Providing Quality Wound Care at the End of Life

Marilyn L. Graves, MSN, RN, CHPN, CWOCN; Virginia Sun, PhD, RN


Journal of Hospice and Palliative Nursing. 2013;15(2):66-74. 

In This Article

Case Scenario

Mrs C is a 77-year-old woman who underwent a left leg arterial bypass graft that became infected postoperatively. The developed infection worsened distally and ultimately required an above-the-knee amputation. The infection did not respond to intravenous antibiotics, and further treatments were also unsuccessful. Mrs C subsequently developed necrotizing fasciitis, and the decision was made to seek hospice care with the goal of comfort at home.

Mrs C presented to hospice on admission with comorbidities of diabetes mellitus, chronic kidney disease, peripheral vascular disease, gastroesophageal reflux disease, and history of cardiovascular accident. Her wounds were dehisced and purulent with exposed bone at the site of the above-the-knee amputation, with likely osteomyelitis. Infection was spreading up the leg to the groin, where there was another open wound site. Her Palliative Performance Scale on admission was 20%. Pain management was the primary goal of care. This was managed with Dilaudid 2 mg every 2 hours as needed and Neurontin 300 mg in the morning and 600 mg at bedtime. Wound exudate and odor were managed with Silvasorb, Dakin solution, abdominal pads, and Kling gauze. Providing emotional support was another important component of the plan of care. Mrs C was visited by the home care hospice nurse and the hospice aide daily for dressing changes and pain management. Three weeks after admission, the wound exudate was decreasing; thus, the plan was changed to xeroform dressing for more comfortable dressing changes. At that time, her Palliative Performance Scale was determined to be 40%. Six weeks after admission, granulation tissue is visible, exudate decreased, and necrotic tissue is beginning to slough. A consult was made to the medical center wound clinic for possible surgical debridement. Seven weeks after admission, Mrs C was discharged from hospice for surgical debridement and closure of the wound at the medical center wound clinic. Mrs C was ultimately fitted for a prosthesis and was ambulatory 3 months later.