Langemo Diane
University of North Dakota College of Nursing, Grand Forks, ND 58202-9205, USA.
Ostomy Wound Manage. 2012 May;58(5):24-6, 28, 30 passim.
The incidence and prevalence of wounds in persons at the end of life is largely unknown, but wounds are estimated to occur in at least one third of hospice patients. At the end of life, healthcare professionals must help the patient and/ or family decide whether the goals of wound prevention and care should focus on healing or palliation. At all times, it is important to consider that a palliative approach does not negate the potential for wound improvement or even closing before death. A review of the literature suggests that, in general, few differences exist between the general principles of wound prevention and care and an optimal palliative care plan. For example, maintenance of a moist wound environment is recommended to facilitate healing in general protocols of care. In end-of-life patients, dressings should be used for general comfort and prevention of skin exposure to wound exudate and to reduce the number of potentially painful dressing changes. Risk factors for tissue breakdown and pressure ulcer development are also similar. Palliative care patients with limited mobility and physical activity are at highest risk for developing pressure ulcers, but measures to help prevent these wounds may have to be adjusted to meet the overall goals of palliative care for a particular patient. Wounds encountered mainly in cancer patients - eg, fungating and radiation wounds - can pose important challenges for healthcare professionals and are very stressful for the patient. Pressure ulcers, fungating, and radiation wounds at the end of life are to be managed palliatively with the overall goal to minimize pain and odor, enhance comfort, and potentially improve the condition of the ulcer. Although research remains limited, it is clear the clinician and patient must balance best wound prevention and management practices while promoting patient dignity, self-esteem, and quality of life.
临终患者伤口的发病率和患病率很大程度上未知，但据估计至少三分之一的临终关怀患者会出现伤口。在临终阶段，医护人员必须帮助患者和/或家属决定伤口预防和护理的目标应侧重于愈合还是姑息治疗。在任何时候，都要考虑到姑息治疗方法并不排除伤口在患者死亡前改善甚至愈合的可能性。文献综述表明，一般而言，伤口预防和护理的一般原则与最佳姑息治疗计划之间几乎没有差异。例如，在一般护理方案中，建议维持伤口湿润环境以促进愈合。对于临终患者，使用敷料是为了让患者感觉舒适，防止皮肤接触伤口渗出液，并减少可能引起疼痛的换药次数。组织破损和压疮形成的风险因素也相似。活动能力和身体活动受限的姑息治疗患者发生压疮的风险最高，但帮助预防这些伤口的措施可能需要调整，以满足特定患者姑息治疗的总体目标。主要在癌症患者中出现的伤口，如溃疡型伤口和放射性伤口，会给医护人员带来重大挑战，也会给患者带来很大压力。临终时的压疮、溃疡型伤口和放射性伤口应采取姑息治疗，总体目标是尽量减轻疼痛和异味，提高舒适度，并可能改善溃疡状况。尽管研究仍然有限，但很明显临床医生和患者必须在促进患者尊严、自尊和生活质量的同时，平衡最佳的伤口预防和管理措施。
