Pressure Ulcers in Individuals Receiving Palliative Care

INTRODUCTION About 300 million individuals, or 3% of the world's population, need palliative or end-of-life care each year.1 Palliative care is designed to provide relief from suffering and enhance the quality of both the living and dying processes for the patient and family,2 while neither hastening nor prolonging death.3 Many professionals concur that pressure ulcers (PrUs) occurring at the end of life are often not preventable and that efforts to prevent them are complicated because of the patient's frail condition.4-9 Many professionals also agree that it may be impossible to eradicate PrUs in the terminally ill because of the multiple risk factors and comorbid conditions.6,10-17 PrU development, however, can decrease quality of life physically, emotionally, socially, and mentally.18-20 A systematic review of research on PrUs and quality of life21 reported that PrUs had significant impact in all aspects of life. Usual care of a PrU is designed to promote healing; however, healing or closing the ulcer in patients receiving palliative care is often improbable. Therefore, the focus of care is better directed to reduce or eliminate pain, odor, and infection and allow for an environment that can promote ulcer closure, as well as improve self-image to help prevent social isolation. Healthcare providers also need to advocate for and develop products that control complications and deliver symptomatic relief to promote a desirable quality of life of the patient and family.2,22 The purpose of this white paper is to review and summarize the current scientific evidence for prevention and care of a PrU in a palliative care patient. Although randomized controlled studies are few, a moderately sufficient informed clinical consensus, as well as less rigorous scientific studies, does exist to support a variety of care approaches for the palliative individual with a PrU. Gaps in the literature will be identified, and current recommendations for practice will also be reviewed. The recommendations presented are those included in the 2009 National Pressure Ulcer Advisory Panel (NPUAP)-European Pressure Ulcer Advisory Panel (EPUAP) International Pressure Ulcer Prevention and Treatment Guidelines.23 DEVELOPMENT PROCESS FOR RECOMMENDATIONS The recommendations in this paper are taken from the 2009 NPUAP-EPUAP Pressure Ulcer Treatment Guidelines.23 The guidelines were developed following a systematic, comprehensive review of the peer-reviewed and published research on PrU prevention and treatment from 1998 through January 2008, as well as supplemental searches. Evidence tables from previous guidelines were reviewed to identify relevant studies published before 1998. Studies meeting inclusion criteria were reviewed for quality, summarized in evidence tables, and classified according to their level of evidence using a schema developed by Sackett (Table 1).24Table 1: SACKETT LEVEL OF EVIDENCE RATING SYSTEM FOR INDIVIDUAL STUDIESSTRENGTH OF EVIDENCE SUPPORTING EACH RECOMMENDATION Once the recommendation was made, the cumulative strength of evidence supporting each recommendation was rated according to the following criteria: A-Recommendation supported by direct scientific evidencefrom properly designed and implemented controlled trials on PrUs in humans providing statistical results that consistently support the recommendation (Sackett level I studies). B-Recommendation supported by direct scientific evidence from properly designed and implemented clinical series in humans providing statistical results that consistently support the recommendation (Sackett levels II, III, IV, V studies). C-Recommendation supported by expert opinion or indirect evidence (eg, studies in animal models and/or other types of chronic wounds). More detailed information on the NPUAP-EPUAP guideline development methodology has been previously published.25 PRESSURE ULCER RISK Individuals with advanced or terminal disease are at significant risk for soft tissue ulceration.9,14,26-30 Significant PrUs can develop and reach Stages III and IV.31 In 1 study, the majority of PrUs in a hospice sample occurred in the 2 weeks before death,32 not unexpected as body systems physiologically begin to shut down 10 to 14 days prior to death.33 A variety of risk factors exist that place the palliative care individual at increased risk for both PrU development and nonhealing. Although the risk profile is not unique when compared with other patient groups, the ability to mediate the risk is often limited. Reifsnyder et al34 studied 980 hospice patients and found that, while 62.3% had a cancer diagnosis, those with a noncancer diagnosis were more likely to develop a PrU. Advanced Age. Increasing age has been found to be significantly associated with PrU development in hospice patients.14,35 The skin of older patients is drier, fragile, and easily injured,14,27 and injured skin is more vulnerable to ulceration. The epidermis thins and cell turnover slows, with cell loss occurring more rapidly than cell replacement.36 Protective function of the epidermis is compromised. In addition, temperature control is lessened with the loss of sweat glands, and collagen renewal deteriorates with age.37 Emollients are helpful for dry skin.38,39 Protein-Calorie Malnutrition. Older individuals are at risk for protein-calorie malnutrition, with the prevalence for older adults in long-term care ranging from 50% to 85%, as compared with 40% to 60% in acute care.40,41 Even if malnutrition is not formally diagnosed, lean body mass was associated with PrU development in a group of 98 hospice patients.14 Catabolism is also common in this patient group, a consequence of a constellation of cachexia, weakness, debilitation, weight loss, and muscle atrophy. The loss of body fat reserves reduces the natural padding over bones, increasing the vulnerability to pressure and soft tissue breakdown. Inadequate nutrition is associated with PrU development.14,31,35,42,43 A large, retrospective cohort study of 2420 adult nursing home residents, with a stay of 14 or more days, and with a risk of developing a PrU, documented that an unintentional weight loss at any body mass index increased the chance of developing a PrU by 147%.43 A state of compromised nutrition, such as unintentional weight loss, undernutrition, protein energy malnutrition, and dehydration deficits, is also a known risk factor for PrU development.44,45 Other nutritional indicators predictive of PrU development include anemia, low serum albumin, and weight loss.46-52 Although serum albumin levels have long been used clinically, they are a poor indicator of visceral protein status related to albumin's long half-life (12-21 days) and numerous factors that decrease albumin levels even in the presence of adequate protein intake. Stress creates a hypermetabolic state. Further, hypermetabolism develops when inadequate nutrition is associated with severe illness and/or infection, which are not uncommon concomitant conditions in a palliative care individual. Cytokines are stress-response proteins produced following tissue injury. Cytokines contribute to metabolic and gastrointestinal changes, including anorexia and malaise, and consequent malnutrition, muscle wasting, decreased nitrogen retention, and decreased albumin synthesis.53 Catabolism also slows all tissue-repair processes from cell proliferation and migration to collagen deposition.54 Immobility. Individuals receiving palliative care progressively become less active, and their immobility increases nearer to their time of death. Immobility is a well-known factor associated with PrU development.6,11,31,35,42,47,55-59 In a study of 98 Swedish hospice patients, the lack of physical activity and mobility were significantly associated with PrU development.14 The risk of PrU development is compounded when the patient is older and has concurrent illnesses that impair mobility or activity.14 An additional component in immobility is seen when some individuals in pain often wish to not move or refuse to move because of fear of pain or dyspnea.60 Friction and Shear. Friction is the "resistance to motion in a parallel direction relative to the common boundary of 2 surfaces."61 Friction can cause injury to the individual's skin from movement of the skin on the bed linens. Friction injuries can also develop in individuals who are in pain but are not able to process the meaning of the sensation of pain (eg, those with confusion or dementia). Rubbing the heels on the bed is a commonly seen friction injury, which can quickly lead to tissue damage on the heels. Shear stress is the "force per unit area exerted parallel to the plane of interest," whereas shear strain is the "distortion or deformation of tissue as a result of shear stress."61 Friction is necessary for shear to occur, and shear forces can damage the skin internally, which is likely to occur when the individual must sit up in bed due to dyspnea and then slides down in bed. Dyspnea is further associated with tissue hypoxia, creating a higher risk of tissue injury. As time in a chair, and eventually a bed, increases, both friction and shear become more significant risk factors. Exposure to Moisture. Moisture can arise from excess perspiration, wound exudates, urine, and/or feces. Sweat is not caustic but can cause skin injury. Sweat between skin folds creates a warm moist environment and promotes growth of several forms of bacteria and yeast.62 Moisture is one of the subscales on the Braden and the Hunters Hill-Marie Curie Center Risk Assessment Scales. Given that the patient's state of health deteriorates as the disease progresses, it is important to assess for risk factors often, beginning at admission and with each significant change in condition. Normal skin pH is acidic at 4 to 6.5, which helps protect the skin against microorganism invasion.63 Frequent use of soap can alter skin pH to an alkaline state, leaving it more vulnerable to microorganism invasion. Skin that is water logged from continual wetness is more easily subjected to breakdown, injured by friction, permeable to irritating substances, and able to be colonized by microorganisms than normal skin,2,55,64-67 as well as PrU deterioration.14,32 Exposure to urine or diarrhea damages the skin and increases the risk of PrUs. Urine is absorbed by keratinocytes (outermost layer of skin), and when these cells are softened, they cannot provide protection from pressure injury. Urine contains urea, and ammonia can damage the skin. In an incontinent individual with a urinary tract infection, urine will also be alkaline and injurious to the skin. Diarrhea strips the outer layer of skin, and the exposed dermis cannot tolerate pressure. Diarrheal fluids are caustic and can damage the skin quickly. When urine is present in combination with feces, which contain bacteria and harsh gastrointestinal tract enzymes, the damage can be even quicker and more severe. In addition to this chemical irritation, the mechanical irritation from cleaning the individual can compound the damage. Fecal incontinence is reported to be 25% in hospice patients32 and 30% in a French study of 1000 nursing home residents.68 Although a number of factors are responsible for fecal incontinence in the frail older adult, poor mobility is a problem in patients receiving palliative care as they become more and more confined to bed, which in turn can contribute to functional and other forms of incontinence. Recommendations 1.1. Assess the risk for new PrU development at the time of admission and on a regular basis in the patient receiving palliative care by using a validated risk assessment tool (strength of evidence = C). 1.2. Use the Hunters Hill-Marie Curie Center Risk Assessment Tool, specific to the patient receiving palliative care, or a general screening tool, such as the Braden Scale, Norton Scale, or other age-appropriate tool, in conjunction with clinical judgment for the adult individual (strength of evidence = C). RISK REDUCTION Pressure Redistribution. Turning redistributes pressure so that tissues can be perfused; it is the cornerstone of PrU prevention. However, in the terminally ill individual, "turning may be harmful or even scary to some patients, while offering immeasurable comfort to others."2 Many patients receiving palliative care prefer a single position for comfort, and turning and positioning may serve only to increase pain, discomfort, and distress.2,30,55,60,69 Comfort is best managed by keeping the patient's pain controlled without extreme sedation.70 Use of opiates and/or sedatives to control pain allows for more frequent position changes with minimal pain. However, if the patient becomes too sedated, there will be a decrease in spontaneous movements. Therefore, finding the proper balance of opiates and nonopiates for pain management without suppression of spontaneous movement is crucial. Increasing immobility is expected as the patient becomes more ill, yet it is important to keep the skin intact for as long as possible. This can be accomplished by placing the palliative care individual on a low-air-loss mattress to provide a dry and cooler microclimate and desirable pressure redistribution. These upscale devices reduce the need for frequent turning and reduce the risk of PrU development. However, patients on any pressure redistribution surface still require turning. For those individuals who are actively dying, prevention and treatment of a PrU may be superseded by the need to promote comfort by minimizing turning and repositioning and allowing the patient to determine frequency of turning and choice of position.14,30,55,60,69 Patients who are in pain do not wish to move, so families may not wish to move them. Nonetheless, repositioning as possible and in accordance with the individual's wishes remains a high priority for symptomatic management.2 Many individuals have a "position of comfort," which they prefer. As possible, these wishes are to be honored. Recommendations 1.0. Reposition and turn the individual at periodic intervals, in accordance with the individual's wishes and tolerance (strength of evidence = C). 1.1. Establish a flexible repositioning schedule based on support surface in use and needs and individual preferences and tolerance (strength of evidence = C).71 1.2. Premedicate the individual 20 to 30 minutes prior to a scheduled position change for individuals with significant pain on movement (strength of evidence = C). 1.3. Observe individual choices in turning, including whether he/she has a "position of comfort," after explaining the rationale for turning (strength of evidence = C).7,60 1.3.1. Comfort is of primary importance and may supersede prevention and wound care for individuals who are actively dying or have conditions causing them to have a single position of comfort (strength of evidence = C). 1.4. Consider changing the support surface to improve pressure redistribution and comfort. (strength of evidence = C). 1.5. Strive to reposition the individual receiving palliative care at least every 4 hours on a pressure-redistributing mattress as consistent with the individual's goals (strength of evidence = A) and every 2 hours on a non-pressure-redistributing mattress and document. Individualize the turn and reposition schedule according to the individual's clinical status and combination of comorbid conditions, as medically feasible (strength of evidence = C).72-74 1.6. General Care 1.6.1. Protect the sacrum, elbows, heels, and greater trochanters, which are particularly vulnerable to pressure and shear. 1.6.2. Use positioning devices, such as foam or pillows, as necessary to prevent direct contact of bony prominences and to avoid having the individual lie directly on the PrU (unless this is the position of least discomfort, per individual preference) (strength of evidence = C).42,71,75 1.6.3. Use heel protectors and/or suspend the length of the leg over a pillow or folded blanket to float heels (strength of evidence = B).75,76 1.6.4. Use a chair cushion that redistributes pressure on the bony prominences and increase comfort for the individual who is seated (strength of evidence = C).42,75 1.7. Skin Care 1.7.1. Maintain skin integrity to the extent possible (strength of evidence = C). 1.7.2. Apply skin emollients per manufacturer's directions to maintain adequate skin moisture and prevent dryness (strength of evidence = C). 1.7.3. Minimize the potential adverse effects of incontinence on skin. NUTRITION AND HYDRATION Even today, very little research is available identifying specific strategies for nutrition in the frail older adult patient.2 Although it is known that adequate fluid intake and maintenance of serum protein levels are important for wound healing, this is not always an achievable goal in the frail older adult or individual at the end of life.2 Further, inflammatory conditions reduce serum proteins, and using them as the only marker of nutrition provides neither an adequate nor accurate picture. Measurement of actual oral intake through nutrient intake studies or monitoring body weight provides more reliable data from which to make clinical decisions. Maintenance of adequate hydration is important.7,77,78 Well-hydrated skin is healthier skin and thus less vulnerable to breakdown. The frail individual and/or the individual at the end of life is less independent, and often, the ability to drink voluntarily is significantly impaired. Making the environment conducive to eating is also important. When the individual is trying to eat, any unpleasant odors should be controlled (including body wastes). Many individuals consume more food when they socialize with others; if possible, family or friends should be encouraged to visit during mealtime. If the individual is short of breath, convert the oxygen to nasal cannula, provide oral care before eating, and offer up to 6 small meals a day. Carbohydrate-dense foods should be minimized because they produce carbon dioxide; fatty foods should be encouraged instead. If stomatitis is present, use mouthwash to reduce pain with eating and serve foods that are mild and cool. If the individual has chosen not to make PrU healing a priority, dietary restrictions for disease management should be lifted and the diet liberalized. Small, frequent meals and snacks can be offered, and the individual can be allowed to consume food and fluids in the types and amounts desired.2 Nutritional guidelines for prevention of PrUs were published in 2009.79 Recommendations 1.0. Strive to maintain adequate nutrition and hydration compatible with the individual's condition and wishes.80,81 Adequate nutritional support is often not attainable when the individual is unable or refuses to eat related to certain disease states. (strength of evidence = C).2 1.1. Allow the individual to ingest fluids and foods of choice (strength of evidence = C).2,42,81 1.2. Offer nutritional protein supplements when ulcer healing is the goal. 1.3. Offer several small meals per day. 1.4. Provide oral care to reduce pain and improve taste. PATIENT ASSESSMENT A holistic assessment is needed of the individual and the PrU(s), designed to realistically appraise the efficacy and cost-effectiveness of achieving PrU closure, including cost of treatment, as well as cost of suffering.2 Healing a PrU requires, at the very least, adequate nutritional intake, pressure redistribution, and local ulcer care. When a nutritional screen identifies a nutritional problem or weight loss or a PrU, refer the individual to a registered dietitian for a nutritional assessment and care plan including nutritional interventions appropriate to the patient's wishes and condition. Patients who are terminally ill often are catabolic and dehydrated, have central and tissue hypoxia, and have impaired mobility. All of these conditions impede PrU healing.9,16,27,30,81-84 Setting Goals. Healing is sometimes, but not always, possible22,81,83; yet occasionally, some wounds do heal in the days or weeks preceding death.22 Masaki et al70 found no statistically significant difference for time for a PrU to heal, or survival time following development of a PrU, between patients with and patients without cancer. On the other hand, McNees and Meneses,85 from a pool of 36,000 wound assessments, matched 18 patients with cancer and 18 patients without cancer who had a chronic wound (preponderance of PrUs) and found a statistically significant difference in healing between groups (cancer = 44% healed, no cancer = 78%; P = .018) and no significant difference in time to healing (P = .625). The researchers also found that patients with cancer who had wounds that healed had significantly more risk factors (P < .001) than those whose wounds did not heal (2.78 vs 1.50). Patients with cancer and wounds that did not heal had more risk factors than those with cancer whose wounds did heal (6.46 vs 2.78). In addition, once the PrU becomes a chronic and nonhealing open wound, it remains in an inflammatory state, further impairing the potential to heal.86 Realistic expectations must be communicated to and from the individual and family. Healing a Stage II PrU may require only weeks; however, closure of a Stage III or IV PrU requires much more time and effort. Not all individuals receiving palliative care will have enough "living time" left to heal some PrUs. Uncomplicated full-thickness PrUs generally close in weeks to months with proper nutrition, pressure redistribution, and local ulcer care. Because of the time needed to heal, it is also imperative that the individual and family have input into the plan of care for the prevention and treatment of the ulcers. The philosophy of palliative care, to prioritize relief from suffering and provide for an optimal quality of life, should drive both setting goals for care and interventions to meet those goals.2 It is crucial to permit nonhealing of an ulcer to be a realistic goal. Given that healing may not be possible, careful consideration needs to be placed on what interventions are appropriate, because most treatments are likely painful, distressing, or expensive in terms of time and dollars.16,22,26,27,60,82 A review of the literature on the quality of life in patients with PrUs21 concluded that persistent pain is very common in older adults, and the pain arises from several different sources. For an individual with a progressing illness and facing inevitable death, goals for wound care may change from cure to comfort and from life extending to preservation of dignity.87,88 "Not providing treatment to aid wound healing or ending wound treatment to aid wound healing may be not only what the patient wants, but what can or should be done for the patient to be free from pain and other distressing symptoms before they die."22 It is up to each patient to determine the point at which palliative care supersedes curative-focused treatment.2 Recommendations 1.0. Set treatment goals consistent with the values and goals of the individual, while considering the family input (strength of evidence = C).42,89 1.1. Set a goal to enhance quality of life, even if the PrU cannot be healed or treatment does not lead to closure/healing (strength of evidence = C). 1.2. Assess the impact of the PrU on quality of life of the individual and his/her family (strength of evidence = C).2,21,22 1.3. Assess the individual initially and with any significant change in condition to reevaluate the plan of care (strength of evidence = C). PRESSURE ULCER ASSESSMENT A thorough PrU assessment includes physical characteristics, such as stage, location, size, wound bed and periwound condition, and odor and exudate,75,90 as well as factors placing the patient at risk.4,6,11,31,32,35,56-58,91 PrU assessments are designed to help guide treatment decisions to facilitate closure and healing. Healing is seldom the goal for these individuals receiving hospice or palliative care,22 and therefore, there is no purpose to frequently measuring the wound size or deterioration because no plans to intervene will be derived in these measurements. It is important to monitor the ulcer to continue to meet the goals of comfort and reduction in ulcer pain and wound symptoms. Evaluating the ulcer at intervals in conjunction with dressing changes is appropriate. The ulcer will likely worsen as death nears, and less frequent assessment is appropriate to minimize the pain when the dressing has to be removed and the individual has to roll over in bed and hold the position long enough for the measurements to be taken. Recommendations 1.0. Assess the PrU initially and with each dressing change, but at least weekly (unless the individual is actively dying), and document findings (strength of evidence = C).42,75 1.1. Monitor the ulcer in order to continue to meet the goals of comfort and reduction of wound pain, and addressing wound symptoms, such as odor and exudates (strength of evidence = C). PAIN IN PRESSURE ULCERS PrUs are painful.18,19,92-94 In a systematic review, 15 studies addressed the impact of pain and concluded that "pain was the most significant consequence of having a PrU and affected every aspect of patients' lives."21 There are 3 different pain mechanisms in chronic wounds. The first is noncyclic acute wound pain that occurs in a single or infrequent single episode(s). The second is cyclic acute wound pain, which occurs on a more regular basis with wound manipulation or with position changes and treatments. The third is chronic wound pain, or the persistent pain occurring without external stimulation; this pain has a multifactorial etiology, making it difficult to manage. The cause is often ongoing pathology or wound inflammation or infection. This type of pain is frequently called neuropathic, and its etiology can be difficult to discern. Cyclic or noncyclic wound pain is usually of a nociceptive nature resulting from actual tissue damage,95 whereas pain persisting long after tissue damage is neuropathic pain.2,96,97 A study of 32 subjects from acute, home, and extended care found that 87.5% of the subjects experienced pain with a dressing change and 84.4% had pain at rest, compared with 12.5% who reported experiencing no PrU-related pain. Of the 28 who experienced pain, 75% of them rated the pain as mild to distressing, whereas 18% rated it as horrible or excruciating. Pain from PrUs can be the most distressing symptom the patient might report.98 In 1995, Dallam et al99 conducted a cross-sectional survey of 44 hospitalized patients with PrUs at 3-month intervals over 1 year. Subjects able to complete at least 1 pain questionnaire reported experiencing pain, with several having severe pain. Those patients with Stage IV PrUs experienced more pain than individuals with lesser stage ulcers. A study in acute care of 23 patients found that 91% reported a PrU as painful.20 Qualitative research findings provide a description of the patient's pain experience. Pain was the encompassing theme that emerged in 1 study after the interviews of 5 subjects with Stage III-IV PrUs.18 These subjects also often reported pain as constant and adversely affecting their lives. Langemo et al19 interviewed 8 individuals with current or past Stage II-IV PrUs, and all 8 had experienced PrU pain, with extreme pain emerging as 1 of the 7 themes. Several subjects commented that the pain was present most of the time despite the use of analgesics. Rastinehad93 interviewed 10 subjects who were hospitalized with a PrU. Subjects reported the pain as severe and often sharp, throbbing, or burning and called upon healthcare providers to be more sensitive, knowledgeable, and responsive to PrU pain. In a qualitative study of 8 patients living with a PrU, movement was reported to heighten pain, the cycle of pain was reported to be constant and severe, the pain was not always recognized by their physician, and analgesia was not always effective.100 Pain Assessment. The assessment for pain needs to be comprehensive, including objective and subjective assessments. The Numerical Rating Scale, the visual analog scale, and the Faces Pain Rating Scale are effective tools to assess pain in patients who can verbalize and can comprehend data intervals.94,99,101-110 Cognitively impaired patients can be assessed using the above tools or by assessing for specific behaviors, such as withdrawal, grimacing, or crying out, as well as other facial expressions, body movements, vocalizations, changes in activity such as refusing food or rest pattern changes, or mental status changes such as crying or irritability.97,105,111 Researchers have recommended initial and routine pain assessment for all patients with a PrU and regular treatment, beyond just at dressing change time or with manipulation.94Patients relate experiencing pain with these treatments. Patients who are nonverbal should also be understood to have pain, even though they cannot verbally report it. Recommendations: Pain Assessment and Management 1.0. Perform a routine PrU pain assessment every shift, with dressing changes, and periodically as consistent with individual's condition (strength of evidence = B). 1.1. Assess PrU procedural and nonprocedural pain initially, weekly, and with each dressing change (strength of evidence = C).42,75,112 Pain management must be integrated into a treatment paradigm for PrUs. Effectively managing pain to enhance quality of life is an important palliative care goal.2 Despite reports of pain in PrUs, only 3 of 123 patients (2%) with PrUs had received pain analgesia within 4 hours of the pain measurement.99 In another study, only 6% of subjects had received medication for their PrU pain.94 It is unacceptable to have patients experience PrU pain that is controllable. Pain Prevention. PrU pain can be minimized by keeping the PrU wound bed moist and covered, repositioning the patient, and keeping linens organized and fairly taught. Urinary