We are back continuing on the prickly conversations, this time about unhealable wounds. How is the ability to heal determined, and how do clinicians’ factor in a wounded persons goals and priorities, sometimes when there’s conflict with health care recommendations? We discuss if palliative wounds are the same as an unhealable wound and a range of ethical considerations when caring for people with these wounds. These wound types need to be discussed more, we hope you find the content relevant and stimulating for your clinical practice.

Timestamps:

00:00 Introduction

00:37 A big thank you to our audience for connecting

0:37 A big thank you to our audience for connecting

02:53 Love the feedback

03:20 How do the different professions and expertise determine what is unhealable

04:24 When an unhealable is in fact healable

05:24 How is a wound determined as unhealable

06:14 It’s not always about the healability but quality of life and symptom management

07:29 When a person is given evidence-based comprehensive information wounds can be healable

07:42 Once fully informed, despite being potentially healable, people may have different goals and priorities

08:27 Wrong information risks wrong decisions

08:35 Lack of knowledge and skills defaulting to unhealability and a “palliative” wound

08:54 What is a “palliative” wound

12:26 The unethical systemic barriers that result in unhealable wounds

13:16 Is a wound “palliative” when someone is transitioning to end-of-life care

14:23 Dying a dignified death without a wound

14:54 Medical professionals more likely to label a wound as unhealable

16:06 Lack of evidence-based wound diagnostics resulting in a wound being assessed as unhealable

16:17 Many wounds need to be biopsied

16:49 Everything is called a venous leg ulcer due to lack of diagnostics

17:29 Skin failure and the Kennedy Terminal Ulcer. Trombley-Brennan Terminal Tissue Injury

18:14 Barriers to identifying and documenting Kennedy Terminal Ulcer versus skin failure versus pressure injury at end-of-life

19:41 An evidence-based approach to determining if a pressure injury on the foot is unhealable

21:38 Questions to ask to assess if a wound is unhealable

22:44 Why are wound consultants not needed when a wound is unhealable?

22:52 Conversations around healability, capacity and dignity of risk

24:35 Healing not always an endpoint especially when linked to unrealistic claims

26:36 Healing plan vs maintenance vs palliation plan

28:42 The role of hygiene and mobility in the unhealable wound

28:54 Impacts of intersectionality and labelling a wound as non-healable

32:23 Clinical callout regarding unhealable wounds

33:15 Agency and the unhealable and healable wound

35:09 Well-being and wounds

39:04 Ethics of labelling a wound “unhealable” and moral injury

Resources mentioned:

• Kennedy Terminal Ulcer (KTU) and Trombley-Brennan Terminal Tissue Injury (TB-TTI) https://www.caresearch.com.au/Health-Professionals/Nurses/Clinical-Care/Symptom-Management/Skin-Failure-and-Pressure-Injuries
• International Consensus Optimising Wellbeing in people living with a wound https://woundsinternational.com/consensus-documents/international-consensus-optimising-wellbeing-in-people-living-with-a-wound/

If you enjoyed this episode please like, subscribe, leave a comment or share with your colleagues.

Connect with us at:

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Disclaimer:

The views expressed in this podcast are our own. This podcast is intended specifically for healthcare professionals. Always follow your organisation's policies and procedures. Please consult your own healthcare provider for individual wound advice.

Welcome to the 2A Kidney podcast.

You're with Mon and Don, two advanced.

Practice nurses with decades of experience in hard to heal wounds burrowing into prickly conversations.

Well, welcome back to the 2Echidnate Wound podcast.

This is Donna Nyar and I'm with Monica Samalik.

And we're really pleased to be back bringing you more prickly topics as we unpack.

Contemporary wound care, wound management, and all those periphery topics as well.

We wanted to kick off this first part of the episode by just actually acknowledging everyone who's listening.

We have received so much feedback.

We are so, so encouraged, aren't we?

Yeah.

And we wanted to just say thank you because it's been, you know, we're seven episodes in, this is episode eight.

And, you know, not only the emails and the DMs, but also the people that have come up to us who know us and don't know us.

I think I have a combination of both who have just said I'm really loving the podcast and I really can't wait for more.

And also there's been some really great clinical questions.

We can't obviously get to all of them, but it's important too.

We just want to acknowledge that we know so far we've just skimmed over the top of a lot of topics and if it's been prickly, if you've had questions, we feel as though that's we're hitting the right spot.

Yeah, not quite mission accomplished.

But that's exactly what we want to happen.

We want people to be able question and you before Monica have said be, you know, confident, to be unconfident.

And it's about that learning journey.

So thank you very much to everyone who's done that.

Please don't stop asking us questions.

We will take deeper dives into a lot of that and your feedback helps us do that.

So we're hitting the right mark.

Did you want to add anything further?

No, I think I've been, I've been surprised at the people who've approached me and given me feedback in some very random places.

And we've just recently been to a, a workshop conference where people were coming up to me and providing, well, of course, face to face, they're going to provide us with positive feedback.

We've had some other feedback that has been really good.

It's been constructive and we'll be working with that.

Yeah, it's been strange.

And I mean, you've got more of a profile on social media than I do and I've got to work on that.

So people don't really recognise me.

And it's often, you know, they approach you and you go, here's mom as well.

Absolutely.

But it's been great to meet new people as well.

I really, really loved that.

Reaching out and reaching new people who might not have been around that womb space.

It's really, really, really great.

So, yeah, we love it.

So please don't hold back and come and say hi to us.

Yes.

And certainly reach out.

We're contactable.

So what are we going to do for this episode eight?

Well, I'm looking at my list, our growing list.

Yeah.

Because it's been a long time between drinks, really recording the first series of podcasts to now and we've created quite a long list.

And so we're deciding this morning, what are we going to do?

And we've decided, I think we talk about the unhealable wound and what is an unhealable wound?

They've tried to define it in the pressure injury specialty or domain.

But when I think about it, and I'll stop in a moment, but when I think about it, I think each one of us, if we're asked, what do you believe to be an unhandleable wound, we'll have very different questions.

And if you are a novice clinician, if you're, for example, a novice nurse or a nurse practitioner, your answers may be very different to a GP or a vascular surgeon.

So I think it.

I think this will give us an.

Opportunity to unpack it, Take some of that out.

Yeah, yeah.

So what are your thoughts?

Well, look, the first thing I'll tell you what first, first comes to my mind is, and certainly in private practice, and as you know, I go into a lot of sectors, is one thing that people come to me quite often and say is actually, I've had it on a lot of my socials as well.

Oh, you're not required.

I. E. You don't need a wound consultation because your wound's not healable or their wounds not healable.

Now, I think sometimes that makes me sad.

Firstly, yeah.

Because they still may be having wound concerns, wound issues.

And it could be as simple as odor, smell, pain, exudate infections, the inability to go out down to the shops and have a coffee with a friend because they can't leave the house, you know, those type of things.

But also who's decided first that it's not healable and it just.

I just think it takes away from the additional things that we can help with.

It just minimizes those.

When in actual fact Sometimes we'll just go in and fix those things up even in healable wounds and the wound will go on to heal.

So I just think that statement is.

Yeah, it just makes me sad in the first, in the first instance.

But the often there's a background kind of.

And I, maybe I'm reading into it or you're not required because it's not healable when that, when someone, it could be that they're getting to the end of life, but not always.

It's just.

And we'll talk about, talk about what.

Is a palliative wound.

Yeah, absolutely.

Okay.

It just seems to cause people what I observe, even in notes, when I'm reading notes, enjoying it, assessments, people, maybe this is a bit critical, seem to take a step back and say, well, that wound isn't important anymore.

Now I know the wound is not always the most important thing and it shouldn't be the most important thing, but where there's complications from it, we can do things.

So it is not the most important thing at the most important times of people's lives.

And I just find sometimes not everyone, I think clinicians set out to do the right thing.

I find it's treated as a bit of a cop out.

Someone still may have years left and there's things that we can do.

So that's the first thing that I think of.

And then as you've said, the changes that happen in someone's skin or causing wounds or it might be around an arterial aetiology, arterial cause where they're making active decisions and we may not be able to heal that wound and.

Yeah, how does that look and how does that affect their life?

Because that can be absolutely devastating.

Yeah, look, as you're talking, I'm thinking there are scenarios where the wound is healable.

We've provided the person with the wound truly given them a lot of information in the manner that they ideally receive the information.

You know, we've even done that, we've done that holistic assessment about how they receive information and process it.

Process it.

So they've got a healable wound.

You've given them a fully informed choice.

And that's another thing.

Fully informed choice and wound measurement another topic.

But fully informed choice.

And they decide.

No, I understand what you're saying, but.

But I've got different goals, different priorities.

There's that.

Then there's what I think happens a lot, where the person's wound is labeled as unhealable when in fact it is.

And then we're giving them, yes, the wrong information.

And then they're making the wrong decision.

And then there's, as you were saying, this hopelessness, helplessness, where.

And I think often it's.

People don't know what to do.

They put their hands up and they say that's an unhealable wound.

And then they talk about they'll often label it as a palliative wound.

And I remember now, when was this?

This is actually quite a funny story.

And I actually raised the topic of, in that forum where I found it really confronting when people would term a wound palliative.

When really the human being undergoes a palliative process or, you know, palliative pathway, but not the wound.

What makes the wound palliative?

Yeah, even a fungating lesion is not necessarily going to be what causes their death.

Yeah.

And you can often debulk these tumours.

But I remember the hymn saying at the time that even after a person dies, because what I was talking of people when they're going through that palliative process, that their wounds still heal.

And they do.

We know that.

So when is a, you know.

Yeah, that is so true.

This is what I did.

I'm not joking.

Yeah.

So I'm on the edge of my chair here just because I've not heard this story and that's really unusual.

So I don't know what's coming out next.

Well, then I started, you know, doing a literature search and I really couldn't find whether hair still grows on the skin after someone dies.

And I remember him saying something like 12, 24 hours post.

So here I am at a Christmas.

Party because you have to know.

And this guy happened to be a funeral director.

Great.

Like manna from heaven.

And I asked him and he looks at me.

No, no.

Well, he hadn't experienced it.

So I don't look whether the skin.

So this is more about, you know, even though we think the body's dying, where's the skin at?

And I have looked after people with end stage disease who had their wounds healed and then other people.

Like we were discussing a case today where that person should be healing and they're not, you know, and so you can see why people may label that person's wound as unhealable.

But yeah, that's a dirty little secret of mine.

No, that's fantastic.

It Makes me think of all the people that you've said that, that I've had along the way, who with battle, struggle, whatever you want to call it, pulled out all the stops for maybe a year or two in a variety of sectors, and we've actually managed to heal, or almost heal their wound, which is.

And everyone's just including the patient has been absolutely wrapped in the family, all the involved clinicians, there's all big teams around people, and everyone's just, oh, that's just amazing.

And then unexpectedly, unexpectedly, they pass away within a really short amount of time, completely unrelated to the wound.

But I've had that happen a lot.

Often those are wounds that people have said are not healable.

Yeah.

And I struggle with that when.

And again, we were talking earlier today in preparation for this.

I have wounds with people in the team who don't really have the experience, expertise, have said, but that wound's not healable.

Or do you really think it's healable, Donna?

Oh, yes.

And I know it is because I've seen it get better.

And where the.

I think there's barriers to wound healing that are about, you might call them endogenous, that are about the person with the wound, but there's also those periphery, you know, exogenous barriers to wound healing.

And when you've got systems or finances, people that are working against you, and that's really complicated reasons why.

Systemic issues.

Systemic issues, yeah, that's a great term.

When they're the barriers to stop a wound healing, I really, ethically find that really challenging.

Yeah.

We just accept that it's not healable and it's really hard to get everyone on the same page working towards that wound healing.

But, you know, then we haven't talked about the wounds where, as you say, the person is palliative and they clearly are on a dying trajectory.

Maybe not quite terminal phase, but, you know, clearly getting close to that.

Yeah.

I would rarely call them palliative wounds.

The wound is not palliative.

Yeah, but that word is still dallied around.

I think, even at a recent conference we went to, the subject was palliative wounds, wasn't it?

We talked a lot about.

It was palliative wounds.

Yes, palliative wounds.

And yet the topic was more about the skin changes over the lifespan, which.

I felt quite appeased by because I was thinking, what the hell are we going to talk about palliative wounds?

Like, what is a palliative wound?

And we didn't talk at all about fungating lesions, cancerous wounds, or managing those Wounds that are associated with the disease process that's going to end their life.

We can talk about those wounds and.

Does this happen to you?

I'm sure it has.

I think this is a loaded question where family come up to you and say, you know, mum has had these wounds for all these years and we're really happy that she died without a wound.

Oh, yes, that's.

Do you know?

Yes.

And you just get so frustrated.

You think, how many other people are being labelled as having an unhealable wound?

You know, and then also.

That's a really big thing.

Yeah, that is a really big thing.

Prickly topic.

The number of times medical professionals label a wound unhealable, I think is disproportionately high compared to some of the other professions.

Yes, yes.

Actually.

And I think we've touched on a previous podcast.

We were talking about the assumptions we make, as amongst our clinical colleagues, about the wound management, the level of.

And the amount of wound management they've had in their undergraduate education.

So I think what we come out is a group of people, professionals, who, through just ignorance, don't know what to do.

They'll do some with a little care, flex and then say, this wound's unhealable.

Is it that they don't know what to do?

That's really challenging.

Are we seeing more of them now than we used to?

I don't know.

That would be very hard to quantify.

I don't know.

But also, are they unhealable because they.

Haven't been taught or.

I mean, again, I think we're going to talk about how to biopsy at a subsequent podcast, but they don't run the proper diagnostics on these wounds and they invariably need biopsy.

And that in itself, getting a GP to biopsy and I, you know, that's one thing I envy of nurse practitioners.

Practitioners.

If you can biopsy, good on you, because that is a skill that's really not being used enough.

I think it would nearly be.

We were talking about this before.

More important to be able to biopsy a wound than to prescribe medications.

Yeah, yeah, yeah.

I would have more of a barrier of that in my practice.

Yeah, yeah.

So we don't run the proper diagnostics or we, you know, the healthcare generalising.

Yeah.

In healthcare, we don't run the proper diagnostics, the proper investigations and, you know, I'll say it again, we call everything a venous leg ulcer.

Took the words right out of my mouth.

Yeah.

And yet how do we know?

How do we know when it's still not healing and you've got that therapeutic compression on and you've addressed all other factors and yet it still is not behaving like a venous sleep ulcer.

Yeah.

So there's them.

I.

The recent summer school that we went to, it was really good to talk about skin failure and acknowledging, Acknowledging Carolyn Carvel here, that there's still a lot we don't know about how the skin.

Skin behaves.

And there's.

It's really good to hear about Kennedy terminal ulcer.

Trembroli Brennan.

Yes.

That was a really good presentation.

Yeah, I've actually, I've looked that up before.

I've known about that, but I've not heard it talked about in presentations before.

So I'm just wondering if it's worth, even in our show notes, putting a bit of a link to a couple of those things.

Things.

I. I do find that I've had a lot of people who will meet me at the door, say, in aged care facilities and say, look, they are palliative, they're on a trajectory and they've just got a wound.

I think it's a Kennedy terminal ulcer, and I don't think it necessarily is, but is it acceptable?

So I'm kind of changing the topic here.

Is it acceptable that someone gets a pressure injury or what looks to be a pressure injury close to the end of life?

And how do we delineate that?

Kennedy terminal ulcer versus skin failure versus pressure injury, when facilities have got to document what that wound is and there's often not someone there at that particular time, you know, I might not be able to get there for a week or two.

And you can't make a judgment based on a photograph.

Yes.

I think Carolyn's presentation made me really more confident to be unconfident.

Yeah.

And then I had a sort of.

Particularly with my background in critical care, I just think, because I remember hearing about the Kennedy ulcer first off, and I'm thinking, oh, I saw that so many times in critical care.

Have you?

Yeah, See, I would say I've not seen.

Seen one.

Oh, yeah, that's good.

But.

And I suppose people working predominantly in aged care would as well.

The other thing is, I think you've touched on what I was going to segue into anyway around pressure injury and skin failure and those skin changes end of life.

And I think after I've worked, done a bit of work in that vascular space.

So when I mean the word vascular, I mean arteries and veins.

Yes.

It's quickly come apparent to me that if we could perform an arterial duplex on every.

This is on every person in aged care, I think we quickly uncover all those people who are at risk of having an unhealable.

Yes.

Pressure injury on the heel.

On the heel.

Malleoli.

Yes.

Oh, on the foot.

On the foot, Yep.

On the foot, period.

Yep.

And.

And now I say to people, even though you think that person, they have a pressure injury, they may be close to end of life, you may still have to have an arterial duplex of their legs because all of a sudden it'll become very evident to everyone, good, documented evidence that that person is not going to heal.

They've got their three major vessels supplying their leg that are blocked.

You ain't going to heal that wound.

And I've been in a situation where a family was potentially litigious and that activity was completely stopped the moment we proved that that wound was unhealable from the outset.

Oh, brilliant.

So as a takeaway.

So I'm just thinking, as we're talking about all this as well, what is a good tip then?

If someone is saying it could be in any of those unhealable circumstances, is it reasonable to ask why do you believe so?

Or why is it not?

If we're saying something's unhealable, wouldn't that be reasonable to document the reasons why or ask them, can you tell me why?

Not to question their judgment.

But we should be able to understand that.

A healthy curiosity.

I think that's.

Yeah.

So that would be my first takeaway.

Ask.

Ask why.

That's good.

I reckon that's really good, Donna, because it puts the accountability on the person who's labeling that wound unhealable.

And I mean, we've gone down that path of pressure injury, but we really haven't done that with other wounds or not.

We.

I'm talking about the global community.

Yes.

Yes.

And I'm just thinking about those times people come to me and say, you're not needed, it's not healable.

That's actually something I can ask people.

So I'm kind of telling myself too well, why do you feel that?

And why aren't we not.

Why are we not needed?

Just because it's not healable.

Because they think it might not be healable.

Don't you get so frustrated?

I mean, and also, I mean the other.

The opposite of that is when I find often in my quest to make sure the person with the wound and the important people in their lives are fully informed and sometimes.

Or not sometimes, often it gets misunderstood as I want to heal the wound and I'm finding, I'm saying no, all I'm doing is providing you the platter of choice.

And again, even now, informed choices, theories that maybe you don't provide as much information.

Again, you know, trying to assess how much information you really give people.

But I just have to make a judgment call at the time.

Yep, yep.

But for me, it's.

Here are the choices.

I'm not saying we go on to try and heal your wound, but if you want to give it the best shot, these are your options.

And you may not be able to afford these options.

Well, that's it.

That's off the table.

Or you can't travel that distance to get that diagnostic.

Well, then that's off the table.

Or maybe that doesn't suit your lifestyle.

Yeah, no problem.

Or if you're so much in pain, forget about your wound.

Let's sort out.

Cause you could have pain for a whole lot of other reasons.

Let's work with that first before we start deciding whether your wound is healable or not.

Like, just as we're talking, I'm now realizing what skills I use to determine whether a wound's healable or not.

But definitely people will think, I think because of.

Yeah, I think people think, oh, that's Monica trying to heal.

No, And I actually don't like the word.

A lot of people will.

Maybe it's just in advertising, but even, you know, we want to heal the wound.

We'll get you in to see if you can heal it.

I'm actually often not interested in healing as an end point because there are so many more things that come first.

I've got in.

Reminds me of.

I've got an image of two dressings in PowerPoints that I run in education where I talk about, you know, is this healable or not?

Before you start to choose dressings and, you know, put interventions in place because that's a really big question that should be asked early on.

And I put two dressings up.

Not advertising dressings.

It's not even a dressing talk.

But they're two dressings that are currently available in the.

In another country.

So which is good for me running education because people understand it.

But one of them is.

Is titled ulcer healing Cream.

And the other one's titled something very similar.

The name of it escapes me now, but like, you know, healing something or other.

But there's the word you healing is in the name now.

I think our governance is much tighter in Australia and I'm really Glad we don't have products like that.

But I use that as an educational tool.

I put up those photos of these products and I make it very clear these are not available in Australia.

And that's a good thing because if you were wanting to heal something and you didn't know that a wound, you know, that your wound wasn't able to be healed for whatever, that's not one of those endogenous reasons.

You're still going to want to go and purchase that product because it's labeled ulcer healing cream.

The actual name of it is also healing cream.

I just find that abhorrent.

It's so I'd like to get my hands on that.

Misleading.

Oh, I'll share it with you, absolutely.

You could probably Google it, but I won't put a copy of it in the show notes.

Yeah, look up ulcer healing cream.

I sometimes wonder too whether you have.

A.

Healing plan, a maintenance plan or a palliation plan.

And when I talk about, and when I talk about palliation, I'm not talking about the wound again, I'm talking about the whole person.

But the difference between say, a healing plan and a maintenance plan for some people is there's not much difference because you still have to manage the exudate, you still need to debride to stop the pain.

You still need to compress.

But often the difference though then is they might be in more pain.

If you maybe decrease the frequency of that or change the product to a more inferior product or a cheaper or simpler, they then get pain.

So I've just last week I had a conversation with a team saying, okay, absolutely and fully understandable that the care plan had changed because the person's circumstances had changed.

But just be mindful that you'll be providing more pain relief.

And that could very quickly tip into palliating that person for other reasons, not because of the pain relief.

But yeah, so, oh boy, I'm really.

Glad you've said that word maintenance, because that was actually on the tip of my tongue to bring up next, you know, how do we label those wounds?

Because I, I will.

My practice is I will use the word maintenance even when I'm discussing, you know, are we getting to a point where we're deciding it's not healable?

Perhaps we set up a maintenance plan.

I find that word is generally understood reasonably well, or that's the first feedback that I get.

But I will document, you know, the maintenance plan.

And we're, and we're actively preventing the things.

But yeah, I now that You've said that the, the regimes are exceptionally similar to an active plan, focused largely on comfort.

Yeah, and.

And choice and lifestyle.

I just say hygiene too, and mobility.

I think hygiene is one where we don't give enough credit to how much comfort it can give people.

But yeah, and I just remembered we were talking about it before we started this, about the impacts of intersectionality on determining whether a wound is healable or not.

Remember that prickly conversation?

Yes.

And so intersectionality for those people who may not be so familiar with the term is when we look at people through.

All through a series of biases and filters and stereotypes.

So you could be racist or ageist, but when, when you start looking at people who.

Of a different skin color to you, different age group to you, identify as a different gender.

Minority groups, minority groups, people with disability.

How often are those people labelled with having an unhealable wound?

Could I go so far as to.

We haven't said this word yet, which is unusual in our podcast.

How many of those people would be more likely also to be labelled non compliant?

Oh, we haven't had a podcast on that yet.

No, we will have a podcast on that language.

I've got a number of social clips on it.

So.

But I find, yes, those minority groups, they're generally the people who are more likely to be labelled.

It's not even a minority group now.

It's people of different sizes and we just, you know.

Yeah.

Oh, boy, that would be a great PhD study the outcomes of people who fit into those groups.

I know from a size inclusive or weight neutral framework.

I've got more about those paradigms on my website.

There's a lot of intersectionality in those spaces as well.

So people with darker skin color, LGBTQI groups and a lot of others are generally more involved in size and weight discrimination and those type of phobias.

So that's a massive area.

So the definition of intersectionality from www.vic.govau refers to the ways in which different aspects of a person's identity can expose them to overlapping forms of discrimination and marginalization.

And, and so the bottom line is if you are brown or black, have brown or black coloured skin, you may identify as asexual, you have a disability and you're of a larger body size and you're 95 years old, you've got Buckleys and, you know, I contend if you have a wound, it may be labeled unhealable.

Yeah, I think that's something that we don't often think about.

Okay.

So it's a massive Topic and I think it would be great for us to follow this up.

We'll add this to our list.

We can do a separate episode on unpacking some of those tips and tricks here for some of those different types of wounds.

That, that would be an episode in itself and some of the strategies that we will use.

But this is an intro to that.

In summary, I suppose an unhealable wound.

I suppose we put the call out to everyone.

If you're using the term unhealable wound or if you hear someone say to you this is an unhealable wound, we urge you to question is it in fact an unhealable wound?

Are you really satisfied that best practice, all best practice efforts have been used to try and heal that wound?

That's if the person wants that wound healed.

That's the other thing that's a really big topic we haven't even touched on.

Everyone else in the team is trying to heal it.

Yeah.

But the person's not interested in it being healed and that's okay.

Yeah, yeah.

So we look at.

Isn't interesting.

I've just thought, as you've been saying that.

So we look at unhealed wounds as being quite negative.

But maybe that's empowering for somebody.

Yeah.

Because that they, they're not willing or don't want to, aren't interested in doing all those interventions and strategies to get it healed.

But that's okay.

That's their judgment call.

Because it's their wound.

Yeah.

Yeah.

And then we come along, say it's unhealable.

Well, maybe that's a good thing for them because it means they can do more in their life.

Yeah.

So you're right.

Who are we to say that they should have a healable wound?

Yeah.

In healthcare it's very one way focused.

It's very clinician focused.

Yeah.

And often.

Oh, here's another one.

So we're progressing.

We were about to finish somewhere.

Sometimes the person with the wound will or the wounds will tell you they want the wound healed, but they're sure as hell acting like they're not doing anything to make that wound heal.

Or when a person says, you're going to heal my wound.

Yeah.

Oh, the nurses are trying to heal my wound.

No, the nurses are trying to help you heal your wound.

You, the person with the wound will be healing your wound.

The team around you, and not only the nurses, but the multidisciplinary team around you are going to help you heal your wound.

Yep.

You do hear that a lot.

Yeah.

You do hear that a lot.

So is the wound healable if the person's not willing to come along the journey?

Well, it's not healable if the person is prepared to come along the journey, then it's highly likely healable.

If it's been assessed as healable and if the person decides, yeah, I understand it, if I did this, this and this, it'll heal, but I don't want to do that for whatever reason, then we respect that.

And then there's concordance.

We haven't touched on well being.

I think that's part of what we've been talking about.

Just to summarise.

Yeah.

And I might put a document in the show, notes about wellbeing and wounds.

Yeah, yeah, that's quite good.

That was actually mentioned at the summer school we went to last weekend as well.

I did mention the well being and work.

It's a couple of years old now, but it's.

It's quite good.

Yeah, yeah, yeah, do that.

Yeah.

So that's a really great resource.

If someone wants to do some more reading, professional development and look up some of this stuff, a lot of the concepts we've talked about will be in there.

So there's also the phenomenon where people have had an absolutely exquisitely painful wound and stay tuned, we're doing it.

We'll be doing a topic on pain and wounds and painful wounds.

But anyway, come along, do your stuff.

And they're quite happy.

Thank you very much.

You've reduced the pain in their wounds.

Frankly, they don't care about it healing, they're just happy that the wound's not painful anymore.

And you go, oh, you know, you sort of have to recalibrate your thinking.

But there are some strategies you can use and addressing that I've used in the past and I still do, which I found out some people aren't very keen on the other day.

Very interesting.

But it's the only time where I've ever used a dressing and for Christmas that year, the family bought me a box of that dressing for Christmas because it had done such an amazing.

Really?

That's fantastic.

Is that for nociceptive pain?

And so.

But that was.

That's been interesting and I've heard my colleagues say that sometimes people just love the fact that the pain's gone and then they don't care that the wound's there.

In this particular case, they'd had, I think, a squamous cell carcinoma removed and maybe there's some remnant squamous cell carcinoma around the wound and I believe that.

Oh, well, you can't believe.

But the story that I got from the.

The person with the wound and their family member is that the surgeon had suggested putting efudix inside the wound, not around the wound.

And they'd been putting it there for six months.

So now we'd had a really necrotic wound and it was in this setting that I used this particular dressing and.

Yes, and then they didn't really care that it didn't heal.

It just didn't have the pain.

Yeah, it didn't have the pain.

It ended up healing, but they didn't care.

They were happy to live with the wound with less pain or no pain than having the pain and the wounds.

I have a few people like that.

It's really great.

It's really great.

It says just all options are on the table.

They are.

We can't box people up when it comes to these topics and.

And make assumptions about people I find.

Get you into trouble.

Yeah.

Well, this has been really illuminating for me.

I've learned some things about you.

Again.

Oh, there are more weird and wonderfuls.

And I think it's a chance topic.

We're going to perfuse through a lot of our future episodes because, you know, many different wound types kind of fall into this category and affect.

Yeah.

A lot of people different ways, and we see a lot of unhealable wounds and some we can fix and some we can't.

But, yeah, it's a really emotive topic and it's a very special area.

It's a very, very special area.

So thank you for unpacking that.

So what about you, Mon?

Have you got any final thoughts before we finish off this episode on non healing wounds?

Yeah, look, of course I do.

I'm thinking that we only really touched on the ethics of labelling something an unhealable wound because as we've sort of uncovered that many times they are healable and we probably haven't done enough as a interdisciplinary team to uncover that.

And I often walk away from situations feeling very compromised.

Because you want to do as much as you can within the multidisciplinary team, but you in some ways relatively powerless if, you know, surgeons make decisions that they don't want to repeat.

Bring people back to surgery or vascular surgeons who say, oh, I did a scan a couple of years ago.

She's right, she's right.

Yep, we had one like that this week.

Yeah.

Or, oh, no, no, we don't need a biopsy.

And so there's that almost that Moral injury that we as wound consultants have.

When people are labelling something unhealable and you're thinking just, it could be.

It could be.

Do you find that just on that ethics?

And another ethical part to that is, as we wrap up, I find that then very ethically challenging when I'm with the patient and their family or their main caregivers to then have that conversation when I feel as though a medical colleague.

Medical.

Surgical colleague has that reaction when I. I don't want to get to the point where I say they're wrong.

And I think there's.

You got to be very articulate and creative when we're with families that, you know, I will go to length, not to put them in a bad light.

I think that's really, really important.

But I find that very challenging.

And yes, moral injury.

To then push further.

You know, I often do.

But, gee, you've got to mix your words really carefully and be very careful who you say it to.

But that's really hard to push back and to empower them to do that.

And sometimes there's.

We slip into that advocacy role for them.

But.

But the frustrating thing is, as nurses, and I'm sure nurse practitioners have got a better chance of this, we can provide all the information about why we're not prepared to call that wound unhealable for all these reasons.

And all it takes is for one surgeon or one medical specialist to say, no, that's not hellable, that's it.

It's like a fait accompli and it's in a real struggle.

I mean, things are changing.

Absolutely.

And I don't see that as much as I used to.

I don't experience as much as it used to.

I would agree with that.

But it still happens.

It does still happen.

Yeah.

You know, sometimes you just say, I know what I'm talking about.

Yeah.

I think sometimes the patient comes to us and says that, but they've.

We know that it's healable too, but they don't want to progress anything.

Yeah, yeah.

And that's.

Look.

But I think as clinicians, we.

We get a feel for that.

We appreciate it.

But when you've set up the right scenario, they're off to see the.

Either the GP or the multidisciplinary team.

It's not usually multidisciplinary teams, it's usually individual clinicians.

Yes.

I mean, and that's the value of the multidisciplinary team, isn't it?

You know, which we don't really have that much exposure to in a regional environment and I suppose even in your work.

But yeah, but it's those isolated clinicians that just make a judgment and as we've mentioned in previous podcasts, maybe had, if they're lucky, half an hour of wound management education over entire decades of career and they make a call like that.

Yep, yep, yep.

Anyway, I think now, I think we're almost done.

We definitely have more to say on this topic and we will, we will do more on this topic.

So please let us know.

Just a reminder to let us know your feedback and your questions.

We're findable through all the details in the show notes and we hope you've enjoyed hearing our intro session to Unhealable Wounds.

Yes.

See you in the next episode.

It's been sort of a zigzag journey, but we got there.

We definitely got there.

Fantastic.

Thanks everyone.

See you soon.

Bye bye.

We are so grateful to have this opportunity to share our learnings and challenges with you today.

Hopefully it has inspired you to be more curious in your clinical practice and burrow down to issues that bug you.

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We will see you in the next episode and in the meantime, go forth, be curious and burrow into some ant nests.

They'll be strong across the be wound.

But that won't stop me coming through.

I give it all give it over.

You but what you do, what I do Take around cover you but would you do what I do.