Hospice is designed to foster quality of life with an emphasis on pain and symptom management. The deterioration of the skin that is detected from pressure ulcers or other wounds is a sign that the systems of the body are diminishing, and even completely breaking down.
Even when nearing the end of life, effective wound care can significantly influence comfort physically, psychologically and emotionally. Wounds tend to ignite feelings of fear, hostility and even suspicion of negligence. Inadequate care, or a lack of care for wounds can be extremely detrimental to the patient, and furthermore, negatively affect the experience of the family throughout the very difficult time of losing a loved one.
Hospice Patients and Bedsores
Pressure ulcers, which are also known as bedsores, are very common among hospice patients, with over 40% of them experiencing them. Despite insistent preventive measures, and usually as a result of diminished muscle, cell, and immune function, among other factors, severely ill patients experience compromised response to healing. For these patients, the development of bedsores may be a visual biological indicator that their severe illness has overwhelmed the body and it is important to note that the breakdown of skin is not fully preventable or treatable.
It is a possibility that once bedsores develop in terminally ill patients, family members may see this as a failure of the interdisciplinary team or the family caregivers themselves to provide adequate care. Furthermore, their response, oftentimes being emotional, can lead to demands that are jeopardizing to the patient’s plan of care that is rooted in comfort.
Nonetheless, attempting to prevent and treat these concerns cannot get in the way of the hospice tenet of providing comfort-based care. Research shows that comfort should overrule preventive measures in situations where advanced illness causes patients to be more comfortable in a particular position. If the hospice interdisciplinary team determines that regularly scheduled patient movements increase their pain, these movements may be suspended.
Other Wounds Common in Hospice
Since hospice teams care for such an extensive variety of patients and conditions, there is an equally wide variety of wound types that they encounter, such as arterial insufficiency wounds, diabetic ulcers, venous ulcers, and tumors or fungating lesions.
Risk Factor Evaluation and Preventive Measures
Upon admission, conducting a comprehensive risk assessment is crucial, and needs to include a check of the patient’s entire body. Bedsores are caused by both internal and external factors, including the lack of mobility, cognitive function deficiency, an inability to verbalize discomfort or sensations like numbness, chronic sickness, aging and poor nourishment.
After the risk factors have been identified, the best practice is to prevent wounds from developing in the first place. Measures for prevention include, but are not limited to consistently inspecting the skin of the patient and observing for appropriate moisture maintenance. Also, suitable positioning, proper techniques for transfer, and nutrition are crucial with regard to the patient’s comfort.
Avoid pressure on the heels and bony prominences of the body, and use positioning devices whenever feasible. As always, remember to document the condition of the skin after assessment.
Staging (Categorizing) Wounds
The National Pressure Advisory Panel established the following wound stages, (NPIAP, 2017):
- Stage I—Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue wound.
- Stage II—Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
- Stage III—Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable wound.
- Stage IV—Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable wound.
- Deep-Tissue Injury—Persistent non-blanchable deep red, maroon or purple discoloration: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness wound (Unstageable, Stage 3 or Stage 4). Do not use deep tissue wound to describe vascular, traumatic, neuropathic, or dermatologic conditions.
- Unstageable—Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 wound will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
Basic Principles of Wound Care
It is imperative to first establish an effective plan for wound care that includes determining the prognosis of the patient, their condition and the potential they have for their wound(s) to heal. For example, it would be fitting to have a less aggressive approach for a patient nearing end-of-life, or when it is clearly displayed that it is not realistic they will heal.
Setting appropriate goals that are determined by the prognosis, condition and potential for healing is essential, and within hospice care, these goals might include:
- Prevention of complications with wounds (i.e. infection or odor)
- Prevention of further skin breakdown
- Minimization of harmful effects on the patient’s overall status as a result of wound(s)
During the process of creating patients’ care plans, it is imperative to consider, and furthermore, incorporate their condition and their wishes. This plan needs to be re-assessed regularly (typically biweekly) to ensure that it is still appropriate for the patient. When a wound does not heal it does not always mean that other methods or treatments are necessarily more fitting, or that the interdisciplinary team should try all other treatment options. The team should rather work to differentiate the plan to utilize the most appropriate options for that given patient based on their condition and wishes at that given time.
A standard plan for wound care will include the following:
- Cleaning the wound of debris
- Possibly debridement
- Absorption of any excess exudate
- Promotion of healing
- Treatment of infection
- Minimization of any discomfort
When a patient is in hospice care, wounds can be significantly stressful for the patient and family with regard to the associated pain, appearance, odor and furthermore the perceived implications of wounds. To maintain the goal of hospice of comfort-focused care, the interdisciplinary hospice team needs to function with diligence and detail to assess and document wounds and any changes to the patient’s condition while also conducting appropriate methods for prevention, and establishing and updating the care plan in consideration of the patient’s needs and wishes.
By decreasing the incidence and intensity of wounds and diminishing their impact, the hospice team provides an improved quality of life, and fosters an environment that allows for a peaceful death experience for both the patient and their loved ones.
The National Pressure Injury Advisory Panel. (2017). NPIAP pressure injury stages. Retrieved from https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf