Palliative Wound Care

J Wound Ostomy Continence Nurs. 2010;37(6):639-644. Published by Lippincott Williams & Wilkins CE WOUND CARE Palliative Wound Care A Concept Analysis Kevin R. Emmons Vicki D. Lachman The concept of palliative wound care is in its infancy, with relevant literature emerging in the 1980s. Palliative wound care has evolved over time as new research and practice initiatives continue to explore its usefulness. We applied Rodgers evolutionary concept analysis to a conceptual exploration of palliative wound care. The findings of this analysis identified reoccurring themes that were grouped into the concept s antecedents, attributes, and consequences. We found that palliative wound care is a holistic integrated approach to care that addresses symptom management and psychosocial well-being, is multidisciplinary, is driven by patient/family goals, and is integrated into wound healing principles and everyday practice. The integration of palliative wound care into the continuum of wound care, not just at the end of life, is the logical conclusion. Introduction A concept analysis aims to provide a working definition and clarify a given concept for use in practice and research. 1 This analysis will focus on the concept of palliative wound care, using Rodgers evolutionary method of conceptual analysis. The history, antecedents, attributes, and consequences of palliative wound care will be examined to clarify the concept and provide a working definition for use in practice and research. Wound Care Acute and chronic wounds can occur at any point during a person s life. Acute wounds heal without complication through a predictable trajectory. 2 In contrast, chronic wounds fail to progress through normal stages of healing and enter a prolonged inflammatory state. 3 In a study examining 593 patients with advanced illness (defined as an incurable disease that generally limits a person s life to 6 months or less), 43 types of wounds were identified and grouped into 9 categories: (1) malignant, (2) pressure ulcers (PUs), (3) iatrogenic, (4) traumatic, (5) diabetic foot ulcers, (6) venous leg ulcers, (7) arterial ulcers/gangrene, (8) infections/inflammatory lesions, and (9) ostomy related. 4 Providing effective wound care is important because the presence of a nonhealing wound threatens physical health and quality of life. 5,6 When the primary goal of wound care is healing, the general principles of care are to (1) control or eliminate causative factors; (2) provide systemic support to reduce existing and potential cofactors; and (3) maintain a local environment that promotes wound healing. 7 These basic principles should guide practice; however, when a patient lacks the physiologic capacity to heal, integrating principles of palliative care may be beneficial. Palliative Care The World Health Organization (WHO) 8 defines palliative care as an approach to improve the quality of life of patients and their families who are facing life-threatening illness. Palliative care addresses physical factors such as alleviation of pain and distressing symptoms, psychological factors such as bereavement counseling, social factors including mobilizing support systems to help family cope with patient s illness, and spiritual factors such as moving toward acceptance of death for patient and families. The multidisciplinary team providing palliative care should seek to enhance the quality of life for the patient and the family and to normalize the dying process. While the WHO criteria provide an overview of the objectives and implementation of palliative care, they do not address the concept of palliative wound care directly. In a concept analysis of palliative care, Meghani 9 reported that essential attributes include provision of total patient care, family support, effective communication, and interdisciplinary teamwork. End-of-life care should always encompass palliative care, but it is a common misconception that palliative care is the same as hospice care. 9 Kevin R. Emmons, DrNPc, MSN, RN, CWCN, Wound Care Specialist, Good Shepherd Penn Partners; Chair, Penn Medicine Pressure Ulcer Task Force, University of Pennsylvania Health System; and Doctoral Nursing Candidate, Drexel University, Philadelphia, Pennsylvania. Vicki D. Lachman, PhD, APRN-BC, MBE, Clinical Associate Professor, Drexel University, Philadelphia, Pennsylvania. The authors have disclosed that they have no financial relationships related to this article. Correspondence: Kevin R. Emmons, MSN, RN, CWCN, 1800 Lombard St, Philadelphia, PA 19146 (Ke35@drexel.edu). DOI:10.1097/WON.0b013e3181f90a4a Copyright 2010 by the Wound, Ostomy and Continence Nurses Society J WOCN November/December 2010 639

640 Emmons & Lachman J WOCN November/December 2010 Palliative care does not always indicate end of life; it extends across the care continuum and can be used in conjunction with curative treatment. Cleary 10 developed a new model that integrates concepts of palliative care long before a person s condition is deemed terminal. Palliative care and wound care are inherently connected. We believe that the principles of palliative care and wound care such as controlling the wound environment, which ultimately impacts quality of life, are congruent. Therefore, we believe that a comprehensive understanding of the history and meaning of palliative wound care is beneficial when integrating this approach into everyday practice. Methods Rodgers 1 proposed an integrated method of conceptual analysis based on a process of defining, evaluating, and refining concepts. The use of an evolutionary approach to analysis is based on the assumption that attributes that comprise the definition of a concept change over time, either by convention or by purpose. 1 We selected this analytic method because it is consistent with the view of Ferris and colleagues, 11 who asserted that palliative wound care is an evolving body of knowledge and skills. We searched the literature using MEDLINE, CINAHL, and the Cochrane Database for Systematic Reviews. Search dates were limited to 1960-2009 for MEDLINE, 1950-2009 for CINAHL, and all available dates for the Cochrane Database were included. We limited our search to these dates because we found no literature prior to 1970 that assisted in clarifying the evolution of palliative wound care. Each key word was truncated to include multiple endings or variations. For example, the term ulcer was used because it includes ulcers, ulceration, ulcerated, etc. Search results were combined using the or option, which lists all related articles that have at least one of the related terms. The first section of words searched related to wounds included wound, pressure ulcer, ulcer, and malignancy. The second set of words searched related to palliative care and included palliative, palliates, hospice, advanced illness, and terminal. These searches were combined utilizing the and Boolean function, which requires both search terms be located in the same article. The search was limited to articles written in the English language. The initial search revealed 117 articles. Each article was reviewed to determine if it would aid in clarifying the concept, resulting in 31 articles deemed relevant to our analysis. Additional resources were also reviewed such as the Oxford English Dictionary, palliative care texts, and wound care texts. Historical Evolution Wound care has been documented for thousands of years, but the concept of palliative wound care is fairly new, emerging within the past 20 years. A majority of literature examining palliative wound care was published after the year 2000. During the 1980s, the concept of palliative wound care grew out of literature exploring PUs at end of life. Colburn 6 reported the importance of preventing PUs in patients in hospice because these wounds complicated care, increased costs, and threatened quality of life. Appropriate management and prevention were advocated in order to improve quality of life, especially among those with PUs. 12 This era s authors focused on PUs in terminally ill persons; however, there was an underlying theme of the palliation of symptoms and improved quality of life. Publications focusing on the care of patients requiring palliative care with wounds increased during the 1990s. 13-18 This trend is attributable to several factors, including national attention on PU prevention and management and an increasing focus on palliative care initiated by the WHO. Standards began to emerge that care and comfort should be stressed rather than the traditional goal of wound healing in the palliative care setting. 13 In addition, patient-centered care and mutual goal setting with patients and families was stressed. 13,14 Chambers 14 recommended a holistic approach for managing PUs in terminally ill patients with a focus on comfort and pain relief. Themes of suffering among patients with PUs who were receiving palliative care began to emerge. 15,16 Walding and Andrews 17 proposed the following aims for patients receiving palliative care: (1) promote comfort and dignity, (2) prevent PUs in patients with intact skin, (3) prevent further deterioration of existing PUs, and (4) encourage healing whenever possible. Several authors observed that general palliative care aspects, such as psychological, social, and spiritual care, were just as important as symptom control when the ultimate goal is maintaining quality of life. 17,18 During the first decade of the 21st century, the practice and literature supporting palliative wound care gained momentum. 11,19-21 Up to this point, nursing literature primarily focused on the palliative management of wounds, although recommendations frequently included a multidisciplinary approach. Descriptions of wounds unique to the end of life such as malignant wounds also began to appear in the literature. 5,22-24 Epidemiologic studies were published reporting higher prevalence and incidence of wounds among patients who were terminally ill. 4,25,26 The concept of skin failure arose, which proposes that not all skin breakdown is preventable. 19,27 In these cases, the primary goal may not be healing, reinforcing the need for palliative wound care. 28,29 A consensus statement was released by the International Palliative Wound Care Initiative that provided specific recommendations for wound care strategies. Several authors began to provide definitions and recommendations for implementing palliative wound care into practice. 11,21,30-35 Concept Analysis According to the Oxford English Dictionary, 36 the term palliative is derived from the palliate, which is defined as

J WOCN Volume 37/Number 6 Emmons & Lachman 641 serving to relieve (disease) superficially or temporarily, or to mitigate or alleviate (pain or other evil). (p102) The Compact Oxford English Dictionary 37 defines palliative as relieving pain or alleviating a problem without dealing with the cause. (p102) Palliative has been used in multiple contexts, including disease cure and eradication. Palliative care, as defined by the Oxford English Dictionary, 36 is the care for the terminally ill and their families, especially that provided by an organized health service. More than 10 definitions for the word wound can be found in 1 dictionary. Two definitions that best fit this concept analysis from the Oxford English Dictionary 36 are as follows: (1) a hurt caused by the laceration or separation of the tissues of the body by a hard or sharp instrument, a bullet, etc, and (2) imperfection, a flaw. (p591) None of these definitions provides an adequate definition for palliative wound care. The dictionary definition of palliative is the antithesis of curative and does not address underlying causative factors. Palliative is described as a temporary relief of problems, a covering up, or cloaking of symptoms. Similarly, the common definition of wound lacks the depth and breadth of the phenomenon as used by wound care specialists. Contemporary Definitions Several authors allude to the meaning of palliative wound care, but we found few explicit definitions. 27,30,33,34 Alvarez and associates 31 recommended care standards that focus on the elimination or reduction of pain, odor, infection, diminished self image, and the increased social isolation that chronic wounds cause. (p8) Chaplin 21 proposed that palliative wound care is a combination of good wound management, a holistic person-centered care approach, and goals that are driven by all patients needs and priorities, all aimed at enhancing quality of life. Tippett 26 defined palliative wound care by its goals that include the relief of pain, elimination of odor, prevention of infection, maintenance of function, and, where possible healing. (p91) Langemo and Brown 28 described relief of suffering and enhancing quality of life as the focus of palliative wound care based on integration of holistic palliative care concepts with chronic wound care strategies. Palliative care may be a natural evolution of patient management, but it has not yet been completely utilized or understood. 35 According to Tice, 38 palliative wound care is listening to the patient s goals combined with a primary focus on quality of life versus healing. In 2007, Alvarez and associates, 32 representing The Center for Curative and Palliative Wound Care, reported the definition of palliative wound care as the incorporation of strategies that prioritize symptom relief and wound improvement ahead of wound healing (total closure) that works in conjunction with curative treatments, and is much more than pain, exudate, or odor management. (p1161) The International Palliative Wound Care Initiative defines palliative wound care as an evolving body of knowledge and skills that takes a holistic approach to relieving suffering and improving quality of life for patients and family living with chronic wounds, whether the wound is healable or not. 11(p37) This consensus statement was the first attempt at broadly defining palliative wound care. However, this definition lacked concept clarification and explicitness, rendering it difficult to operationally define it for use in practice and research. Related Concepts Literature on both palliative wound care and general palliative care embrace the notion that palliative concepts can be applied across the care continuum. However, palliative care often is associated with end of life. Related concepts include end-of-life wound care, hospice care, and symptom management. Palliative care is not synonymous with withholding or withdrawing care, providing substandard care, or giving up hope of healing. Similarly, palliative wound care may be implemented in order to reduce suffering from wound-related symptoms and improve quality of life. 9 Antecedents are situations, or experiences that precede the concept 1 (Table 1). Conditions and treatments are 2 antecedent categories of palliative wound care. Although end of life is the most common setting for palliative care, it is not the only indication. Examples of antecedent conditions include (1) chronic debilitating disease, (2) malnutrition and dehydration, (3) long standing wounds, (4) advanced illness, (5) uncorrected physiologic pathologies (eg, arterial disease, venous disease, cancer), and (6) difficulties in symptom control. 15,33,34,39 A curative approach to treatment that focuses on wound healing may be less focused on the burden of the treatment to the patient and family; in contrast, palliative wound care specifically focuses on this burden. 38 Antecedent treatment such as the use of advanced mechanical modalities, surgical debridement, and expensive topical wound therapies are traditionally thought of as too aggressive for palliative wound care. However, multiple high-tech or invasive interventions have been successfully incorporated into palliative wound care including surgery, radiation, chemotherapy, negative pressure wound therapy, and larval debridement. 23,40-42 Prevention is also an important antecedent of palliative wound care. It is particularly essential in the care of patients in whom skin failure is diagnosed near the end of life. 28,31 In these patients, it has been shown that while it may not be possible to prevent all skin breakdown, increased vigilance may decrease severity and avoid unnecessary breakdown. Nevertheless, the concept of skin failure remains controversial and additional research is required to more clearly define the characteristics of this phenomenon. Attributes The attributes of palliative wound care are symptom management, a multidisciplinary approach to care,

642 Emmons & Lachman J WOCN November/December 2010 TABLE 1. Identified Antecedents, Attributes, and Consequences of Palliative Wound Care Antecedents Attributes Consequences Conditions Chronic debilitating disease Malnutrition and dehydration Chronic long standing wounds Advanced illness Uncorrected physiologic pathologies Difficulties in symptom control Terminal illness Treatment Advanced mechanical modalities Surgeries such as debridement Aggressive topical wound therapies Prevention Symptom management Prevention of deterioration and stabilization of the wound Promotion of a clinically clean and protected wound environment Minimization of infection and sepsis Control of pain, odor, and excessive exudate Reduction in the frequency of dressing changes, Minimization of bleeding Prevention of trauma Management of maceration Elimination of pruritus Multidisciplinary team approach Nurses Physicians Physical and occupational therapists Nutritionists Psychologists Patient/family Others Patient/family-centered goals Goals are directed by patient/family Collaborates with health care team May differ from health care team goals Psychosocial well-being Provides a sense of well-being Alleviates fears related to the illness Promotes dignity Addresses spirituality Provides increased autonomy and decision making Eliminates social isolation, feelings of uncertainty, and family/caregiver guilt Reduces caregiver burden Positive Control of symptoms Relief of suffering Improved quality of life Improved quality of death Increased psychosocial well-being Wound healing Negative Lack of appropriate care Excuse for poor outcomes Used only to decrease cost and not improve care patient/family-centered goals, and psychosocial well-being. Relieving suffering, and therefore preserving or improving a person s quality of life, is a common theme in palliative wound care. 11,16,33,35 The goals of symptom management are as follows: (1) preventing deterioration and stabilization of the wound, (2) promoting a clinically clean and protected wound environment, (3) minimizing infection and sepsis, (4) controlling pain, odor, and excessive exudate, (5) reducing the frequency of dressing changes, (6) minimizing bleeding, (7) preventing trauma to the wound bed and periwound skin, (8) managing maceration, and (9) eliminating pruritus. 5,14,19,21,26,27,30,31,39 These goals are implemented by a multidisciplinary team including nurses, physicians, physical and occupational therapists, nutritionists, psychologists, and others, as indicated. 17,20,26,28,31,43 In palliative wound care, it is important that goals are directed by patients and families in collaboration with the health care team. 20,21,31,33-35,43,44 Tice 38 points out that learning what the patient wants is essential to developing a plan of care, especially since these priorities may differ from those of the health care team. Although not a primary goal of this concept analysis, the potential financial aspects of palliative wound care are relevant. Cavicchioli 45 argues that investing money and resources to postpone death without benefit to the patient and the family is pointless. Implications for WOC Practice With further research and practice, the concept of palliative wound care will continue to evolve. Ultimately, these principles should integrate seamlessly into general wound

J WOCN Volume 37/Number 6 Emmons & Lachman 643 FIGURE 1. Integrated approach of palliative wound care. care. This integration will be enhanced when inaccurate beliefs that palliative wound care is characterized by giving up hope and disregarding curative treatment. It applies only to end-of-life care. Conclusion Palliative wound care is a complex concept that extends beyond the concealing of unpleasant symptoms. As a holistic and integrated approach to care, palliative wound care encompasses (1) symptom management, (2) the improvement of psychosocial well-being, (3) a multidisciplinary team approach, and (4) patient/family-driven goals. It is not indicated only for care of terminally ill patients, rather it should be used in conjunction with curative treatments when healing is the goal (Figure 1). KEY POINTS Palliative wound care is often mistakenly perceived as withdrawing or withholding appropriate care. Palliative wound care occurs across the care continuum. A holistic and integrated approach to palliative wound care consists of (1) symptom management, (2) the improvement of psychosocial well-being, (3) a multidisciplinary team approach, and (4) patient/family-driven goals. References 1. Rodgers BL. Concept analysis: an evolutionary view. In: Rodgers BL, Knafl KA, eds. Concept Development in Nursing: Foundations, Techniques, and Applications. 2nd ed. Philadelphia, PA: Saunders; 2000:77-102. 2. Monaco J. Acute wound healing: an overview. Clin Plast Surg. 2003;30(1):1-12. 3. Menke NB, Ward KR, Witten TM, Bonchev DG, Diegelman RF. Impaired wound healing. Clin Dermatol. 2007;25:19-25. 4. Maida V, Corbo M, Dolzhykov M, Ennis M, Irani S, Trozzolo L. Wounds in advanced illness: a prevalence and incidence study based on a prospective case series. Int Wound J. 2008;5(2):305-314. 5. Grocott P, Browne N, Cowley S. Quality of life: assessing the impact and benefits of care to patients with fungating wounds. Wounds. 2005;17(1):8-15. 6. Colburn L. Pressure ulcer prevention for the hospice patient. Am J Hosp Care. 1987;4(2):22-26. 7. Rolstad BS, Ovington LG. Principles of wound management. In: Brant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 3rd ed. St Louis, MO: Mosby; 2007:391. 8. World Health Organization. National cancer control programmes: policies and managerial guidelines. Geneva, Switzerland: World Health Organization; 2002. 9. Meghani SH. A concept analysis of palliative care in the United States. J Adv Nurs. 2004;46(2):152-161. 10. Cleary JF. Integrating palliative care into head and neck oncology. Int J Radiat Oncol Biol Phys. 2007;69(2):S83-S85. 11. Ferris FD, Abdullah Al Khateib A, Fromantin I, et al. Palliative wound care: managing chronic wounds across life s continuum: a consensus statement from the international palliative wound care initiative. J Palliat Med. 2007;10(1):37-39. 12. Lishinsky ES. A philosophy of care: pressure sores in hospice patients. Today s OR Nurse. 1988;10(4):20-23. 13. Hoffman R, Lile JL, Mace K, Pase M. Standard of care for hospice patients with pressure ulcers. Decubitus. 1991;4(4):19-24. 14. Chambers N. The holistic management of pressure sores in terminal illness. J Wound Care. 1997;6(8):359-360. 15. Sopata M, Luczak J, Glocwacka A. Managing pressure sores in palliative care. J Wound Care. 1997;6(1):10-11. 16. DeConno F, Ventafridda V, Saita L. Skin problems in advanced and terminal cancer patients. J Pain Symptom Manage. 1991; 6(4):247-256. 17. Walding M, Andrews C. Preventing and managing pressure sores in palliative care. Prof Nurse. 1995;11(1):33-38. 18. Lile JL, Pase M, Hoffman R, Mace K. The Neuman systems model as apply to the terminally ill client with pressure ulcers. Adv Wound Care. 1994;7(4):44-48. 19. McDonald A, Lesage P. Palliatve management of pressure ulcers and malignant wounds in patients with advanced illness. J Palliat Med. 2006;9(2):285-295. 20. Eisenberger A, Zeleznik J. Care planning for pressure ulcers in hospice: the team effect. Palliat Support Care. 2004;2:283-289. 21. Chaplin J. Wound management in palliative care. Nurs Stand. 2004;19(1):39-42. 22. Langemo DK, Anderson J, Hanson D, Hunter S, Thompson P. Managing fungating wounds. Adv Skin Wound Care. 2007; 20(6):312-314. 23. Grocott P. Care of patients with fungating malignant wounds. Nurs Stand. 2006;21(24):57-66. 24. Piggin C. Malodorous fungating wounds: uncertain concepts underlying the management of social isolation. Int J Palliat Nurs. 2003;9:216-221. 25. Reifsnyder J, Magee HS. Development of pressure ulcers in patients receiving home hospice care. Wounds. 2005;17(4). 26. Tippett AW. Wounds as the end of life. Wounds. 2005;17(4):91-98. 27. Langemo DK, Anderson J, Hanson D, Thompson P, Hunter S. Understanding palliative wound care. Nursing. 2007;37(1):65-66.

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