Response to "Risk Factors and Wound Management for Palliative Care Patients"

To the Editor:

An article entitled "Risk Factors and Wound Management for Palliative Care Patients"1 caught our attention. The summary and recommendation stated, "Although this review revealed limited evidence on specific treatment approaches to manage pressure ulcers in patients at the EOL [end of life]" and "Further research is needed for the development and implementation of the specific evidence based practice guidelines to address the issue of wound management among palliative care patients at the EOL [end of life]." We agree with this and would like to share our experience with patients who are at the end of life and have pressure ulcers.

Hospice Care of Kansas is a medium-size hospice located in the Midwest that started an aggressive palliative wound care program in February 2002. Although this may sound like a contradiction, listen to the reasoning and results. Our initial thought was to achieve a pain-free wound by treating aggressively the site of pain. Our goal was to achieve palliation while resolving stage I or II pressure ulcers and skin tears, although the literature said that this would not happen because these patients need their energy to overcome the terminal disease. What we found astounded us and our community. We found a 32% healing rate on all stages of wounds and skin tears, regardless of age, sex, diagnosis, or place of service. Although this was not a formal research project, we do believe the statistics are telling us something: patients at the end of life can heal their wounds.1 During this 4-year period, we used modern standards of care relating to wound management.2,3 We found that the wounds can be treated aggressively, but we can still keep patients comfortable and, in the long run, palliate their symptoms better by actually healing many of the wounds. We found this to be true even in patients with a previous history of multiple pressure ulcers, advanced age, central nervous system disorders (strokes and dementia), decreased mobility, fractures, and evidence of protein malnutrition (weight loss and low albumin/pre-albumin levels).

To illustrate our point, we share the case of Mrs. D, who presented to our hospice service with a subdural hematoma. She was essentially aphasic and unable to put two words together to form a thought. She had two leaky, malodorous stage IV heel wounds and a stage III wound on her coccyx. It took us a while to autolytically debride the heels and get the coccyx wound to resolve. One day I walked into her room and she said "Wow, you've lost weight." It was the first time anyone heard her speak a sentence. By aggressive wound treatment, we believe we relieved her pain. As a result, she began to eat better and get out of bed more; all of her wounds healed in an 11-month period. Amazingly, she is still alive 4 years later and has a better quality of life and has regained her dignity.

In summary, we found that by achieving a more aggressive palliative wound care approach, getting the patient comfortable locally, and educating caregivers on proper wound management, patients who are at the end of life respond by feeling better, beginning to eat, gaining weight, getting out of bed, and enjoying activities. This results in better quality of life and more dignity. We feel, as the article stated, that there is a void in evidence-based approaches to EOL wound care, and we are interested in joining with anyone else in further investigation in this area of EOL care.

Rick E. Hall, BA, RN, CWCN

is a Consultant of Hospice Care of Kansas Wichita

Kevin Bryant, MD

is the Medical Director of Hospice Care of Kansas Wichita

References