Comfort-Focused Wound Care: Development of Standardized Protocol for Wound Care at End-of-Life

Successful wound management in the palliative care and hospice arenas is a challenging process that requires progressive clinical knowledge, explicit goal communication, and creativity to provide comfort and symptom control. While most acute and chronic wounds encountered by a provider can be healed effectively if the appropriate treatment is employed, there are some recalcitrant wounds and many comorbidities that prevent wound healing, especially at the end of life. This circumstance causes providers to evaluate appropriate interventions for wound maintenance. Providers should be able to utilize protocols with symptom control in mind when providing palliative, or comfort-focused wound care (CFWC). The literature regarding palliative wound care is abundant. However, the availability and utilization of a standardized protocol for palliative wound care and symptom management is lacking.

Purpose

The purpose of this capstone project was to conduct a comprehensive literature review to determine the knowledge base regarding the treatment of wound from a comfort-focused, or palliative aspect. The researcher noted that, although there is a great deal of information regarding the treatment of wounds at the end of life, there was no formal protocol that provided treatment guidelines. The researcher developed a palliative wound care protocol that addressed the elements of palliative wound care, including pain, odor, drainage, bleeding, and bacterial bioburden.

Manifestation and Treatment of Pain

Several studies in the integrative review discussed the manifestation and treatment of pain in relation to palliative wound care. One study found that pain was the most distressing symptom regarding wound care and affected a myriad of other activities, such as sleep, mobility, and relationships (Chrisman, 2010). The assessment of pain is important data to extract and influence treatment. One must attempt to ascertain the onset, location, duration, aggravating & alleviating factors, characteristics, radiation, and timing of the pain as part of history of present illness information. There are measurement tools to assist with objectifying pain, such as the Numerical Pain Rating Scale (0-10), McGill Pain Questionnaire, and the FLACC score (Alvarez, et. al., 2007). Secondly, there are several non-pharmacological interventions for the treatment of pain as well as utilization of medications. Many studies review relief mechanisms such as leg elevation, sitting or stretching, cooling. Also, using non-adherent dressings that avoid trauma or epidermal stripping during dressing changes is encouraged (Alvarez, et. al., 2007; Naylor, 2005). Pharmacological treatments include numbing agents such as lidocaine, pain relievers such as acetaminophen and non-steroidal anti-inflammatories as well as opiate analgesia. The provider should consider both systemic and local uses of pharmacological treament (Naylor, 2005).

Manifestation and Treatment of Odor

Regarding malodorous wounds, many studies were reviewed and offered rationale for wound odor in addition to possible treatment options. Wound odor is typically caused by bacteria within the wound, typically organized in nonviable tissue. Anaerobes are the most common cause of wound odor, and examples include Pseudomonas, Klebsiella, and Clostridium species (Gethin, 2011). Options for treatment of wound odor in the palliative setting include topical metronidazole for the treatment of anaerobic bacterial bioburden, debridement of devitalized tissues, honey, and charcoal dressings (Chrisman, 2010; Gethin, 2011; Naylor, 2005). Many wounds with odor correspond to a malignant fungating wounds (MFW). There is an assessment tool to better gather data regarding patient symptomatology and perception related to MFW called the Malignant Fungating Wound Assessment Tool (MFWAT) (Lo, et. al., 2011). There are other interventions related to environmental changes, such as scented candles in the environment, cat litter under the bed to absorb odor, and open trays of coffee beans (Gethin, 2011).

Manifestation and Treatment of Drainage

Comparatively, the literature reviewed yielded fewer articles discussing the pathophysiology and management of drainage. There are tools available for the measurement of exudate or drainage, most commonly noted are the PUSH tool and BWAT tool. As mentioned before, heavy exudate can impede wound healing as well as leak out of dressings and get on clothes or linen, causing embarrassment and possibly social isolation (Naylor, 2005; Chrisman, 2011). It is important to choose a topical dressing that can absorb the drainage the wound produces without drying out the wound bed. Also, dressing choice should include a dressing that meets absorption needs while limiting the number of dressing changes as much as possible to reduce discomfort and pain (Alvarez, et. al., 2007). It is also important to review drainage amount with each dressing change and alter the dressing choice if drainage changes occur (Chamanga, 2015).

Manifestation and Treatment of Bleeding

Many of the articles reviewed regarding bleeding associated with recalcitrant wounds were related to tumor burden. Discussion regarding the pathophysiology of problematic wound bleeding relates to fragile vessels within the wounds. Other factors for bleeding include bone marrow suppression, disseminated intravascular coagulopathy, and thrombocytopenia (Recka, et. al., 2011). Regarding local wound care, it was discussed that slow, careful removal of dressings that have been previously moistened with warm saline are a mainstay in prevention of bleeding associated with dressing change. Dressing choices should be made with the understanding that the bleeding should be wicked away from the wound bed and absorbed (Chrisman, 2011). Secondly, pharmacologic treatments are dicussed, such as the use of topical vasoconstrictors like epinephrine, cocaine, and oxymetazoline. Chemical cauterization is an option as well with the utilization of silver nitrate. Systemic therapies include vitamin K, fresh frozen plasma and other blood products. If the tumor burden can be relived with radiation or surgery, this should also be considered (Recka, et. al., 2011). There was no noted assessment tool in the integrative literature review as it relates to wound bleeding.

Management of and Treatment of Bacterial Bioburden

Bacterial bioburden is a common problem regarding recalcitrant wounds. Bacterial colonization of a wound increases the risk of chronicity. Davis and colleagues report that there is suggestion regarding wounds with more than 1,000,000 organisms contributing to delay in wound healing (Davis, et. al., 2013). Similarly, wounds with bacterial colonization can become more painful, increase drainage, and contribute to odor. Wound infection and colonization can be related to the body’s response to the bacteria, and the virulence of the particular offending bacteria (Butcher, 2012). There are several topical agents that have been cited in the literature review regarding topical control of bacterial bioburden. Silver is an agent that has been used in wound care for many years. The silver element is antimicrobial in nature, inhibiting bacterial growth. There are many wound care dressings that contain silver. However, there have been growing concerns regarding the possibility of silver toxicity and silver resistance (Butcher 2012). Iodine has been used in wound care since the Civil War time period (Schwartz, et. al., 2012). Iodine works on the bacterial bioburden by disrupting the bacterial cell membrane and causing cell death (Schwartz, et. al., 2012). The iodine can be used in the form of a pained swab over a stable wound with dry eschar or as an ingredient in cadexomer iodine, which will also aid with drainage absorption. The literature review has also revealed the usefulness of medical grade honey in the management of bacterial bioburden. Although the mechanism is not fully known, it seems that the hyperosmolar properties of the honey inhibit the access to water by bacteria, causing bacterial cell death (Butcher 2012).