Discussion:
While all types of wounds are present in the palliative care patient, pressure wounds are the most prevalent. The authors note that not all pressure wounds are avoidable. Patients who are malnourished at baseline will be at higher risk and pressure ulcers may be very difficult to avoid. While much of the risk assessment is the same in all patients, with palliative care patients it is especially important to assess mobility. If such a patient is tube fed, the head of the bed should be elevated which increases the pressure on the sacral area, where pressure ulcers are most common. The routine use of risk assessment tools to implement prevention activities can dramatically reduce the incidence of pressure ulcers. Additionally, the authors note, reimbursement roadblocks for prevention activities can increase patient risk.

Palliative care patients may require some additional considerations. For instance, bed-bound patients with pain may need alternate methods to assure low-risk repositioning. The authors note the use of “slider sheets” that reduce friction and pain associated with turning. To reduce the need for repositioning, the use of an alternating pressure mattress. Adjunctive prevention strategies, such as range of motion exercises, incontinence management, and nutrition support were recommended.

Clinical experience showed that despite a patient’s hospice status or progressive illness, wounds will continue to heal. Treatment options should be discussed with patients and their family or caregivers to determine an appropriate balance of risks and benefits. In palliative care, the chance of cure versus non-curative therapy to suppress the problems associated with pressure ulcers, such as osteomyelitis, should be included in the considerations for types of therapy recommended.

A combination of therapies might be recommended to reduce risk and support healing of pressure wounds. Pressure-relieving surfaces can be matched to need, but the authors note that there is more research needed to determine the types of devices that are associated with benefits for particular categories of patients and wounds. Nutrition support has been associated with a decreased incidence of pressure wounds. Higher protein, vitamin C, and other nutritional supplementation have been associated with improved wound healing. Treatment for urinary incontinence centers on protecting the wounded area from moisture.

The authors suggest that there may be an underestimation of the prevalence of venous ulcers in various settings. While treatments are the same as for other patients, special considerations can be given to the benefit of compression therapy to reduce pain and inflammation and possibly reduce the need for oral pain medications. Pain control will include appropriate bandaging, compression, and walking (heel to toe) therapy. Topical lidocaine was recommended. The authors shared their experience in evaluation of their records to show that in comparison with curative care, the palliative care patient had no difference in their wound healing rate or success.

The authors recommended surgical intervention for palliative care patients to improve healing and reduce pain in ischemic wounds. High levels of pain improvement were seen even in patients who did not successfully heal their ischemic wounds. In addition, the authors suggested that infection prevention, pain control, and odor control should be priorities in palliative care patients. Reduction of pain and discomfort was achieved with leg dependency therapy and warm heating pads. Compression therapies with high compression, rapid sequence, and arterial intermittent pneumatic compression devices appeared to improve the benefits of walking therapy without adding pain or injury.

For malignant wounds, the authors again suggest setting realistic goals and weighing burdens and benefits to quality of life. The same goals for symptom management - efforts to manage pain, odor, and improve healing - should be included in the plans. In addition, consideration of psychosocial issues that affect patient adherence and comfort are important factors, such as cosmetic appearance of dressings. Local skin pain can be managed with a topical lidocaine while topical metronidazole may be used for cases of high odor tumor wounds, though it may cause temporary stinging pain due to its alcohol content unless formulated in a non-alcohol cream base.