(P09) Palliative Care for a Resident with Chronic Wound

Introduction: Managing residents with chronic wounds presents significant challenges. Managing these challenges is crucial for residents, caregivers, nursing staff, and providers. This case involves a nursing home resident with a chronic, non-healing arterial wound, necessitating an interdisciplinary approach that incorporated palliative care.

Case Description : A 78-year-old male with a history of stroke, Type 2 Diabetes and Peripheral Artery Disease was admitted to a skilled nursing facility with a chronic left foot wound. On admission, the wound measured 3x3x0.1 cm on the plantar foot with 100% dark eschar on the 4th and 5th toes. By three weeks, the wound expanded to cover the entire plantar foot, heel, and the 2nd, 3rd, 4th, and 5th toes, with 100% necrotic tissue. With his severe arterial disease, Vascular specialists recommended a below -knee amputation (BKA) as the only viable option. The resident made care decisions with input from his family. He opted not to pursue amputation and expressed his wishes to receive active management for his wound.
The resident and family had frequent discussions with the providers, including the wound care nurse practitioner and the vascular surgery providers. At this time, the resident agreed to talk with a palliative care provider. With the palliative care input, the resident elected symptom management and supportive care, as below knee amputation did not align with his life goals. He and his family acknowledged the risk of sepsis and death from the worsening wound. He stayed in the nursing facility, receiving wound care and symptom management. The clinical team at the nursing facility and the palliative service supported his wishes and goals of care decisions. The resident and his family appreciated the palliative care support that made the care decisions less challenging.

Discussion: Wounds in residents with underlying vascular disease may deteriorate to a level where amputation may be life-saving. Amputation is not an easy decision. Sometimes, amputation may not align with the resident’s values. For this resident, the care team approached palliative care to elucidate the goals of care.
The timely introduction of palliative care helped this resident identify realistic goals. Palliative care can support the resident in decision-making, provide emotional support to the resident and family, and improve the resident's quality of life. Palliative wound care is an approach that prioritizes comfort over wound healing, with interventions focusing on the management of symptoms such as pain, odor, bleeding, and exudate. The wound care nurse practitioner at the facility felt supported by the palliative care input in managing the wound. Palliative care was a significant aspect of this resident's care, highlighting the importance of a multidisciplinary approach in skilled nursing facilities.