General Principles and Approaches to Wound Prevention and Care at End of Life: An Overview
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The same author did a case-series analysis of 192 consecutive patients referred for wound consultation. The majority were women, mean age of 82 years, with multiple comorbidities. Forty percent of the wounds were pressure ulcers, located primarily on the sacrum and almost exclusively Stage III and IV pressure ulcers, with concomitant necrosis and gangrene.4 The author concluded that “wounds at the end of life are a problem of tragic proportion for the nearly 1 million hospice patients and millions of other frail, elderly persons living with chronic disease.”4
Most, if not all, individuals at the end of life are at risk for developing soft tissue ulcerations.7,8,13-20 The vast majority of wound care professionals agrees that pressure ulcers occurring at end of life are often unavoidable and largely attributable to the individual’s frail, compromised condition.7,8,10,13,14,20,21 A panel at the 2010 National Pressure Ulcer Advisory Panel (NPUAP) Consensus Conference on Avoidable versus Unavoidable Pressure Ulcers22 unanimously agreed that not all pressure ulcers are avoidable, a determination supported in the literature — ie, it is likely impossible to eradicate pressure ulcers in end-of-life patients owing to their many comorbid conditions and risk factors.7,14-15,21-26 NPUAP conference attendees recognized that end-of-life patients experience body organ system and homeostatic mechanism failure. As such, they are rendered unable to counter insults such as pressure, friction, and shear, making some pressure ulcers unavoidable.5,27
Individuals at the end of life who have a wound face a conundrum of considerations, including whether to accept aggressive curative wound treatment or a palliative approach. Patients need to be apprised of care options available and educated regarding the fact that many wounds at end of life do not close or heal, particularly as the body’s organs shut down. It is often overlooked and not included in patient/family education that the skin is the largest organ of the body and can and does fail along with the other organs.4,13 Some studies report that up to 50% of wounds heal at end of life; others report far smaller percentages.2,4 When care is shifted from a curative to a palliative focus, it is not unexpected to see some deterioration in the condition of the wound, even though care of the wound never stops; for individuals at the end of life with a nonhealing wound, supportive, comfort-enhancing interventions may be the most appropriate strategy.
By educating the patient, including a comprehensive question-and-answer session between the patient and family and primary care provider(s), the goal of care should be established. Moving a patient from a curative to a palliative treatment plan is incumbent on the fact that the primary care provider has determined the wound is ultimately nonhealing and not merely undertreated, and that the patient has agreed to accept a palliative approach.5,28
The purpose of this overview is to summarize how some of the general principles of wound prevention and care may apply to end-of-life care patients.
Common Risk Factors for Skin Breakdown and Pressure Ulcer Development
Multiple factors place the individual at the end of life at risk for tissue breakdown and impaired wound healing. Impaired oxygenation results from low hemoglobin levels and impaired gas exchange.