Wound care helps restore patient's self-esteem

Hospice received CHAP commendation

When staff at the Hospice of Chattanooga in Tennesse, provide wound care, they work to help the patient recover a sense of wholeness.

Families sometimes feel that even if their loved one is dying, they want to help heal the wound because it's at least one thing they can accomplish, says Terry A. Melvin, MD, FAAHPM, a fellow of the American Academy of Hospice and Palliative Medicine, and the chief medical officer at the Hospice of Chattanooga.

From the patient's perspective, a healed wound can help the patient feel whole and presentable to visitors, Melvin adds.

Melvin worked with a hospice nurse to develop a standardized wound care program with the goal to heal patients' wounds whenever possible and to improve them when healing isn't possible.

"I looked at all of the different products and came up with something affordable that works for our hospice budget," she says. "In the year and a half we've been doing this, we've had patients die and their wounds had healed."

Healing wounds is less dependent on the patient's physical or nutritional status than it is on the consistency of the care of the wound, Melvin says.

"The theory is that because a patient has low albumin and the nutritional status is poor, then on that basis the wounds won't heal," she explains. "My theory has been that I don't care if your albumin is low; if I have consistent wound care and turning, I can help that wound heal."

One patient told hospice staff that she wanted them to work with her to heal the wound on her abdomen, even if meant she would spend three hours each day doing her own dressing change, Melvin recalls.

"And she did heal," she says. "That was the patient's sense of wholeness: 'I know I'm going to die, but at least I feel whole.'"

Wound care rarely is a top priority in hospice care, but it is one of those services that can make a big impact on a patient and family, partly for emotional reasons.

"When a family member sees a wound or pressure ulcer on their loved one's bottom, and it won't heal, they think they have failed and didn't do a good job," Melvin explains.

The wound care program's main components are selecting the best products to use, identifying at-risk patients, and educating family members.

  • Finding the right products: "We honed in on a debridement agent that worked for us," Melvin says. "It's important to me that everybody is getting a high standard of care."

Melvin's model of care is the answer to this question: "Is this the care that I would want my mother to receive?"

To this end, wound care needs to be standardized, tried, tested, and improved.

"From a home health standpoint, the goal is getting somebody better — that's the standard," she says.

In hospice care, you take that standard, acknowledge that the patient will die, but let the patient know that you will do everything you can for that person until he or she dies, and that includes doing your best to heal his or her wound, Melvin explains.

"We've had patients who died with a stage 3 wound, and they had started off with a stage 4 wound," she says.

"We've had patients with a stage 4 wound, and they died with a stage 4 wound," Melvin adds. "But it was clean and not smelly, and the care that the patient was receiving was something that the patient and caregiver got into, and it was a ritual for them."

  • Identify at-risk patients: Hospice staff need to prepare for tackling a wound care case before the program begins. One way they do this is by identifying which patients may be at risk for wounds and having a special mattress placed in those homes, Melvin says.

"We need to teach the family turning techniques to prevent wounds from occurring," Melvin says.

While the hospice receives the same per diem rate no matter how much money is put into wound care prevention and education, this is a model that will save money in the long run, Melvin notes.

"Prevention saves money, and our supply costs have actually decreased and the cost per patient per day has not increased," Melvin says. "It's more constant because we're ordering all of the same things, and there is a system by which the products are being used."

When the hospice began the program, no one knew if it would prove to be very costly or whether some of the spending could be recouped, Melvin notes.

"But I felt we had to do everything we could to prevent and to improve wound care," she says. "We even sent one of our nurses to school and paid her salary, so we now have two ostomy nurses — that's how important it is."

The ostomy nurses keep the staff updated and educated and assist with nursing skills lab, and they're available for a consultation when a nurse believes a patient is at risk, Melvin adds.

  • Educating the patient and family: Educating patients and family is an important part of the wound care program.

An interdisciplinary team teaches family members about wound care, but only if they're willing to learn, Melvin says.

"There are families who won't clean the wounds, so for those families we increase visits or bring in certified nursing assistants, so we can get the wound to the point where there isn't a need for a daily dressing," Melvin says.

"So when the family sees that you're really working hard with this, they kind of pitch in, knowing that we're doing this for them, and they're doing it for their loved one."

The hospice's wound care program has gained a very favorable reputation in the area, and now there are calls for its support at nursing homes and elsewhere.

"We have two wound care nurses making rounds in the nursing home, in homes, and in the community," Melvin says.

"So are we spending a little bit more attention to it? — Yes," she says.

The worse-case scenario is a hospice admission where the patient has a smelly wound that is painful to change, but after the hospice's wound care, it loses its odor and becomes cleaner, Melvin says.

"You give back some hope to the patient and the family," Melvin says. "We show the patient that we respect him and his body, even though we know we can't heal him of the terminal illness."

It took some time to achieve staff buy-in on the new wound care program, and the staff initially were resistant to change, Melvin says.

"We picked nurses within each of the teams and tried to get them to buy-in," she says. "We educated them on when to use this product, and when a patient had a wound issue, the team would ask the trained nurse or back-up ostomy nurse or me what to do."

Over time, the entire team learned to provide the same quality wound care, and referrals from nursing homes began to increase because of the hospice's reputation in dealing with wounds, Melvin says.

"We have families who say, 'Daddy has metastatic cancer, and his bottom has broken down, and we want your hospice because we know you will do something for his wound,'" Melvin says. "We had a survey from CHAP, and they gave us a commendation as a result of our wound protocol."