, or it may become the total focus of care. Palliative wound care should center on symptom management and is a viable option for patients whose chronic wounds do not respond to standard interventions, or when the demands of treatment are beyond the patient’s tolerance or stamina.2
In addition, palliative wound care strategies must work in conjunction with curative treatment objectives as wounds often heal completely in spite of serious illness and advanced disease.3 Palliative wound care is much more than pain, exudate and odor management. One should never ignore common curative treatment goals such as physical correction of the underlying pathology, facilitating optimal nutrition and other supportive aspects of care, and considering sensible (non-harmful) local wound treatments.
Palliative care is not synonymous with the abandonment of hope or treatment options. With the growing acceptance of treatments that do not necessarily have as the eradication of a disease process as their end point, palliative care is becoming increasingly more sophisticated. Consequently, it is becoming more effective at achieving its overarching objectives of symptom control and supportive care for both patients and their families.4
* a thorough assessment (that reveals relevant pathophysiology);
* determination of pharmacological and non-pharmacological options; and
* treatments that consider goals, risks and expected benefits.
What The Literature Reveals About Chronic Wounds And Palliative Care
Among patients receiving palliative care, the most prevalent wound is the pressure ulcer. Malignant skin wounds (fungating tumors), vascular wounds, diabetic ulcers and inflammatory wounds are also present but they are not nearly as common.5-7 According to the National Pressure Ulcer Advisory Panel (NPUAP) monograph, the prevalence of pressure ulcers among the hospice population ranges from 14 to 28 percent.7 Similar prevalence rates exist in long-term care and rehabilitation settings (2 to 28 percent), and among those with spinal cord injury (10 to 30 percent).8
Tippett and colleagues conducted a prevalence study of chronic wounds in more than 400 patients enrolled in large Midwest hospice, and reported that 35 percent had a skin wound. Pressure ulcers were the most common wound type, comprising 17.5 percent of patients in the study and 50 percent of all wounds.3
Reifsnyder and Magee investigated the prevalence of pressure ulcers in a retrospective review of data for 980 patients admitted to four different hospice programs during the first six months of 2003.5,6 The prevalence of pressure ulcers was 26.9 percent and the incidence was 10 percent during the study period. Not surprisingly, of those patients with pressure ulcers, 71 percent had malnutrition and 66 percent had multiple wounds.
The most common disease comorbidity among this pressure ulcer cohort was dementia (affecting greater than 45 percent of these patients). This was followed by stroke, peripheral vascular disease, diabetes and cancer. Most wounds were on the sacrum followed by the foot/heel. Interestingly, African-Americans were more likely to have a foot ulcer, ischemic wound or gangrene. This could very likely reflect the increased prevalence of diabetes within this ethnic group. Caucasians were more likely to have skin tears and traumatic wounds as were women. Men were more likely to have surgical wounds, tumors or neuropathic wounds.7
Seven Keys To Palliative Care
Given the population trends we are seeing and the challenges of providing optimal wound care for elderly patients, we offer a closer look at conservative treatment of chronic wounds affecting the foot and ankle. Our objective is to share our experience and approach to palliative wound care. We summarize our approach with the mnemonic SPECIAL:
S=Stabilizing the wound
P=Preventing new wounds
A=Advanced, absorbent wound dressings
L=Lessen or reduce dressing changes
Accordingly, let us review case studies in palliative wound care that illustrate the rationale, principles and recipes for each of the steps of the “SPECIAL” approach.
Case Study One: When A Patient Has A Chronic Venous Ulcer Complicated By Squamous Cell Carcinoma
An 84-year-old female presented with an ulcer on the lateral aspect of the left lower extremity that was affecting the ankle. The wound’s surface area was 38 cm2 with copious drainage as evidenced by the macerated wound margins. The patient claimed this wound had a 20-year history of non-healing.
The examination revealed that the wound was secondary to chronic venous insufficiency (CVI) with its clinical characteristics (hemosiderosis, lipodermatosclerosis, dermatitis, burning local pain and interstitial edema). The Doppler sounds were biphasic and the ankle-brachial index (ABI) was 1.1. The patient did not admit to claudication or resting pain. The neuropathic exam was unremarkable.
In most circumstances, it is recommended to obtain a biopsy from the wound to rule out a cutaneous malignancy if the wound has not healed in more than a year.9 However, this patient did not want a biopsy taken at this time.
We established a treatment plan that incorporated the wishes of the patient and her family. The plan was to treat the wound and the edema secondary to CVI with a simple non-adherent wound dressing and four-layer compression bandage. The patient agreed to return to the clinic weekly for follow-up. At the week four visit, if the wound did not demonstrate significant improvement (a decrease in the baseline surface area), we agreed to take a biopsy for dermatopathology.
Accurate and reproducible wound measurements are important as studies have demonstrated that a reliable predictor of wound healing is a 50 percent or greater reduction in surface area after four weeks.10 We utilize digital planimetry software (PictZar Digital Planimetry) that allows for accurate measurements from a digital photograph.
After four weeks of consistent management with adequate compression, the wound had not significantly improved. Dermatopathologic studies revealed squamous cell carcinoma and physicians consulted an oncologist. Since there was no lymph node involvement, the options were a wide excision or a below-knee amputation. We recommended that the patient and proxy consult with a plastic surgeon in order to better understand the surgical procedure that would be involved.
Thereafter, doctors discussed the two treatment options in detail with the patient and proxy. One was curative (surgical excision) and the other palliative (stabilization of the wound and conservative management with compression). The patient did not want surgery and chose the symptom management (palliative) approach. Our goals were to manage wound odor, control the wound exudate and employ oral medication to reduce the pain caused by the ulcer.
We have continued to see this patient on a weekly basis for the past two years. The patient reports no pain and weekly treatments of topical metronidazole 1% cream twice weekly to manage wound odor.11 Wound care is simple and consists of a non-adherent primary dressing, an absorbent secondary dressing and a four-layer bandage (Profore, Smith and Nephew). Dressing changes are twice weekly (one at home by a visiting nurse and the other at the wound center).
This patient responded well to the palliative treatment plan and was able to perform her normal activities of daily living. The response to treatment has been favorable. We have been able to attain our palliative care goals and have seen a slight improvement in wound healing.
Case Study Two: How To Address A Wound With Exposed Bone And Tendon In A Patient With Multiple Comorbidities
The second case study illustrates a similar approach but this patient in question had already undergone surgical excision for a Marjolin’s ulcer, leaving her with a wound with exposed tendon and bone.12
The 82-year-old female had a history of lung cancer, peripheral arterial occlusive disease (PAOD), senile dementia, osteoarthritis, diabetes and squamous cell carcinoma of the wound on her right lower extremity. There was a large area of anterior tibia exposed. Subsequent skin and lymph node biopsies demonstrated metastatic disease.
The patient’s primary physician discussed the risks and benefits of further surgery with the patient and her daughter, and referred the patient to our center. Our goals for this patient were: to avoid wet gangrene; eliminate pain; protect the tendon and bone; reduce exudates; and control wound odor.
The use of topical lidocaine decreased her wound pain to a level acceptable to the patient.2 We were able to control exudate and odor with cadexomer iodine (Iodoflex® Smith & Nephew), topical metronidazole cream to eliminate odor, and an absorbent dressing. We applied a very light compression bandage to the leg. The bandage was comprised of Kerlex and an Ace bandage we applied at 30 percent stretch (tension). Dressing changes initially occurred three times per week with the assistance of a visiting nurse service. After six months, the wound had improved significantly, the patient reported no pain, and both the patient and her family were quite happy.
Case Study Three: Addressing A Non-Healing Ischemic Ulcer With Exposed Bone
A frail 83-year-old male presented with a wound on the medial aspect of the left foot along the first metatarsal. The wound had a four-month history of non-healing. Within the wound, there was an exposed first metatarsophalangeal joint (MPJ), including the medial aspect of the first metatarsal head. Close examination showed that the metatarsal head had pitting in the periosteal surface and we assumed chronic osteomyelitis was likely.
The medical history included coronary arterial disease, peripheral arterial occlusive disease (PAOD), stable intermittent claudication and resting pain. The ABI on both legs was less than 0.6. A subsequent vascular consult lead to a successful angioplasty. Arterial blood flow to the foot improved, resting pain resolved and the ABI increased to 0.7. In addition, we consulted with a podiatric surgeon to discuss the possibilities of an amputation of the hallux or a Keller bunionectomy. We then educated the patient and family as to the risksand benefits of the surgery and offered palliative wound care alternatives. The patient selectsed palliative wound care that included treatment using oral antibiotics and local wound care. Local wound care consisted of a microscaffold collagen sponge with and without silver (Puracol® Plus AG, Medline Industries) and Biostep Collagen Foam Dressing (Smith and Nephew), offloading (with a custom shoe) and dressing changes twice a week.13
Improvement came slowly but within one month, 50 percent of the bone had granulation tissue covering it. After eight months, the wound healed completely.
Case Study Four: When There Is Chronic Lymphedema With Fibrosis And Papillomatosis
A 79-year-old male presented with chronic lymphedema of the lower extremities. In addition to having hypertension and type 2 diabetes, the obese patient had a very large circumferential wound of the left ankle/foot. The patient admitted to having this ulcer for more than 15 years. The patient had been going from provider to provider seeking relief of pain and odor from the massive, heavily draining venous ulcer.
The exam of the foot revealed fibrosis and induration of the foot and leg. In addition, there was papillomatosis of the distal foot and toes due to secondary chronic lymphedema. Biopsies from multiple sites were negative for malignancy.
We discussed a conservative plan with the patient. This heavily draining wound would necessitate daily dressing changes. We achieved odor control with a combination of metronidazole cream and oral trimethoprim/sulfamethoxazole 80/400 (Bactrim, Roche or Septra, Glaxo SmithKline). The patient received a prescription for an intermittent pneumatic compression pump and sleeve (Bio 2004, Bio Compression Systems), which he used for one hour BID at 55 mmHg.14
After six months of adhering to our palliative wound care protocol, the patient had an 18 percent reduction in calf circumference and a 20 percent reduction of the ulcer surface area. Prior to the initiation of this protocol, the patient had frequent episodes of cellulitis (five times in 2006) that required admission to acute care. Since he started this protocol, the patient has not had cellulitis.
Case Study Five: When A Patient With Bilateral Plantar Wounds Has Cutaneous Pyoderma Gangrenosum
A 51-year-old female presented with bilateral plantar foot wounds. She had a history of epilepsy, obesity, hypertension, vasculitis and protein S deficiency. The patient sought relief from the painful plantar foot lesions that prevented her from ambulating. She had the wounds for more than six years and had several failed partial-thickness autografts.
The physical exam revealed normal lower extremity circulation and normal ABIs. Typically, one may initially suspect diabetic neuropathy when a patient presents with chronic wounds on the plantar surface of the foot. However, after an exam that revealed no neuropathic abnormalities and careful observation of the exact location of the wounds (on the arches of the feet), we agreed to biopsy a new satellite lesion at the wound margin for dermatopathologic study. The biopsy revealed cutaneous pyoderma gangrenosum.
We started the patient on a therapeutic regimen of diamino-diphenyl sulfone (Dapsone) (100 mg QD), which she was unable to tolerate because of myalgias. The patient wanted to be able to walk without pain and felt very comfortable dealing with daily wound care.
We instituted a palliative treatment regimen that involved custom shoes to redistribute pressure, bactroban ointment for prophylaxis and light wound debridement with removal of callousity every two weeks. The primary dressing was Xeroform (Covidien) with a conforming bandage. We managed the wound pain with topical lidocaine.2
To date, the wounds have not healed completely but they have improved as there has been a 25 percent reduction in the baseline surface area. She is no longer confined to a wheelchair and is able to ambulate with limitations.
Case Study Six: Managing Ulcerations In A Patient With Sickle Cell Disease
The palliative care of wounds of differing etiology obligates the healthcare specialist to be prepared to deal with individual challenges for each patient. One must have the ability to be flexible and have a variety of regimens available to meet the patients’ needs.
One patient presented with multiple chronic wounds secondary to sickle cell anemia. One of the main challenges with such a patient is pain control. There needs to be coordination with the patient’s hematologist and careful examination of all medications is important. For example, many sicklers are often treated with hydroxyurea (Hydrea, Bristol Myers-Squibb) to reduce the frequency of crisis. Hydroxyurea can halt wound healing and often is the cause of skin ulceration.15
A careful balance of lidocaine, oral pain management, and compression therapy to reduce edema now help this patient have a better quality of life.
Case Study Seven: When A Patient Has A Neuroischemic Ulcer With Localized Gangrene
A 60-year-old male presented with a gangrenous great toe on the left foot. The patient had advanced diabetes, end-stage renal disease, retinopathy, peripheral neuropathy and critical limb ischemia. The patient’s surgical history included amputation of the second toe of the right foot.
The immediate goals were to keep the wound and necrotic tissue dry to avoid wet gangrene and get a more detailed evaluation regarding his vascular status. Although most of the smaller vessels were calcified, it was decided that an artherectomy may improve local perfusion and facilitate relief of ischemic pain. At that time the vascular surgeon recommended amputation of the great toe.
The patient did not want an amputation and asked us what his other options were. We discussed a conservative (palliative) wound care plan involving meticulous wound care and vigilance.
Treatment consisted of painting the tip of the toe with povidone iodine swabs and subsequent use of a dry protective sock. Bear in mind that bulky bandages sometimes are very occlusive even if one applies them dry and inadvertently a moist environment can be created.
Weekly visits to the clinic consisted of light debridement of the non-viable tissue at the line of demarcation. After several weeks, the eschar sloughed off and the wound healed completely.
Both palliative and curative wound care require a thorough understanding of the underlying pathology. Realistic goals and expectations must be clearly communicated and both the patient and the caregiver must be in agreement. It should be clear that the priority of palliative wound care is one of symptom management that places more of a holistic emphasis on the patient.
The priority is now the aforementioned SPECIAL mnemonic. However, never assume that palliative wound care cannot facilitate healing as more than 50 percent of wounds treated with palliative measures do heal completely.2
Dr. Wendelken is a licensed RN who specialized in emergency medicine. He is affiliated with the Calvary Hospital Center for Palliative and Curative Wound Care in Bronx, NY. He is an Adjunct Professor in the Department of Radiology at Temple University School of Podiatric Medicine. Dr. Wendelken is a principal in BioVisual Technologies, LLC, and is the inventor of PictZar® Digital Planimetry software program.
Dr. Markowitz is a staff physician at the Center for Curative and Palliative Wound Care at Calvary Hospital in Bronx, NY.
Dr. Alvarez is the Director of the Center for Curative and Palliative Wound Care at Calvary Hospital in Bronx, NY. He is a Professor in the Department of Medicine at the New York Medical College in Valhala, NY.
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2. Alvarez OM, Kalinski C, Nusbaum J, Hernandez LM, Pappous E, Kyriannis C, Parker R, Chrzanowski G, Comfort C. Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds. J Palliative Med 2007; 10(5);1161–1189.
3. Tippett, AW. Wounds at the end of life. Wounds 2005; 17(4):91-98.
4. Education for Physicians on End of Life Care (EPEC), Module 2. EPEC Project Princeton, NJ: Robert Wood Johnson Foundation, 1999;2-7.
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7. Cuddigan J, Berlowitz DR, Ayello EA. Pressure ulcers in America: prevalence, incidence and implication for the future: An executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care 2001; 14(3):208-215.
8. Association for Advancement of Wound Care. Government and Regulatory Task Force, 2005. Summary algorithm for venous ulcer care with annotations of available evidence, 2005, p. 25.
9. Phillips TJ, Machado F, Trout R, Porter J, Olin J, Falanga V. Prognostic indicators in venous ulcers. J Am Acad Dermatol 2000; 43(4):627-630.
10. Sheehan P, Jones P, Caselli A, Giurini JM, Veves A: Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care 2003, 26(6):189-1882.
11. Kalinski C, Schnepf M, Laboy D, Hernandez LM, Nusbaum J, McGrinder B, Comfort C, Alvarez OM. Effectiveness of a topical formulation containing metronidazole for wound odor and exudates control. Wounds 2005; 17(4):84-90.
12. Ryan RF, Litwin MS, Krementz ET. A new concept in the management of Marjolin’s ulcer. Ann Surg 1981; 193(5):598-605.
13. Dillon E, Champion L, Chivily D, Wendelken M, Alvarez OM. A case series illustrating conservative management of wounds that expose bone with a microscaffold collagen sponge (MCS). Abstract presented at the combined meetings of Symposium on Advanced Wound Care/Wound Healing Society, Dallas, TX, 2009.
14. Alvarez OM, Waltrous L, Wendelken M, Markowitz L, et al. Intermittent, gradient, pneumatic compression plus standard compression for hard to heal venous ulcers in subjects with secondary lymphedema and chronic venous insufficiency: analysis of a prospective randomized clinical trial. Wounds (Abstract) 2007; 19(3);A37.
15. Sirieix ME, Debure C, Badout N, Dubertret L, Roux E, et al. Leg ulcers and hydroxyurea: forty-one cases. Arch Derm 1999;135(7);818-820.