Pressure Injury/Ulcer Risk Management in Palliative Care and Hospice

Palliative care and hospice care are not the same, but they both share one goal. They both focus on a patient's physical, mental, social, and spiritual needs. Palliative care can begin at diagnosis and treatment or for patients at any stage of their illness. Patients may not want to receive aggressive treatment of non-healing wounds because of underlying diseases, pain, and/or cost.¹ Hospice care is for terminally ill patients who are within six months of dying. These patients no longer want to be in pain or seek new or difficult treatments that may not improve or extend their life. Hospice is dying with dignity, which can be considered the model for quality of life, and it features a team-oriented approach that is tailored to honor a patient’s needs and wishes.¹ Although palliative care and hospice are different, the interventions for preventing or reducing the incidence of pressure injuries/ulcers are similar for both:²

• Turn and reposition at periodic intervals, per the patient’s wishes and tolerance. You may change the support surface to improve pressure redistribution and comfort:
  • every four hours on a pressure redistributing mattress
  • every two hours on a non–pressure redistributing mattress
• Pre-medicate the patient 20 to 30 minutes before position changes for patients with significant pain during movements.
• Observe patients' choices in "position of comfort," after explaining the rationale for turning and positioning.
• Comfort is most important and may supersede prevention and wound care for patients who are actively dying.
• Pad and protect the sacrum, elbows, heels, and greater trochanters.
• Use positioning devices, such as foam wedges and pillows, to prevent direct contact of bony prominences. Utilize positioning devices in wheelchairs or chairs to reduce shearing.
• Use draw sheets to pull up, transfer, and position your patient. DO NOT DRAG.
• Use heel protectors and/or suspend the heels with a folded blanket or pillow.
• For patients seated up in chair, use a cushion that increases comfort while redistributing pressure on bony prominences.
• Maintain skin integrity as much as possible. Use moisturizing lotion to prevent dryness.
• Minimize the potential adverse effects of incontinence.

Pressure Injury/Ulcer Assessment

The wound assessment is to be performed at weekly intervals with dressing changes and includes pressure injury/ulcer stage, location, size, wound bed tissue, periwound, odor, and exudate. Evaluate and monitor the wound to coincide with comfort goals. Less frequent wound evaluations will be appropriate as death nears, to avoid causing unwarranted discomfort to a patient at the end of life.

Wound Pain Management

Managing wound pain is one of the most important components of comprehensive treatment. Health care professionals should perform an initial pain assessment to determine the necessary course of action in helping their patient remain comfortable. Avoid positions that increase pressure by using a lift to minimize friction when repositioning; this technique can help prevent painful flare-ups. Pain management should be regularly assessed every shift, preferably during dressing changes. Wound pain can be minimized by promoting an optimal moist environment and minimizing the frequency of dressing changes as possible. Moisten dressings with normal saline before removal to reduce risk of any extra pain. Encourage patients to request a time out during a dressing change or procedure that causes pain. Anesthetics and analgesics can be applied topically to the wound bed for pain relief. These agents act on opioid receptors. The most common topical opioid anesthetic used is 2% lidocaine gel.³

Wound Bed Preparation

Wounds should be regularly cleansed to promote healing and reduce the risk of complication. Cleansing helps remove any foreign matter and allows the health care professional to make a more accurate assessment of the healing progress. Use a cleanser with pH matching that of the skin and antiseptic if risk of infection is suspected. Debridement can also help remove necrotic tissue and promote wound healing if warranted.⁴

Dressing Considerations

In palliative and hospice care, the patient's wishes are priority. There are no standardized protocols for the dying patient because of the lack of research. Choosing a treatment and care plan should be determined from a patient-centered approach. Pressure injuries/ulcers require dressings that can keep the wound moist, manage exudate, reduce the risk of infection, and prevent the ingress of foreign material (particularly in the case of incontinent patients). Hydrocolloids, transparent films, hydrogels, alginates, hydrofibers, foams, and antimicrobial dressings can each provide benefits, depending on the wound and stage of healing. Health care professionals should also make efforts to decrease the frequency of dressing changes, thereby reducing discomfort for patients, cost, and time. Secure, gentle, waterproof medical adhesives should be considered for this purpose.⁵

Exudate Management

When choosing a dressing to absorb exudate, select a dressing that will not only wick away exudate but also control odor and protect the periwound. Preventing desiccation of the ulcer while maintaining a moisture-controlled environment is key to preventing further skin breakdown. Silicone-bordered foam dressings can help absorb exudate, protect fragile periwound skin, and reduce pain during dressing removal. Utilize skin protectants or barrier dressings to protect the periwound and surrounding skin as indicated.

Infection and Odor Control

Devitalized tissue is the main cause of wound odor. Bacteria flourish on wound exudates. Removing dead tissue is essential for eliminating odor. Debridement methods should not be too aggressive because patient comfort is a priority. Pre-medicate patients 20 to 30 minutes before any sharp debridement procedures.⁶ Removal of necrotic tissue is recommended with autolytic and/or enzymatic methods. Avoid sharp debridement of fragile tissues and those that bleed easily. There is an array of impregnated dressings that have been shown to be helpful in controlling odor in wounds:

• Charcoal – Activated charcoal attracts and binds wound odor molecules, thus minimizing odor.⁷
• Povidone-iodine – Antibacterial agent that controls odor.⁸
• Metronidazole – Antimicrobial agent effective against anaerobic bacteria and Trichomonas.
• Cadexomer iodine – Antiseptic that releases iodine at a low concentration rate. If oversaturation occurs, the odor control action diminishes.⁹
• Sodium hypochlorite – Dakin solution 0.25%–soaked gauze packing can be placed into wound dead space for odor control.⁸
• Silver dressings – Antimicrobial that is impregnated into alginates, collagens, contact layers, foams, hydrogels, hydrofibers, hydrocolloids, and transparent film dressings.²

External odor control methods can be used (per policy and procedure); wound care–specific formulations for airborne odors are available, or you may consider other options such as kitty litter placed under the bed, coffee beans, vinegar, vanilla, potpourri, clove oil, and/or a candle in the room.¹⁰

Pressure Injury/Ulcer Risk Factors

The following factors increase a patient’s risk of developing a pressure ulcer/injury. Patients should be evaluated for risk factors and have appropriate interventions in place to help mitigate these risks.

• Immobility – Perhaps the greatest risk factor for pressure injuries is immobility. Because pressure injuries/ulcers are caused by sustained pressure, patients who are unable to change positions are much more likely to develop them. Immobile patients are also more likely to be unable to feel the injuries/ulcers developing, thereby further adding to the risk.¹¹
• Friction and Shear – Signs of shearing can often be identified by the presence of a wound that manifests with an irregular shape and undermining. There may even be evidence of excoriation and blistering on areas in contact with support surfaces. Friction usually, but not always, accompanies shear. Friction is the force of rubbing two surfaces against one another. Shear is a gravity force pushing down on the patient's body with resistance between the patient and the chair or bed. Pad and protect vulnerable areas (transparent, hydrocolloid, composite, or foam dressings) as per facility protocol.
• Moisture and Incontinence – Incontinence- and moisture-associated skin damage can increase the risk of pressure injuries, as well as increase risk of more serious complications from the damage, such as infection. Open pressure injuries can become infected if exposed to incontinence, thus posing a risk of irritation, sepsis, and death.^5,11
• Malnutrition – Overall nutrition can affect skin health, particularly in patients with lowered albumin levels.¹¹ To reduce this risk, patients should be on a program of standardized energy and protein intake, according to National Pressure Ulcer Advisory Panel (NPUAP) guidelines.⁵
• Medications – Certain medications, such as steroids, increase the risk of developing pressure injuries.
• Other Medical Conditions and/or Terminal Diseases – Medical conditions and/or terminal diseases can increase a patient’s risk of developing pressure injuries/ulcers. Some conditions that may increase a patient’s risk include cancer, diabetes, peripheral vascular disease, congestive heart failure, cerebrovascular accident (stroke), dementia, renal disease, and depression.
• Sensory Perception – Patients who have limited ability to feel pain or discomfort are at greater risk of damage because they may not be able to respond to the early stages of the condition and are more likely not to shift from positions of sustained pressure.
• Age – Age is one of the major risk factors for pressure injuries. It increases the likelihood that the patient will be affected by another risk factor such as immobility or incontinence, as well as contributing additional risk factors, such as thinner, more sensitive skin.¹

End of Life Skin Changes: An Introduction to Skin Failure and The Kennedy Terminal Ulcer

In 2009, the concept of Skin Changes at Life's End (SCALE) was instituted to describe a variety of unusual wounds that develop during the end of life.¹² There is a wide range of wound types that can manifest at end of life, from a classical pressure injury/ulcer, deep tissue injury, unavoidable pressure injury, ischemic ulcer, or mottling to a tumor. Patients who are dying are more susceptible to pressure, friction, shear, stress and strain, hemodynamic instability, reperfusion injury, and critical ischemia. The NPUAP Consensus Statement #11 states, "Terminally ill individuals who become immobile are at increased risk for unavoidable pressure ulcers."¹²

What is Skin Failure?

Skin failure is quite different from a pressure injury/ulcer.¹³ Tissue tolerance is compromised to the point that cells cannot survive as a result of hypoxia, local mechanical stress, impaired delivery of nutrients, and a buildup of toxic metabolic byproducts. To date, there are no organ failure studies including skin failure.¹⁴ According to Jeffrey M. Levine, MD, "Once skin failure becomes properly coded, the door is opened to add a modifier to pressure injury/ulcer when used for quality measurement."¹⁴

What is a Kennedy Terminal Ulcer?

The Kennedy terminal ulcer was born 29 years ago, after the NPUAP organized their first conference in Washington, DC.⁴ The Kennedy terminal ulcer originated from Karen L. Kennedy-Evans RN, FNP, APRN-BC, who described pressure ulcers that appeared just before a patient’s death. She described them as purple areas on bony prominences, particularly on the sacrum, that preceded death by two to three days. This is what we now call a deep tissue pressure Injury. However, not all deep tissue pressure injuries/ulcers signal death. The Kennedy terminal ulcer is predominately found in the geriatric and terminally ill population.^5,11 Statistics report that more than 50% of these ulcers develop at the end of life in older adults.⁵

Potential Causes and Characteristics of a Kennedy Terminal Ulcer

There are several theories on the causes of a Kennedy terminal ulcer. One theory is that there is a blood perfusion problem that has been exacerbated by the dying process. Another theory is that because the skin is the largest organ, it can reflect what is going on inside the body, such as internal organs slowing down, followed by multiorgan failure.^4,15 The Kennedy terminal ulcer usually manifests as a superficial, large ulcer that has sudden onset and progression as a person is dying. The ulcer will then deteriorate quickly with depth and devitalized tissue such as slough and eschar. It is important to remember that the presenting characteristics can sometimes vary from patient to patient. When assessing any wound, health care clinicians should look at location, shape, and color.

• Location – It usually manifests on the sacral/coccygeal area; other areas include the heels, posterior calf, arms, and elbows.^15,16
• Shape – The shape can vary, but it has been described as a butterfly, horseshoe, or pear shape. The ulcer may change in shape and size as it progresses.
• Color – Kennedy terminal ulcers can contain all wound tissue types. Red, yellow, black or purple
• Onset – Onset is sudden, and deterioration follows quickly. Kennedy terminal ulcers may begin with the appearance of a bruise and then rapidly decline into a full-thickness ulcer.
• Borders – These are usually irregular and rarely symmetrical.

Treatment Options for Kennedy Terminal Ulcers and Wounds at End of Life

Treatment options for the Kennedy terminal ulcer are no different from treatment options for any other pressure injury/ulcer regarding treating the level of tissue destruction. When aged patients draw closer to death, it is more difficult to promote healing or wound closure. The primary goals are to manage wound pain, monitor for signs and symptoms of infection, control odor, and maintain a moist wound healing environment. Dressing changes should be infrequent, if possible, but at the same time ensure that the dressing is able to absorb exudate properly.² Treatment plans should promote quality of life and a sense of well-being; if not, the treatment plan should be changed.¹⁷

Special Populations

Pediatric Population

Pediatric intensive care units report Kennedy terminal ulcers at a rate as high as 27%, and neonatal intensive care units report these ulcers at a rate of 23%. Pediatric patients share the same intrinsic factors as older adults in regard to pressure injury/ulcer development. Patients with spina bifida, cerebral palsy, ventral septal defect repairs, intubation lasting for longer than seven days, cardiopulmonary bypass, and congenital heart defects make up the highest-risk groups. There are currently 10 pediatric pressure ulcer risk assessment scales in use.¹⁸

Bariatric Population

Bariatric patients are at high risk of pressure injury/ulcer development because of their high body mass index, immobility, and tendency to be malnourished. Health care clinicians are challenged in many ways with caring for the bariatric population. Bariatric patients are affected every day by weight bias and discrimination. Transferring and positioning must be performed with safe handling for the patient and health care worker. Education is imperative to everyone involved in care for the bariatric patient. The word OBESE is a mnemonic tool to help you remember skin management essentials for the morbidly obese patient.¹⁹

O: Observe for atypical pressure ulcer development.

B: Be knowledgeable about common skin conditions.

E: Eliminate moisture on skin and in skin folds.

S: Be sensitive to the patient’s emotional distress.

E: Use equipment to protect the skin and for safe patient handling.

Conclusion

In the hospice and palliative care settings, completely healing a pressure injury/ulcer may not be possible. The focus should therefore be on taking a multidisciplinary holistic approach to wound care. Wound care management will help relieve pain and suffering even though the wound may not heal to closure. Clinicians should learn to identify comfort versus healing while maintaining dignity and quality of life for the palliative and hospice care patient.

References

1. Compassus. Hospice vs. palliative care. 2018. https://www.compassus.com/for-caregivers/hospice-vs-palliative-care. Accessed on October 7, 2018.

2. Langemo DK, Black J, National Pressure Ulcer Advisory Panel. Pressure ulcers in individuals receiving palliative care: a National Pressure Ulcer Advisory Panel White Paper. 2016. http://www.npuap.org/wp-content/uploads/2012/01/pressure_ulcers_in_indi…. Accessed on October 7, 2018.

3. Popescu A, Salcido R. Wound pain: a challenge for the patient and the wound care specialist. Adv Skin Wound Care. 2004;17:14–20.

4. Kennedy Terminal Ulcer. http://www.kennedyterminalulcer.com/. Accessed on October 6, 2018.

5. Ferris FD, Al Khateib AA, Fromantin I, et al. Palliative wound care: managing chronic wounds across life's continuum: a consensus statement from the International Palliative Wound Care Initiative. J Palliat Med. 2007;10(1):37–9.

6. McDonald A, Lesage P. Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. J Palliat Med. 2006;9:285–95.

7. Naylor W. Malignant wounds: aetiology and principles of management. Nurs Stand. 2002;16:45–56.

8. Ferris F, von Guten C. Malignant wounds. 3rd ed. Fast Facts and Concepts #46. Palliative Care Network of Wisconsin. 2015. https://www.mypcnow.org/blank-v8s5p. Accessed on October 7, 2018.

9. Falanga V. Iodine-containing pharmaceuticals: a reappraisal. In: Proceedings of the Sixth European Conference on Advances in Wound Management. London, United Kingdom: Macmillan Mags Ltd; 1997.

10. Barton P, Parslow N. Malignant wounds: holistic assessment and management. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Sourcebook for Healthcare Professionals. 3rd ed. Wayne, PA: HMP Communications; 2001:699–710.

11. Hughes RG, Bakos AD, O'Mara A, Kovner CT. Palliative Wound Care at the End of Life. Agency for Healthcare Research and Quality Archive. Bethesda, MD: United States Department of Health and Human Services; 2016.

12. Krasner DL, Stewart TP. SCALE wounds: unavoidable pressure injury. Wounds. 2015;27(4):92–4.

13. White-Chu EF, Flock P, Struck B, Aronson L. Pressure ulcers in long-term care. Clin Geriatr Med. 2011;27(2):241–58.

14. Levine JM. Skin failure: an emerging concept. J Am Med Dir Assoc. 2016;17(7):666–9.

15. Kennedy KL. The prevalence of pressure ulcer in an intermediate care facility. Decubitus. 1989;2(2):44–5.

16. Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4);206–11.

17. Saunders J, Regnard C. Management of malignant ulcers—a flow diagram. Palliat Med. 1989;3:154–5.

18. Baharestani MM, Ratliff CR. Pressure ulcers in neonates and children: an NPUAP white paper. Adv Skin Wound Care. 2007;20(4):208–20.

19. Hebert GR. Providing skin care for bariatric patients. Wound Care Advisor. https://woundcareadvisor.com/providing-skin-care-for-bariatric-patients…. Accessed on October 7, 2018.

Resources

Cuddigan J. Critical care. In: Pieper B, ed. Pressure Ulcers: Prevalence, Incidence and Implications for the Future. Washington, DC: National Pressure Ulcer Advisory Panel; 2012.

Haesler E, ed. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Developed by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Cambridge Media: Osborne Park, Australia; 2014.

Kalinski C, Schnepf M, Laboy D, et al. Effectiveness of a topical formulation containing metronidazole for wound odor and exudates control. Wounds. 2005;17:74–9.

Newman V, Allwood M, Oakes RA. The use of metronidazole gel to control the smell of malodorous lesions. Palliat Med. 1989;34:303–5. World Health Organization. Updated on 2017.

10 facts on obesity. 2013. http://www.who.int/features/factfiles/obesity/en/. Accessed on October 7, 2018.