Barbara Dale BSN RN CHHN CWOCN

Quality Home Health Livingston TN

1. Describe the difference in hospice and

palliative care.

2. Discuss symptom management in palliative

care.

3. Identify practical approaches that integrate

basic wound care principles into palliative

care.

“We live in a very particular death-denying society. We isolate both the dying and the old, and it serves a purpose. They are reminders of our own mortality. We should not institutionalize people. We can give families more help with home care and visiting nurses, giving the families and the patients the spiritual, emotional, and financial help in order to facilitate the final care at home” 1972, Dr Elisabeth Kubler-Ross at a U. S. Senate special committee on aging hearing (National Hospice & Palliative Care Organization[NHPCO], n.d., p.1).

Started as a hospice movement in the 19th century, religious orders created hospices that provided care for the sick and dying in London and Ireland.

In recent years, Palliative care has become a large movement, affecting much of the population.

Began as a volunteer-led movement in the United states and has developed into a vital part of the health care system.

The goal is to improve the quality of life for

individuals who are suffering from severe

diseases.

Palliative care offers a diverse array of

assistance and care to the patient.

Palliative care:

provides relief from pain and other distressing

symptoms;

affirms life and regards dying as a normal

process;

intends neither to hasten or postpone death;

integrates the psychological and spiritual aspects

of patient care;

offers a support system to help patients live as

actively as possible until death;

offers a support system to help the family cope during the patients illness and in their own bereavement;

uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;

will enhance quality of life, and may also positively influence the course of illness;

is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

Palliative care can be provided from the time

of diagnosis.

Palliative care can be given simultaneously

with curative treatment.

Both services have foundations in the same

philosophy of reducing the severity of the

symptoms of a sickness or old age.

HOSPICE: The patient has both

• a limited life expectancy (specifically six months or

less);

• and the goals for care are exclusively to achieve and

maintain comfort, regardless of the symptom burden.

PALLIATIVE CARE: The patient has either

• a limited life expectancy (regardless of symptom burden

or goals for care),

• or a significant symptom burden (regardless of

prognosis or goals for care) or goals for care

exclusively to achieve and maintain comfort

(regardless of prognosis or symptom burden).

Division made between these two terms in

the United States

Hospice is a “type” of palliative care for

those who are at the end of their lives.

Image courtesy of

http://www.ersj.org.uk/content/32/3/796.full

Palliative

Care

Graphic by Anne Kinderman, MD; used with permission.

August 2011 Interpreting in Palliative Care 11

1. Symptom management

2. Patient/family goals

the goals of healthcare are "to cure

sometimes, relieve often, and comfort

always." Hemani, 2008.

pain from the wound

odor/smell

amount of drainage

pain from dressing changes

bleeding

appearance of the wound

Itching

Usually listed as last goals as they may be the most

difficult to modify

decreasing wound size

complete healing of the wound

Emmons, 2014

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 pruritis

Emmons, 2014

Explain and document that complete wound healing may not

be a primary outcome 2/2 (list conditions, end stage..,

arterial disease, Ca, etc). The plan of care will focus on

meeting the needs of the patient/family. By providing

excellent care, if physiologically possible, wound healing

may occur.

Ask the patient and family, what is most bothersome about

the wound.

List out of the problems and develop a plan for each issue

Prioritize each issue based on what is the worst and what

can be achieved.

Set realistic goals

Emmons, 2014

Beneficence: do good

Non-maleficence- do no harm

Autonomy-patient‟s right to decide

Justice-fairness

Pressure ulcers,

Skin tears,

Venous and/or arterial leg ulcers,

DFiabetic ulcers,

Fungating/malignant wounds.

Happy wounds are

healing wounds

3 requirements for wound healing

Etiology-what “caused” the wound. Try to

correct or manage the cause.

Systemic- is the pt „able” to heal? Education to

pt to improve healing ability.

Topical- what is done to the wound to make the

wound happy. Happy wounds are healing wounds.

Based on DIPAMOPI.

Determine the cause

Correct or manage the cause

Pressure-support surfaces, turning, etc

Venous stasis-compression

Arterial-vascular consult

Surgical-NA

Diabetic-glucose control, offloading

Atypical-varies, referral to dermatology (?)

Skin tears-improve skin integrity, pad items

Nutrition-protein 1.2-1.5g/kg/d & calories 30cc/kg/d

Perfusion-decrease reducible factors

BMI-appropriate wt/ht

Activity-

Glucose management

Hydration-30cc/kg/d typical

Immune system

Manage co-morbidities

D Debride any non viable tissue

I Infection

P Pack dead space

A Absorb exudate

M Maintain moist environment

O Open closed wound edges

P Protect from trauma

I Insulate

Addressing ALL of these components make for a

happy wound.

Soupy wet or dried out.

Cold (frequent changes)

Lots of necrotic tissue

Infection

Pressure

Moist

Warm

Protected from trauma

Controlled bacteria (bioburden)

Free: http://www.epuap.org/wp-

content/uploads/2012/07/SCALE-Final-

Version-2009.pdf

Statement 9: The probable skin change etiology and

goals of care should be determined. Consider the 5 Ps

for determining appropriate intervention strategies:

Prevention

Prescription (may heal with appropriate treatment)

Preservation (maintenance without deterioration)

Palliation (provide comfort and care)

Preference (patient desires)

Braden

Norton

Hunters Hill (specifically for Palliative Care)

Pressure Ulcers

Although risk can be assessed to develop

individual care plans, all palliative patients are

high risk and should be treated the same. The

three ingredients of a successful prevention

program5 include 1) pressure

relief/redistribution for bed and chair, 2)

pressure relief/redistribution for heels, and 3)

lubricating the skin with aggressive emollient

therapy.(Tippett 2012)

Most bothersome symptoms: Drainage and itching

Itching---lanolin and topical abx can exacerbate eczema and actually

cause itching

Venous Hypertension: Back pressure on the venous system exerted either

from central or pulmonary sources, or from extrinsic compression

syndrome. Example, a mass, tumor or tight girdle.

Venous Insufficiency: An obstruction which blocks outflow, valvular

incompetence, which permits retrograde flow, or muscle pump failure,

resulting in incomplete emptying of the venous system in the lower leg.

Venous Leg Ulcers: Wounds that usually occur on the lower leg in people

with venous insufficiency disease. Venous Leg Ulcers are also known by

such terms as venous stasis ulcer and venous insufficiency. Ulcers result

from chronic venous hypertension caused by the failure of the calf

muscle pump.

CHF- dyspnea

Venous stasis ulcers

Other:

Rheumatoid arthritis

PVD/Arterial wounds/gangrene

Clean – Free of bacterial proliferation eliciting no response from the host.

Contamination – The presence of bacteria on the wound surface without proliferation.

Colonization – Presence and proliferation of bacteria eliciting no response from the host.

Infection – Invasion of bacteria which proliferates and elicits a response from the host e.g.,erythema, pain, warmth, edema, exudates

Bacterial balance describes the bacterial level present in a wound and their ability to cause damage or infection. All chronic wounds contain bacteria. However, the impact of these bacteria on healing is dependent on several factors, including the number of organisms, the virulence of these organisms and host resistance (Sibbald, Woo, & Ayello, 2006).

Bdale@qualityhomehealth.com

Woundostomycontinence.com

WOCN.org

Special shout out to Dr Emmons for

sharing your wisdom and resources!

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