Palliative Wound Care Case #8: A Patient with Paraplegia and a Stage IV Coccyx Pressure Ulcer
A 68-year-old male paraplegic patient develops a wound in the sacral area while recuperating from other medical problems in a skilled nursing facility. This wound in the sacral area is a deep tissue injury. At the time of the initial visit, the wound is classified as unable to stage but is expected to be a Stage 4 pressure injury which it ultimately develops into. After discussion of the case with his primary care physician, the plan developed included:
1. alginate in the sacral wound daily
2. weekly visits to the wound center
3. plan for probable NPWT in the near future
4. protein by mouth as much as possible
5. pressure redistribution mattress
6. no further workup for infection warranted at this time as there is no evidence of infection noted
7. cannot be in a wheelchair except for meals, and then only for a limited time
8. side to side in bed, not directly on his back, on a schedule that is appropriate for patient satisfaction.
Initial presentation from the nursing home. There is still non-viable tissue in this coccyx wound that will need to be debrided. Eventually, we use negative pressure wound therapy for this wound.
After two months with the use of negative pressure wound therapy, we discussed the option with the patient of whether to proceed forward with a plastic surgeon. I told him that we would eventually be able to get his wound healed up in the lower lumbar sacral area but it would take another few months. I explained to him that a plastic surgeon would require him to spend time completely offloaded on a specialty bed in a rehabilitation center for an extended time period. After weighing his options, he prefers to take a palliative route and we can monitor this over time, constantly informing him of our progress.
Palliative Discussion Points
1. We provide patients with information to make choices. In this case, the patient chose to continue with current care involving negative pressure wound therapy and dressing changes three times a week over possible faster cure from a surgical procedure.
2. In our experience, most patients that have undergone surgeries to repair complicated lower back pressure ulcers (a common event in patients with paraplegia, for example), choose not to have a similar procedure ever repeated again. The reasons are mostly psychosocial: placed on a bed that immobilizes them, sent to a location away from their usual social resources, and often with outcomes that even after those hardships, fail or with continued consequences (hospitalizations for repairs, infections, continued restrictions involving offloading of the wound).
3. With every subsequent visit, we review whether a patient wants to reconsider a surgical approach to cure. In palliative care, reviewing choices with patients is one of the more important cornerstones. As with the surgical approach, neither can we accurately guess healing rates of deep wounds with this extent of injury, especially when the care of the patient is dependent on multiple caretakers whose experience cannot be vouched for nor whose diligence in care can be monitored.
4. In the management of this patient, we were fortunate that the patient could make his own decision. In many cases, the clinicians are making choices with the family involved. Given the medical-legal aspects of wound care (and specifically with the care of pressure injuries), choices of care are often made without further regard to what the patient will need to endure; rather, decisions are made that are in favor of protecting against a malpractice claim (the physician) or guilt (the family or friends).
5. As in many cases, this pressure injury developed somewhere along the path of his transition from the home to the skilled nursing facility. Attention to the care of at-risk patients is key to prevention and progression of disease.
© 2016 Scott Matthew Bolhack MD, MBA, CWS, CMD, FACP, FAAP