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Apr 4, 2016

Documentation for the Patient with Palliative Wounds

Documentation that reflects discussions with patients and their families can be invaluable in the understanding, education, and defense of patients that are failing with continued skin changes at the end of life, including those patients with pressure ulcers. In your absence as the clinician or wound expert, the staff will refer to the chart and review your notes with the family. Communication that is concise can lead patients and families to ask additional questions and be part of the process.

Here are several phrasings to consider when discussing and documenting the care of wounds in patients that are following a palliative approach to their care. Of course, these descriptions only apply to patients in which they apply.

1. Complete wound closure is not a realistic goal in this patient because…

2. The wound can be managed for drainage and odor, but complete healing is not expected.

3. Along with the wound, the patient has a slowly progressive or irreversible medical condition(s)

4. The patient has other active medical problems for which the treatments make it difficult to treat the wound for cure.

5. Patient has an end-stage or terminal condition; or the patient is on hospice and the treatment for the wound would require too much discomfort to the patient.

6. The wound developed in the face of additional medical problems with the acknowledgement that the individual is progressing towards death.

7. Despite multiple interventions which are documented in the record, repositioning the patient is uncomfortable for the patient and they have continually redirected the staff to leave them alone.

8. Attempts with advanced dressings and/or treatments [add particular dressing or therapy: alginates, collagen, negative pressure wound therapy, etc.], the wound has not healed.

9. Patient has been losing weight and or not eating well despite appropriate nutritional interventions, which is not favorable for healing the wounds.

10. The treatment plan is focused now on comfort measures which include minimizing pain related to the care of the wound

11. The presence of deep tissue injuries, as with Stage 3 or 4 pressure ulcers, in combination with significant active comorbidities and medical instability (for example, systemic infection), may indicate general instability, decline, or a terminal episode.

12. Advanced directives by patient or substitute decision-maker to forego artificial nutrition and hydration can further challenge the ability to heal wounds.

13. Repeated hospitalizations or ER visits during the past six months indicates overall decline and instability.

14. The patient has tested for low protein stores for several determinations despite attention to increasing protein in the diet; without adequate protein, the ability to heal wounds is difficult.

I want to thank Karen-Lou Kennedy-Evans, RN, FNP, APRN-BC for her contribution for this list of suggestions. For more information about Ms. Kennedy please refer to www.kennedyterminalulcer.com.