Documentation in Palliative Wound Care

Hi, I'm Dr. Windy Cole. I am the director of wound care research at Kent State University College of Podiatric Medicine and I practice in Cleveland, Ohio.  

Palliative wound care is really important and as we have an aging population, I think we're going to really see the increased need for palliative wound care treatment algorithms. So In the traditional wound care model, clinicians are really focused on implementing aggressive therapies that are aimed to achieve complete wound closure or full wound healing. Oftentimes, it means invasive procedures like frequent debridements, frequent dressing changes, and a variety of advanced wound care treatments that might be uncomfortable for our patients. When a patient enters into a palliative wound care pathway, we will take a more holistic approach and really prioritize the well-being and comfort of the patient over wound healing. Now, it's not to say that the wounds won't heal. It just that they might take longer to do so. And we really, in our treatment algorithms, want to emphasize the importance of maintaining dignity, alleviating pain, preventing these complications that could result in patient returning to the hospital or needing surgery. And we really want to minimize the need for hospitalizations because the whole idea of palliative care is to keep the patients in their preferred environment, typically at home, around their loved ones too. So, the ultimate goal of palliative wound care is really to enhance the patient's quality of life and making sure they have a good experience with wound care so it's more supportive in their wound journey during the end stage of their life. 

When clinicians transition patients into a palliative wound care pathway, what is most important to include in the medical record? 

So again, when you're transitioning a patient into palliative care, it's important to document your why. So why is that patient a palliative care patient? And it's best obviously to rely on evidence that's already out there showing patients would probably benefit from palliative care. So, utilizing evidence-based healing probability assessments, there are checklists that are out there that could be a helpful tool to help support the transition from active wound management into a palliative care pathway. And some of these things that should be documented in the chart would be that the wound is over three months and hasn't been on a healing trajectory even after you've done all the supportive appropriate evidence -based clinically indicated treatment for those patients. Documented that the chronic wound patient is non-adherent to wound care therapies or non-concordant and that might not be of their own accord. Maybe they can't make it to the wound care center every week because they are so sick or they have limited function. But documenting that as part of the medical record is really important. Their age and typically advanced age over 85 will contribute to their frail scale and potentially make them a chronic non-healer. Any substance abuse or chemical dependency even smoking over one pack a day even with counseling and their inability or unwillingness to quit should be part of their medical record. Recurrence of wounds or continued breakdown in the skin, again even with a good therapy is important. If the patient is incontinent to feces and/or urine that's important because that's a definite complication to healing. Patients that have unintentional weight loss of greater than 5% in the next 90 days could show that they're having malnutrition issues or failure to thrive. Patient that is unable to ambulate without assistance. Patients that have a non-operational malignancy or that are undergoing chemotherapy or radiation. Refractory osteomyelitis is also a reason why patients might be transitioned to palliative care. Patients that are bed or wheelchair -bound, again non-ambulatory, if they have uncontrolled comorbidities such as diabetes or PAD and they're not a candidate for surgical intervention. if patients have end-stage kidney failure or heart disease or liver disease. Again, that means they might not be able to heal and palliative care might be best for them. And patients with any history of autoimmune disease or they're on high levels of immunomodulating medication that could delay wound healing is also one of the indications for palliative care.  

So, making sure that we capture all of this as part of the medical record, again, you're “why.” Why are you transitioning these patients into palliative care? Why do you feel that they're a good palliative care candidate is really important. 

What additional clinical considerations should be kept in mind for documentation in the medical record? 

So, as we mentioned, even though our ultimate goal of palliative care is not complete wound closure, the wounds may close, and we want to obviously provide good wound care in order to support wound healing that just may take us a little bit longer, and our primary goals in palliative care, again, are to support the patients from returning to acute hospitalizations, need for nursing home or high levels of nursing care. So, we should always document our standard wound assessments. We should continue to include wound photos and wound measurements, debridements as appropriate and as the patient can tolerate, is really important. The wound tissue quality, the periwound tissue quality, any signs and symptoms of infection or increased bioburden are also really important to note.