It is well-known that many residents in the post-acute and long-term care setting have contracted, suffered from, and succumbed to COVID-19. Lesser known is that many PALTC wound experts expect the rates of pressure injuries to increase due to the virus’s impact on oxygen perfusion and the vascular system. These experts are encouraging PALTC clinicians to have candid conversations with patients and their responsible parties about the concept of maintenance and/or palliative wound care (Wound Manag Prev 2020;66:5–7).
Maintenance wound care acknowledges that intrinsic and extrinsic factors exist that may impede the process of normal wound healing. Chronic wounds seen in the PALTC environment are often maintenance wounds because older adults are more likely to have intrinsic factors such as chronic comorbid conditions, impaired nutrition, and limited mobility, and extrinsic factors such as medical devices or smoking that negatively impact normal wound healing. Additionally, chronic wounds may develop abnormal wound edges such as epibole (rolled or curled-under wound edge) or callus that may also contribute to delayed wound healing.
Maintenance wounds may nevertheless heal, but they are unlikely to heal as quickly or smoothly as the wound of a healthy individual. Therefore, the primary goal of wound care for maintenance wounds shifts from wound closure to preventing further decline by minimizing the risk of infection, focusing on symptom management, and removing any potential modifiable barriers, when applicable.
Palliative wounds are also commonly seen in PALTC. These wounds are unlikely to heal due to irreversible ischemia, malignancy, and/or the individual being at the end of life. Types of palliative wounds include pressure injuries, arterial and venous ulcers, fungating/malignant tumors, iatrogenic radiation injuries, Kennedy terminal ulcers, and Trombley-Brennan terminal tissue injury. A broader concept discussed in the wound care community that encompasses palliative wounds is SCALE: Skin Changes At Life’s End (see the Resources box for additional reading).
Experts agree there are observable skin changes at the end of life, but further research is needed to understand the causes. Additional consensus statements and clinical guidelines from several professional wound organizations support the observation that pressure injuries may be unavoidable at the end of life, despite providing standard wound care. In these cases, the goals of care should focus on symptom management and maximizing quality of life rather than on wound healing.
Management and Dressings
Excluding ischemic palliative wounds, management of both maintenance and palliative wounds is the same as management of healable wounds. This management includes general wound principles of maintaining a moist wound environment, managing bioburden, caring for wound edges, and focusing on prevention, protection, and offloading.
The selection of wound dressings for maintenance and palliative wounds should take into account who is doing the dressing changes, what the goals are for the wound, and whether any financial considerations apply. For example, if a palliative wound has a copious amount of drainage and the patient has pain with dressing changes, then PALTC clinicians should consider alginates, hydrofibers, foam dressings, or a combination of these to maximize absorbency while also minimizing the frequency of dressing changes.
Wound technology has evolved to support less-frequent changes when dressings are used correctly. One way to ensure the appropriate use of advanced wound products would be to confirm the indications and contraindications for use before application. Most wound products are available with a silver component, which can help manage bioburden. Even with palliative care wounds, debridement may be an option if it aligns with the goals of care of the individual, and it could improve quality of life.
One of the most crucial components for successful wound care is documentation. Although there has been no direct guidance from the Centers for Medicare & Medicaid Services in the State Operations Manual for Long Term Care Facilities regarding maintenance wounds, CMS does point out that there are modifiable and nonmodifiable risk factors that impact wound healing. In addition, CMS recognizes pressure injuries that may occur at the end of life and the characteristics surrounding the Kennedy terminal ulcer.
Interestingly, the International Classification of Diseases (ICD-10) does not currently provide any codes to support accurate coding of end-of-life wounds or any COVID-19 skin manifestations, so it is vital that wound documentation correctly describes skin manifestation etiologies. Wound documentation should also identify a wound prognosis (healable versus maintenance versus palliative) and then discuss the evidence to support this prognosis. For example, the phrase “delayed wound healing is expected due to” would be followed by a succinct but clear explanation of the factors impeding normal wound healing to establish realistic expectations for maintenance and palliative care wounds.
For example, if managing a wound in a diabetic patient with uncontrolled blood sugars and underlying vascular disease, it would be reasonable to document “delayed wound healing expected due to poor perfusion and uncontrolled diabetes.” This patient’s maintenance wound may eventually close if blood sugars are regulated and perfusion is restored (if a candidate). Importantly, the clinician needs to document which standards of wound care are being followed to justify that a stalled or declining wound is not due to a lack of appropriate care.
When the primary focus for a wound is no longer wound closure, the documentation should still reflect what can be done for the wound (see the table
). It is inappropriate to declare any palliative wound untreatable and not continue to apply wound care standards simply because wound closure is unlikely.
Table. Palliative Wound Goals of Care
Measurable wound goals can and should be identified. For example, a malodorous wound treated with a palliative care prognosis could have a goal focused on minimizing the smell so the family can tolerate being at the bedside. Dressing selection, perhaps with charcoal, would align with this goal, and the measurable outcome would be diminished odor reported by the family.
In a world where older adults with chronic illness are living longer, successful wound management is not always defined by wound closure. Many maintenance wounds and even some palliative wounds do eventually heal. The goal for maintenance and palliative wound care, like any other condition, is to develop realistic plans of care and then take that next step to educate the patient and caregivers so everyone has the same expectations.
Dr. Nalls is the director of education for Capital Caring Health (CCH), where she collaborates with all CCH service lines to meet their educational needs as well as provides wound care consults to CCH patients in their home environment. She serves on the board of directors for the Association for the Advancement of Wound Care. She may be reached at [email protected]
Palliative Wound Care Resources
National Pressure Injury Advisory Panel (NPIAP) white papers, including guidance on COVID-19 and palliative wound care: https://npiap.com/general/custom.asp?page=WhitePapers
Palliative Wound Pro, a wound care app: https://palliativewoundpro.com/
Pressure ulcer guidelines: Wound, Ostomy and Continence Nurses Society, “WOCN Society Position Paper: Avoidable Versus Unavoidable Pressure Ulcers (Injuries),” WOCN, 2017; https://bit.ly/2XxK4cF
SCALE: Skin Changes at Life’s End Final Consensus Statement: Adv Skin Wound Care
Types of palliative wounds: Adv Skin Wound Care
Wound Source, useful for dressing questions: https://www.woundsource.com/
WoundSource white paper on palliative wound care: Tippett et al., “Perspectives on Palliative Wound Care: Interprofessional Strategies for the Management of Palliative Wounds,” WoundSource, 2011; http://bit.ly/3i64we6
March 17, 2021
In this episode Wayne Saltsman and Elizabeth Galik highlight the realted articles.