Pressure Ulcers at End of Life: An Overview for Home Care and Hospice Clinicians

Incidence and Characteristics of Hospital-Acquired Pressure Injuries in Acute Palliative Care Patients: A Four-Year Analysis

AIM

To describe the cumulative incidence and characteristics of hospital-acquired pressure injury in acute palliative patients.

DESIGN

Secondary data analysis of hospital-acquired pressure injuries during 2019-2022.

METHODS

The setting was a palliative care unit at a tertiary hospital in Queensland, Australia, including adult (≥ 18 years) acute-phase palliative inpatients. Retrospective data from four databases were used to identify and analyse hospital-acquired pressure injury cases from 2019 to 2022. Clinical characteristics of patients with and without hospital-acquired pressure injury were compared.

RESULTS

The incidence of hospital-acquired pressure injury in acute palliative care patients was 3.9% over the 4 years. These patients were predominantly male, with an average age of 74 years, with 66 of 78 cases developing in the deteriorating palliative care phase. Using the Waterlow Score, 51.3% of patients were assessed as at very high risk of pressure injury. Ninety-five hospital-acquired pressure injuries were reported in 78 patients; 16.8% were medical device-related, 40% were Stage 1 injuries, and the most common injury sites were the sacrum, heels and genitals. Patients with hospital-acquired pressure injury had significantly higher (worse) scores on both the palliative care Resource Utilisation Group-Activities of Daily Living and Problem Severity Scores. Regression analysis identified a high Problem Severity Score on admission as a significant predictor for hospital-acquired pressure injury development.

CONCLUSION

The incidence of hospital-acquired pressure injury in acute palliative patients is lower than in previous studies. However, many injuries occurred in those in the deteriorating phase, with higher scores for severity of symptoms. These findings suggest that acute palliative patients do require nursing care for pressure injury prevention, as well as for symptom management and activities-of-daily-living. Overall, this research contributes to a deeper understanding of pressure injury incidence and characteristics for acute palliative care patients. Future research should focus on population-specific pressure injury risk assessment to explore risk factors in greater detail.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Current pressure injury risk assessment tools, like the Waterlow Score, may not provide the comprehensive evaluation needed for the acute palliative care cohort. To better address the unique needs of this cohort, it may be necessary to refine existing tools or develop new instruments that integrate palliative-specific assessments, such as the Resource Utilisation Group-Activities-of-Daily-Living (RUG-ADL) and Problem (symptom) Severity Score (PSS). These adaptations could help improve pressure injury prevention care planning and enhance outcomes for patients in this setting.

IMPACT

This study separated acute palliative care patients from those at end-of-life and found a 3.9% cumulative incidence of pressure injuries. There were no significant differences in age, gender, or cancer diagnosis between patients with and without injuries. Patients without injuries were more likely to be in the deteriorating phase, while those with injuries had higher (worse) RUG-ADL scores. Regression analysis showed that each one-point increase in the PSS (symptom severity) made patients 1.2 times more likely to develop a pressure injury. The findings suggest that combining a validated risk assessment tool with the RUG-ADL and PSS tools could provide a more accurate risk assessment for hospitalised acute palliative care patients.

REPORTING METHOD

STROBE reporting guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Defining palliative wound care: A scoping review by European Association for Palliative Care wound care taskforce

BACKGROUND

Deciding whether to transition to wound palliation is challenging for health care professionals because there is no agreed definition or understanding of palliative wound care, including the goals, core elements and differences from general wound management.

OBJECTIVES

To conduct a scoping review with qualitative synthesis to define palliative wound care in terms of its conceptual framework, goals, principles, components, and differences from general wound management, and provide a new definition of palliative wound care based on this scoping review.

ELIGIBILITY CRITERIA

Published literature that refers to the definitions, concept, goals and core elements of palliative wound care using any methodological approach, without any time limits, published in English.

SOURCES OF EVIDENCE

The searches were conducted in CINAHL Complete via Ebsco, Medline via Ovid, Cochrane Library, Scopus, and Google Scholar.

CHARTING METHODS

A data extraction form was developed by the review team and used independently for data charting purposes. Braun and Clarke's six phases of thematic analysis guided the qualitative synthesis.

RESULTS

A total of 133 publications met the inclusion criteria. Three main themes were developed to define palliative wound care and understand its differences from general wound management: 1- Healing potential of wounds and patient vulnerability, 2- Understanding the impact on individuals and family to address needs, 3- Towards new goals and perspectives in approach to care.

CONCLUSIONS

Palliative wound care focuses on symptom management, comfort, and dignity, but does not always target the healing of the wound, which is the goal of general wound care. The needs of the individual and their family must be addressed by clinicians through the provision of care and support that takes into account the true meaning of living and dying with a palliative wound.

PROTOCOL REGISTRATION

A review protocol was developed but not registered.

Interactive Evidence-Based Pressure Injury Education Program for Hospice Nursing: A Quality Improvement Approach

PURPOSE

The purpose of this quality improvement (QI) project was to develop and implement an interactive, evidence-based pressure injury (PI) education program and evaluate the impact on frontline hospice nursing staff knowledge and practice.

PARTICIPANTS AND SETTING

The QI setting was a 12-bed inpatient hospice unit in a tertiary care Veterans Affairs (VA) Medical Center in Cleveland, Ohio. Nineteen licensed and unlicensed hospice nursing staff participated in this pre-/postworkshop project.

APPROACH

Chart audit determined baseline PI incidence and prevalence on the inpatient hospice unit. Interviews with key leaders informed the need to develop and implement innovative PI education opportunities. A literature review determined existing standards regarding the benefits of PI education for nursing staff but did not reveal measurable targets in hospice settings. We developed a PI education intervention based on Kolcaba's Theory of Comfort framework and a Plan-Do-Study-Act (PDSA) performance improvement model. Education was delivered in 7 workshops, lasting 2 hours each. Knowledge, practice, and comfort for inpatient hospice nursing staff were evaluated at baseline and 8 weeks following the final refresher visit. Workshop satisfaction was collected once using standard program evaluation forms after final workshop delivery.

OUTCOMES

We observed a significant improvement in staff PI knowledge (P = .001) and practice (P = .001) after initial workshop attendance and repeat engagement (P = .001). There was a large magnitude of effect for overall knowledge change (d = 1.04); similarly PI care planning and practice showed a large magnitude of effect and significant improvement (P = .001, d = 2.64). Staff comfort with job duties was stable with low effect size (mean 4.52, d = 0.04), and satisfaction with the workshop education was high (100% agreement with trainer effectiveness).

IMPLICATIONS FOR PRACTICE

We found that frontline hospice nursing staff knowledge and practice improved after attendance at our evidence-based PI education program. Results of this QI project have stimulated ongoing discussion on how to sustain this program in our hospice setting.

Promoting and Maintaining Skin Integrity in End-of-Life Care: A Systematic Review

OBJECTIVE

To systematically review recommendations for promoting and maintaining skin integrity in end-of-life care and their level of evidence.

DATA SOURCES

MEDLINE (PubMed interface), CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and The Cochrane Library were systematically searched using a combination of key terms including end-of-life care, skin care, skin hygiene, and skin cleansing.

STUDY SELECTION

Articles were included if they (1) described skin care recommendations, including but not limited to the use of skin care products and interventions such as cleansing procedures; and (2) included adult patients who were expected to die within 12 months. There were no restrictions on study design, study setting, or language. Articles with a publication date before 2000 were excluded.

DATA EXTRACTION

Two data extraction forms were developed. The first included information about the author, publication year, type of evidence, study topic, sample, sample size, setting, limitations of the study, level of evidence, and quality of the study. The second included recommendations for promoting and maintaining skin integrity in patients at the end of life.

DATA SYNTHESIS

Because of methodological heterogeneity, results were synthesized narratively, and no meta-analysis was performed.

CONCLUSIONS

The information contained in the recommendations will assist nurses in promoting and maintaining skin integrity in patients at the end of life. More research is needed on end-of-life skin care, with an emphasis on patient-centered, holistic strategies that improve patient well-being and quality of life. In most current research, recommendations are limited to literature reviews and level V evidence. Skin care must balance the promotion and maintenance of skin integrity, wound prevention, and management while promoting patient dignity and quality of life.

Palliative care aspects of wound healing in complex patients: a case report

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Preventing and managing pressure ulcers in patients receiving palliative care

Pressure ulcers are more common in patients being cared for in palliative care settings than in the general population. Patients with life-limiting illnesses are living longer than ever before, and many present with multiple co-morbidities. Palliative care involves improving the patient's quality of life by achieving a balance between treatment, comfort and maintaining dignity. The length of time required to heal pressure ulcers in this patient population can prove challenging, requiring significant resources and expertise. However, when the appropriate nursing expertise and resources are available, prevention, improvement and healing of pressure ulcers are achievable.

Prevalence, incidence and associated factors of pressure injuries in hospices: A multicentre prospective longitudinal study

BACKGROUND

Patients in palliative care are the population cohort that most frequently develop pressure injuries, severely impacting their quality of life. Data from prospective studies on the prevalence and incidence of pressure injuries in hospices are lacking.

AIM

To describe the point prevalence and cumulative incidence of pressure injuries in patients admitted to residential hospices, and to analyze their predictive factors over time.

DESIGN

Multicentre prospective longitudinal observational study.

SETTING/PARTICIPANTS

Adult patients (n = 992) enrolled in 13 Italian residential hospices, with a minimum sample of 280 for each macro-region (North, center, South/Islands).

METHODS

Assessments including the Karnofsky Performance Status, Braden, Edmonton Symptom Assessment System Revised scales and pressure injury staging according to National Pressure Ulcer Advisory Panel were conducted at least every four days, from admission to patients' death/discharge.

RESULTS

The 7,967 observations recorded provided prevalence and incidence rates of 34.1% and 26.5%, respectively. The logistic regression model showed non-cancer disease (OR = 2.39, 95%CI = 1.65-3.47), age >80 (OR = 2.01, 95%CI = 1.49-2.71), Braden score 'at risk' (OR = 1.92, 95%CI = 1.17-3.14), urinary catheter (OR = 1.96, 95%CI = 1.40-2.75), drowsiness (OR = 1.41, 95%CI = 1.02-1.95) and artificial nutrition (OR = 1.47, 95%CI = 1.01-2.14) as the variables associated with pressure injury at admission. The generalized estimating equations models, built on the timeframes for observation groups, revealed male gender (OR = 1.68, 95%CI = 1.01-2.79) and Braden score 'at risk' (OR = 4.45, 95%CI = 1.74-11.34) as predictive factors of a new pressure injury developed up to three weeks before a patient's death, while in the last ten days of life these predictors were replaced by diagnosis of cancer (OR = 1.80, 95%CI = 1.11-2.91), worsening pain (OR = 1.65, 95%CI = 1.10-2.49), drowsiness (OR = 1.79, 95%CI = 1.25-2.57) and dyspnea (OR = 1.48, 95%CI = 1.01-2.18).

CONCLUSIONS

The high incidence and prevalence of pressure injuries confirm the importance of palliative care nurses continuously focusing on prevention and management strategies. In the last three weeks of a patient's life, the predictive power of the Braden scale for a new pressure injury is not confirmed, throwing doubt on the effectiveness of aimed interventions at modifying risk factors. Along the different disease trajectories, pressure injuries developed during the instability/worsening phases of illness, occurring before hospice admission for non-cancer patients and in the end-of-life phase for cancer patients. Despite continuous provision of appropriate interventions, most of the new pressure injuries were detected during the last ten days of a patient's' life and assessed as 'unavoidable'. These results are crucial to guiding palliative care nursing plans during the different phases of illness, and to predicting care needs, possible management strategies ('wound management' vs. 'wound palliation'), and resource utilization.

An Introduction to Skin as an Interface: Implications for Interprofessional Collaboration and Whole-Person Care

GENERAL PURPOSE

To increase health care professionals' awareness and perceptions of the skin as one of the largest body organs with multidimensional aspects and significant implications for interprofessional collaboration in whole-person care.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Apply physiologic and integumentary knowledge to assessing common skin variations and problems.2. Summarize the results of the authors' literature review of the evidence regarding the emotional, psychosocial, cultural, and spiritual aspects of skin health and disorders.

ABSTRACT

The skin reflects not only a person's physical state of health, but also the dynamic interplay of emotional and cultural influences. This article will increase health practitioner understanding of the skin and skin assessment by highlighting its multidimensional aspects and significant implications for interprofessional collaboration in whole-person care. Through a multidimensional assessment of the skin, practitioners can better understand the health story of each patient and intervene holistically to improve overall well-being and quality of life.

Pressure Injury Progression and Factors Associated With Different End-Points in a Home Palliative Care Setting: A Retrospective Chart Review Study

CONTEXT

Patients with advanced illnesses show the highest prevalence for pressure injuries. In the palliative care setting, the ultimate goal is injury healing, but equally important is wound maintenance, wound palliation (wound-related pain and symptom management), and primary and secondary wound prevention.

OBJECTIVES

To describe the course of healing for pressure injuries in a home palliative care setting according to different end-points, and to explore patient and caregiver characteristics and specific care activities associated with their achievement.

METHODS

Four-year retrospective chart review of 669 patients cared for in a home palliative care service, of those 124 patients (18.5%) had at least one pressure injury with a survival rate less than or equal to six months.

RESULTS

The proportion of healed pressure injuries was 24.4%. Of the injuries not healed, 34.0% were in a maintenance phase, whereas 63.6% were in a process of deterioration. Body mass index (P = 0.0014), artificial nutrition (P = 0.002), and age <70 years (P = 0.022) emerged as predictive factors of pressure injury complete healing. Artificial nutrition, age, male caregiver (P = 0.034), and spouse (P = 0.036) were factors significantly associated with a more rapid pressure injury healing. Continuous deep sedation was a predictive factor for pressure injury deterioration and significantly associated with a more rapid worsening.

CONCLUSION

Pressure injury healing is a realistic aim in home palliative care, particularly for injuries not exceeding Stage II occurring at least two weeks before death. When assessing pressure injuries, our results highlight the need to also pay attention to artificial nutrition, continuous deep sedation, and the caregiver's role and gender.

Prevalence, incidence and associated factors of pressure ulcers in home palliative care patients: A retrospective chart review

BACKGROUND

Terminally ill patients are at high risk of pressure ulcers, which have a negative impact on quality of life. Data about pressure ulcers' prevalence, incidence and associated factors are largely insufficient.

AIM

To document the point prevalence at admission and the cumulative incidence of pressure ulcers in terminally ill patients admitted to an Italian home palliative care unit, and to analyse the patients' and caregivers' characteristics associated with their occurrence.

DESIGN

Retrospective chart review.

SETTING/PARTICIPANTS

Patients ( n = 574) with a life expectancy ⩽6 months admitted to a palliative home care service were included in this study.

RESULTS

The prevalence and incidence rates were 13.1% and 13.0%, respectively. The logistic regression models showed body mass index ( p < 0.001), Braden score at risk ( p < 0.001), Karnofsky Performance Scale index <30 ( p < 0.001), patients' female gender, patients' age >70 and >1 caregiver at home as the dichotomous variables predictors of presenting with a pressure ulcer at time of admission and during home palliative care.

CONCLUSION

The notable pressure ulcers' incidence and prevalence rates suggest the need to include this issue among the main outcomes to pursue during home palliative care. The accuracy of body mass index, Braden Scale and Karnofsky Performance Scale in predicting the pressure ulcers risk is confirmed. Therefore, they appear as essential tools, in combination with nurses' clinical judgment, for a structured approach to pressure ulcers prevention. Further research is needed to explore the home caregivers' characteristics and attitudes associated with the occurrence of pressure ulcers and the relations between their strategies for pressure ulcer prevention and gender-related patient's needs.

Time to get serious about assessing - and managing - psychosocial issues associated with chronic wounds

PURPOSE OF REVIEW

This article comprises a review of the literature published during the period January 2011 to June 2012 on the topic of the psychosocial impact of wounds and strategies to manage them.

RECENT FINDINGS

There is a growing discussion of the reciprocal link between psychological influences and wound healing. Although the mechanisms underlying these influences are not well understood, evidence from the reviewed literature adds to the existing body of evidence demonstrating that negative psychological states can impair immune function and wound healing. Despite this recognition, there are still few studies that provide strategies to address the identified psychosocial issues associated with wounds, particularly those of chronic duration.

SUMMARY

A wide range of psychosocial factors likely to be associated with a wound have been identified. The importance of understanding the nature and extent of their impact is illustrated by the patients' experiences of living with a chronic wound which they rate as serious as cancer or myocardial infarction. Although there is currently limited evidence on which to base management strategies, it is recommended that interventions should commence with a comprehensive individualized assessment which can then inform the development of an appropriate management plan that includes the identified psychosocial issues.