Factors Associated With the Management of Pressure Injuries at the End of Life: A Scoping Review

Pressure injuries are a major problem in all health care settings. The incidence of pressure injuries at the end of life is as high as 58% in some facilities, and there is little consensus on how pressure injuries are managed at the end of life. A scoping review was conducted, to investigate what is known of the factors associated with the management of pressure injuries at the end of life. Literature was sourced from several databases. A total of 1760 potential sources were identified; after applying the Population Concept Context inclusion and exclusion criteria, 16 empirical research articles were sourced: 10 were quantitative, 5 were qualitative, and 1 was mixed methods. Studies were published between 2003 and 2021 and originated from Italy, the United States, Australia, Sweden, Brazil, Taiwan, Turkey, and Canada. Key interventions included regular second hourly turning, wound debridement, wound assessment, and application of various wound coverings. The most widely discussed management strategy, regular second hourly turning, proved controversial and inconsistent in practice. There were also inconsistencies with wound assessment, with practice not always following best evidence-based assessment guidelines. Research findings also highlighted issues with prognostication and identification of the end-of-life phase with no consistent tool applied to assist end-of-life pressure injury management decision-making.

Knowledge, attitude and practice of family caregivers on pressure injury prevention for community-dwelling older adults: a cross-sectional study in an Indonesia City

BACKGROUND

Older adults in Indonesia are mostly living at home with their families. Informal care provided by family caregivers is essential to prevent older adults from getting pressure injuries (PIs). The objectives of this study were to examine the knowledge, attitude and practice of family caregivers regarding PI prevention among community-dwelling older adults in Indonesia.

METHODS

A cross-sectional survey was conducted involving 267 family caregivers randomly selected from a population list provided by municipalities in Bandung, West Java, Indonesia. The study utilized the paper-based Knowledge, Attitude, and Practice on Pressure Injury (KAP-PI) questionnaire. Descriptive analyses (i.e. percentage, mean and standard deviation) were used to present participants' scores in each domain based on their characteristics or categories and scores in every single item of questions or statements. Bivariate comparison analyses were conducted using independent t-test or ANOVA test to compare scores and a Chi-square was run to check correlations between knowledge, attitude and practice domains.

RESULTS

This study show that more than half of the participants (61.0%) had insufficient knowledge about PI prevention, but nearly all participants (94.4%) had a positive attitude toward PI prevention for their older relatives. Still, 41.2% of the participants had inadequate practice on PI prevention. A correlation analysis revealed that having sufficient knowledge and a positive attitude towards PI prevention were positively correlated with practice (p < .05).

CONCLUSION

This study highlights a significant gap in family caregivers' knowledge and practice regarding pressure injury (PI) prevention, despite their generally positive attitudes toward the care of older relatives. The findings are the initial diagnosis to guide educational strategies. Research should be performed to explore effective educational materials and an education program and also the necessary professional support to strengthen family caregivers' role in PI prevention.

Development and psychometric evaluation of an instrument to assess Knowledge, Attitude and Practice of Family Caregivers at Preventing Pressure Injuries (KAP-PI) in Indonesian community-dwelling older adults

Background

The prevalence of pressure injuries among community-dwelling older adults in countries worldwide is still a serious problem. In Indonesia, older adults mostly rely on family members for (medical) care. Therefore, involving family members in the prevention and treatment of pressure injuries (PIs) could potentially decrease its prevalence rates. However, family members are usually not trained for such tasks. Hence, it is essential to first get more insight into the current state of affairs on family members’ knowledge, attitude and actual practice of preventing PIs. Due to the lack of an existing instrument to measure knowledge, attitude and practice of family caregivers in preventing PIs, this study focuses on the development and evaluation of psychometric properties of such an instrument.

Methods

Three phases of instrument development and evaluation were used, including item generation, instrument construction and psychometric testing of the instrument. A total of 372 family caregivers of community-dwelling older adults who randomly selected participated in this study. Principal factor analysis, confirmatory factor analysis and Cronbach’s alpha were performed to evaluate factor structure and internal consistency of the Knowledge, Attitude and Practice of Family Caregivers at Preventing Pressure Injuries (KAP-PI) instrument.

Results

The final version of the KAP-PI-instrument consists of a 12-item knowledge domain, a 9-item attitude domain, and a 12-item practice domain with Cronbach’s Alpha values of 0.83, 0.93 and 0.89, respectively. The instrument appeared to be both reliable and valid.

Conclusion

The KAP-PI instrument can be used in family nursing or community nursing practice, education, and research to assess knowledge, attitude and practice of pressure injury prevention of family caregivers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00957-4.

Does Recognition of the Dying Phase Have an Effect on the Use of Medical Interventions?

During the dying phase, patients often receive interventions that are not aimed at promoting their comfort. We investigated how recognition of the dying phase affects the use of interventions by comparing patients for whom the dying phase had been recognized with patients for whom it had not been recognized. We included 489 of 613 patients (80%) who died either in a hospital, nursing home, or primary care setting between November 2003 and February 2006. After the death of patients, nurses filled in questionnaires, and patient records were searched for information about therapeutic and diagnostic interventions applied during the dying phase. Caregivers had recognized the dying phase of 380 patients (78%). The number of patients who had received diagnostic interventions during the last three days of life was significantly lower when the dying phase had been recognized (39% vs. 57%) (p=0.00). Therapeutic interventions were used in similar frequencies in both groups. We conclude that recognition of the dying phase reduces the number of undesirable diagnostic interventions.

Palliative Wound Care at the End of Life

Wound care, a form of palliative care, supports the health care needs of dying patients by focusing on alleviating symptoms. Although wound care can be both healing and palliative, it can impair the quality of the end of life for the dying if it is done without proper consideration of the patient’s wishes and best interests. Wound care may be optional for dying patients. This article will discuss the ethical responsibilities and challenges of providing wound care for surgical wounds, pressure ulcers, and wounds associated with cancer as well as wound care in home health compared to end of life.

Análise da prevenção e tratamento das úlceras por pressão propostos por enfermeiros

A úlcera por pressão ainda é considerada um problema grave, especialmente em pessoas idosas e nas situações de adoecimento crônico-degenerativo. O objetivo do estudo consistiu em identificar as produções bibliográficas sobre ações de prevenção e tratamento realizadas por enfermeiros publicadas no período de 1999 a 2004, descrevendo o conhecimento produzido na temática. Trata-se de levantamento bibliográfico descritivo de periódicos de enfermagem indexados na LILACS e MEDLINE, acerca da temática no período de 1999 a 2004. A coleta de dados ocorreu entre os meses de maio a junho de 2005. Procedeu-se o exame do material que compreendeu leitura exaustiva, o que proporcionou a identificação de três aspectos estudados: prevenção das úlceras por pressão, tratamento das úlceras por pressão e cuidados de enfermagem às úlceras por pressão. Concluiu-se ainda a necessidade de pesquisas envolvendo a atuação do enfermeiro na avaliação clínica do cliente e no desenvolvimento de programas de prevenção sistematizados.

Wounds in advanced illness: a prevalence and incidence study based on a prospective case series

A prospective observational sequential case series was studied in order to ascertain an accurate inventory of the various wound types, their point prevalence and incidence rates and their anatomic locations in patients with advanced illness. Five hundred and ninety-three patients were serially assessed until their deaths. Forty-three individual wound types were identified and grouped into nine distinct classes. Data were stratified between patients suffering from malignant and non malignant disorders. One thousand and thirty-six individual wounds (average 1.8 wounds per patient) were identified at baseline. Eight hundred and ninety-one individual wounds (average 1.5 wounds per patient) were identified between baseline and their date of death. Pressure ulcers constituted the most commonly occurring wound class affecting more than 50% of all patients. Malignant wounds were observed only in cancer patients. Baseline point prevalence for pressure ulcers, traumatic wounds, venous ulcers and arterial ulcers in non cancer patients exceeded that in cancer patients. At baseline, iatrogenic wounds were more prevalent in cancer patients than in non cancer patients. Incidence rates for pressure ulcers, traumatic wounds, diabetic ulcers, arterial ulcers and ostomies in non cancer patients exceeded those in cancer patients. The broad range of wounds along with high rates of prevalence and incidence, identified in this study, reflects that wounds represent a significant management issue for patients with advanced illness. Therefore, there exists a need for advancement in modalities and measures aimed at risk assessment, prevention and appropriate goal-oriented management.

Factors Associated with Pressure Ulcers in Palliative Home Care

BACKGROUND

Studies have identified factors associated with pressure ulcers in many health care settings including acute care, complex continuing care, long-term care, and home care.

OBJECTIVE

The purpose of this study was to identify factors associated with pressure ulcers among palliative home care clients. Identifying associations specific to each setting is important for ulcer prevention and has implications for clients overall well-being and quality of life.

METHODS

The study included all palliative home care clients diagnosed with terminal cancer from one palliative home care agency in Ontario. Information on health was gathered using the interRAI instrument for palliative care.

RESULTS

The study found male gender, the inability to lie flat because of shortness of breath, catheter, or ostomy care, and a reduced ability to perform activities of daily living to be associated with pressure ulcers.

SIGNIFICANCE OF RESULTS

In some instances, treatment and prevention of pressure ulcers is the primary goal of care. However, pressure ulcers are also suggestive of deterioration and considered as a part of the disease trajectory. Sometimes the primary goal of care of treatment and prevention is displaced by a greater need for comfort.

When the goal is palliative care

OBJECTIVE

An analysis of the literature regarding palliative care of patients with wounds.

DATA SOURCES

Health care literature, including national and international reports, focusing on enhancing quality of life for individuals with wounds who are receiving palliative care.

CONCLUSION

The literature on palliative care of patients with wounds is limited. Integration of palliative care concepts and chronic wound management is challenging; however, palliative care, which focuses on comfort and symptom management for quality of life, can provide the best quality care within the parameters of disease and individual patient wishes.

Care planning for pressure ulcers in hospice: The team effect

Objective: The standards of care for patients at risk for or with a pressure ulcer in hospitals and nursing homes focus on prevention and ulcer healing using an interdisciplinary approach. Although not a primary hospice condition, pressure ulcers are not uncommon in dying patients. Their management in hospices, particularly the involvement of family caregivers, has not been studied. The objective of this study is to identify the factors that influence care planning for the prevention and treatment of pressure ulcers in hospice patients and develop a taxonomy to use for further study.

Methods: A telephone survey was conducted with 18 hospice directors of clinical services and 10 direct-care nurses. Descriptive qualitative data analysis using grounded theory was utilized.

Results: The following three themes were identified: (1) the primary role of the hospice nurse is an educator rather than a wound care provider; (2) hospice providers perceive the barriers and burdens of family caregiver involvement in pressure ulcer care to be bodily location of the pressure ulcer, unpleasant wound characteristics, fear of causing pain, guilt, and having to acknowledge the dying process when a new pressure ulcer develops; and (3) the “team effect” describes the collaboration between family caregivers and the health care providers to establish individualized achievable goals of care ranging from pressure ulcer prevention to acceptance of a pressure ulcer and symptom palliation.

Significance of results: Pressure ulcer care planning is a model of collaborative decision making between family caregivers and hospice providers for a condition that occurs as a secondary condition in hospice. A pressure ulcer places significant burdens on family caregivers distinct from common end-of-life symptoms whose treatment is directed at the patient. Because the goals of pressure ulcer care appear to be individualized for a dying patient and their caregivers, the basis of quality-of-care evaluations should be the process of care rather than the outcome of an incident pressure ulcer.

"Beauty is only skin deep": prevalence of dermatologic disease on a palliative care unit

Skin disease affects the palliative care patient population because of their immunosuppressed state and decreased mobility; however, the prevalence of skin disease in this population has not been studied. We collected dermatologic histories and examinations of patients admitted to a hospital-based tertiary palliative care unit. Repeat examinations were performed to assess the incidence of cutaneous disease, as well as the progression of existing conditions. Sixteen of 65 patients admitted during 9 consecutive weeks participated in regular examinations. Six patients developed decubitus ulcers or had progression of existing ulcers. Dermatitis, xerosis, and pruritus were common diagnoses. Six patients sustained cutaneous trauma. Of the 49 non-participating patients, 4 developed decubitus ulcers, 1 had a drug reaction, and 3 had cutaneous infections. Palliative care patients are prone to developing decubitus ulcers and cutaneous infections. Aggressive control of systemic symptoms may exacerbate skin disease. Consideration of dermatologic conditions is an important factor in optimizing skin control in this population.