General Principles and Approaches to Wound Prevention and Care at End of Life: An Overview
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Index: Ostomy Wound Manage. 2012;58(5):24–34.
The incidence and prevalence of wounds in persons at the end of life is largely unknown, but wounds are estimated to occur in at least one third of hospice patients. At the end of life, healthcare professionals must help the patient and/or family decide whether the goals of wound prevention and care should focus on healing or palliation. At all times, it is important to consider that a palliative approach does not negate the potential for wound improvement or even closing before death. A review of the literature suggests that, in general, few differences exist between the general principles of wound prevention and care and an optimal palliative care plan.
For example, maintenance of a moist wound environment is recommended to facilitate healing in general protocols of care. In end-of-life patients, dressings should be used for general comfort and prevention of skin exposure to wound exudate and to reduce the number of potentially painful dressing changes. Risk factors for tissue breakdown and pressure ulcer development are also similar. Palliative care patients with limited mobility and physical activity are at highest risk for developing pressure ulcers, but measures to help prevent these wounds may have to be adjusted to meet the overall goals of palliative care for a particular patient. Wounds encountered mainly in cancer patients — eg, fungating and radiation wounds — can pose important challenges for healthcare professionals and are very stressful for the patient. Pressure ulcers, fungating, and radiation wounds at the end of life are to be managed palliatively with the overall goal to minimize pain and odor, enhance comfort, and potentially improve the condition of the ulcer. Although research remains limited, it is clear the clinician and patient must balance best wound prevention and management practices while promoting patient dignity, self-esteem, and quality of life.
Keywords: wounds, palliative care, pressure ulcer, review, prevention
Potential Conflicts of Interest: none disclosed
For individuals at the end of life who have a wound, palliative care is most often the most appropriate care approach. Palliative care is focused on holistically supporting the individual for comfort rather than to cure or heal the wound, while improving the quality of living and dying. A 2002 National Consensus Project1 described palliative care as an organized and highly structured system of care focused on promoting the greatest comfort for and dignity of the patient (www.nationalconsensusproject.org) that is best delivered by a multidisciplinary team.2 Following the release of this report, many US hospitals developed palliative care units or palliative care teams to serve end-of-life patients.
It is estimated that one fifth of the US population will be 65 years or older by 2030,1 and more and more people are experiencing multiple comorbid illnesses in their later years.3 Concomitant with this demographic shift is the fact that the number of frail, elderly patients will increase and likely elect palliative rather than curative care at the end of life. Overall, limited information exists on wounds at end of life; however, at least one third of the nearly 1 million hospice patients in the US are known to have a wound, and this does not account for persons who are not in hospice care.4 Few studies on the prevalence and incidence of wounds at end of life exist.5 Reported prevalence rates vary between 13%6 and 47%,7-9 and incidence rates vary from 8%2 to 17%.7-12
Tippett4 conducted a cross-sectional study of 383 hospice patients and found 35% had skin wounds. Of these wounds, 50% were pressure ulcers.