Risk assessment.

International guidelines recommend pressure ulcer risk assessment for palliative care patients on a regular basis using a structured consistent approach (National Pressure Ulcer Advisory Panel [NPUAP] and European Pressure Ulcer Advisory Panel [EPUAP], 2009). Rather than assessing pressure ulcer risk solely by completing a risk assessment tool, they also recommend using a validated risk assessment tool, a comprehensive skin assessment, and clinical judgment with regard to key risk factors. Pressure ulcer risk assessment can be obtained using the Braden risk assessment form (Reifsnyder and Magee, 2005), the Hunters Hill pressure ulcer risk assessment tool specifically for the individual at or near the end of life (Chaplin, 2000; McGill and Chaplin, 2002), or the Waterloo risk assessment tool. In contrast, many experts suggest that every palliative care patient should be considered at “high risk” for pressure ulcer development (Richards et al, 2007; Walding, 2005).

Factors that contribute to pressure ulcer formation in palliative care patients include fragile skin condition, older age, decreasing food and fluid intake, altered sensation, poor general physical condition, and lean body constitution (Chaplin, 1999; Henoch and Gustaffson, 2003; Naylor and McGill, 2005). Of interest, Brink et al (2006) found that patients who used an indwelling urinary catheter or had an ostomy were more than four times more likely to develop one or more ulcers. Additional unique variables associated with pressure ulcer formation included new pain site, shortness of breath, and inability to lie flat (Brink et al, 2006). One fourth of all palliative home care patients experienced the inability to lie flat because of shortness of breath, which increased the patient’s risk of pressure ulcer formation. Decreased mobility, unrelieved pain, lack of appetite, and muscle wasting are other risk factors for pressure ulcer development in the palliative care patient (Liao and Arnold, 2007; Morgan, 2009; Walding, 2005). Risk assessment should be obtained within 6 to 12 hours of admission and should be reassessed on a daily basis because of the speed with which the palliative patient’s condition can change (McGill and Chaplin, 2002).

Prevention.

Pressure ulcer prevention interventions are vital for the palliative care patient population, particularly because the development and resulting treatment often are painful (Eisenberger and Zeleznik, 2004). At the same time, the pressure ulcer prevention plan of care must be reflective of and consistent with the patient’s clinical picture and end-of-life goals. Reducing or eliminating some risk factors may not be achievable or in accordance with the comfort-focused goals of palliative care (Reifsnyder and Magee, 2005). For example, maintaining the head of bed lower than 30 degrees or turning the patient every 2 hours may not be realistic or consistent with the patient’s wishes. In these instances, complete patient and family education becomes more critical than ever so that the patient and family are fully informed before they make decisions that may lead to pressure ulcer development. At the same time, it is the responsibility of the wound care provider to recommend the support surface that would best redistribute coccyx pressure while accommodating the patient’s need for an elevated head of bed. The international pressure ulcer treatment guidelines (NPUAP-EPUAP, 2009) instruct the care provider to consider changing the support surface to improve pressure redistribution and comfort.

Prevention measures that are most universally appropriate in palliative care include (1) adequate and appropriate offloading with a support surface, (2) adequate pain control for optimal positioning, and (3) incontinence management (containment and skin protection). However, good pain management is critical to being able to provide these basic prevention interventions (Liao and Arnold, 2007). The NPUAP-EPUAP 2009 guidelines stipulate the patient should be premedicated 20 to 30 minutes prior to a scheduled position change when he or she experiences significant pain with movement.

Whether all pressure ulcers that occur in palliative care patients are preventable or whether some are inevitable is not clear (Chaplin, 2004). Debate is growing about the possibility that as death approaches the skin begins to fail, primarily because of altered perfusion, which puts the patient at risk for further breakdown (Stanley et al, 2008). Richards et al (2007) reported that among a group of 61 end-of-life patients in palliative care, 8 of 13 new ulcers developed within 2 weeks of the patient’s death. In another study of palliative care wounds, nearly half of the pressure ulcers healed despite short treatment periods, underscoring the point that palliative wound care measures resulted in significant healing. However, regardless of the outcome of this debate, it is incumbent upon the wound specialist to provide care that is compliant with national guidelines for the prevention of pressure ulcers. Furthermore, documentation should record the implementation of assessments and interventions reflective of the guidelines as well as when interventions were withheld and why. A nosocomial pressure ulcer then can be considered inevitable when it develops even though the care provided met the standard of care for pressure ulcer prevention.