Case Studies In Palliative Wound Care

Martin E. Wendelken, DPM, RN, Lee Markowitz, DPM, and Oscar M. Alvarez, PhD

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

   When it comes to the use of palliative care, we recommend the following approaches for all patients:

   * 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

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