In an 80‑year‑old patient with congestive heart failure and a non‑healing scalp wound, how should care be managed to prioritize comfort, pain control, and appropriate wound care?

Management of Non-Healing Scalp Wound in an Elderly Patient with End-Stage Heart Failure

In an octogenarian with congestive heart failure and a non-healing scalp wound with minimal healing potential, shift the focus immediately to palliative wound care with emphasis on symptom control, pain management, and comfort measures rather than aggressive wound healing interventions. 1, 2

Establishing Goals of Care

The first priority is to confirm the diagnosis of end-stage heart failure and establish an advance care plan with the patient and family. 1 This patient likely meets criteria for end-stage disease given:

• Advanced age (late 80s)
• Chronic poor quality of life
• Non-healing wound suggesting poor perfusion and cachexia
• Multiple comorbidities 1

Conduct a goals-of-care discussion immediately to understand patient preferences for treatment intensity, preferred place of care, and resuscitation status. 1, 2 These conversations must address:

• Preferences regarding emergency treatments and hospitalization 2
• Do-not-resuscitate orders 1
• Preferred location for end-of-life care (home vs. facility) 1
• Treatment goals shifting from cure to comfort 1

Palliative Wound Management Approach

For the non-healing scalp wound, prioritize comfort-focused wound care over aggressive healing protocols. 1, 2 This includes:

Pain Control

• Assess and treat wound-related pain aggressively using opioids (morphine or oxycodone) as first-line agents for moderate to severe pain. 1, 3
• Consider paracetamol for mild pain 1
• Prescribe anticipatory medications for breakthrough pain that can be administered at home 1

Wound Care Interventions

• Use appropriate dressings and preparations for wound management focused on odor control, exudate management, and preventing infection rather than healing. 1
• Avoid aggressive debridement that may cause additional pain or bleeding 1
• Consider topical antimicrobials if malodorous to improve quality of life 1

Symptom Management Beyond the Wound

Conduct frequent assessment of all physical symptoms including dyspnea, fatigue, edema, nausea, and depression using validated measures. 2

Dyspnea Management

• Optimize diuretic therapy (furosemide, bumetanide, or torasemide) to manage congestion. 1, 2
• Prescribe morphine with an antiemetic for breathlessness relief. 1, 2
• Consider benzodiazepines (lorazepam, clonazepam) for anxiety-related dyspnea 1

Nausea and Gastrointestinal Symptoms

• Use metoclopramide or ondansetron as needed 1, 2

Medication Optimization and Deprescribing

Review all current medications and consider deprescribing those not providing symptomatic benefit. 1, 2 Specifically:

Medications to Consider Stopping

• Discontinue statins and antiplatelet therapies if they no longer align with comfort-focused goals. 2
• Remove medications focused on long-term risk reduction rather than immediate symptom relief 1, 2

Heart Failure Medications to Adjust

• Continue diuretics for symptom control but adjust doses based on comfort rather than aggressive fluid targets. 2, 4
• Consider down-titrating beta-blockers if causing symptomatic hypotension or worsening congestion. 2
• Adjust or discontinue ACE inhibitors/ARBs if causing symptomatic hypotension 2

Care Setting and Coordination

For this frail, non-ambulatory patient, home-based care is most appropriate if consistent with patient preferences. 1 Home care provides:

• Access to immobile patients 1
• More reliable assessment in the patient's own environment 1
• Reduced burden of transportation 1

Establish a multidisciplinary team including the primary care physician, heart failure nurse, palliative care specialist, and family caregivers. 1, 2 Coordination should occur through a shared care approach 2

Anticipatory Prescribing for Home Management

Provide prescriptions for medications that may be needed urgently at home to empower patient and caregiver self-management. 1 Essential anticipatory medications include:

• Opioids for pain and dyspnea (morphine, oxycodone) 1
• Diuretics for acute congestion (furosemide) 1
• Antiemetics (metoclopramide, ondansetron) 1
• Anxiolytics (benzodiazepines) 1
• Wound care supplies 1

Hospice Referral Consideration

For patients with expected survival less than 6 months, timely referral to hospice can improve quality of life. 2 This patient likely qualifies given:

• End-stage heart failure with poor functional status
• Non-healing wound suggesting cachexia and poor perfusion
• Advanced age with multiple comorbidities 1

Hospice services should focus on relief of breathlessness through frequent diuretic administration rather than solely analgesics, as suffering in heart failure is characteristically linked to dyspnea. 1

Critical Pitfalls to Avoid

• Do not pursue aggressive wound healing interventions (advanced wound therapies, hyperbaric oxygen, surgical interventions) that will not improve quality of life and may cause additional suffering. 1, 2
• Avoid hospitalizations for acute decompensations unless absolutely necessary for symptom control that cannot be managed at home. 1
• Do not delay palliative care discussions until the terminal phase—these should occur early in end-stage disease. 2, 5
• Avoid benzodiazepines for routine use due to fall risk and somnolence in elderly patients, reserving them for acute anxiety or dyspnea. 1

Ongoing Monitoring and Support

Provide psychological and spiritual support through open communication and address spiritual needs according to patient preferences. 2

Ensure bereavement support is available for family caregivers both during the illness and after death. 5, 6