palliative wound care-balancing the burdens & benefits for...

8/31/2016

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PALLIATIVE WOUND CARE:

BALANCING THE BURDENS &

BENEFITS FOR PATIENTS ON

HOSPICE CARE

Pamela ScarboroughPT, DPT, CDE, CWS, CEEAA

Director of Public Policy and Education

America Medical Technologies

DisclaimerThe information presented herein is provided for educational and

informational purposes only and to promote the safe-and-

effective use of the wound care products provided. It is for the

attendees’ general knowledge and is not a substitute for legal or

medical advice. Although every effort has been made to provide

accurate information herein, laws change frequently and vary

from state to state. The material provided herein is not

comprehensive for all legal and medical developments and may

contain errors or omissions. If you need advice regarding a

specific medical or legal situation, please consult a medical or

legal professional. Gordian Medical, Inc. dba American Medical

Technologies shall not be liable for any errors or omissions in this

information.Copyright © 2016 Gordian Medical, Inc. dba American

Medical Technologies. www.amtwoundcare.com

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• This program will discuss ideas and treatments for preventing

pressure injuries in patients/residents on palliative/hospice

care.

• In addition, the presentation will review appropriate goals

and interventions for palliative wound care for patients who

are receiving hospice care.

Copyright © 2016 Gordian Medical, Inc. dba American


Article Available for You

Guidelines for Wound Management in Palliative Care

• Basic wound care article.

• Contains good palliative wound care principles.

• Author out of New Zealand so some products are different

than those in U.S.

• Great section on Guide to Wound Dressings for those who are

not wound specialists or just starting wound care as part of

their practice.

• Excellent supplement to this talk.



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This Article Has Been Provided for You to

Download

• White paper from the National Pressure Ulcer Advisory Panel



Promotes Quality of Life

Palliative Care

Affirms Life

Treats the Person

Supports the Family

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Palliative Care’s Overreaching Goal

• “Goal is MUCH MORE than comfort in dying;

• Palliative care is about living, through meticulous attention to

control of pain and other symptoms, supporting emotional,

spiritual, and cultural needs, and maximizing functional

status.”

• Credit: Nse. Punithavathi Inbanathan



National Pressure Ulcer Advisory Panel

• “The goals of palliative wound care are comfort for the

individual and limiting the impact of the wound on quality of

life, without the overt intent of healing.”



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Pressure Injury (PI) Risk in Individuals with

Advanced or Terminal Disease

• These patients are at significant risk for pressure injury

• Stage 3 and 4 pressure injuries common

• Majority of PI in hospice occur ~2 weeks before death

• Correlates with physiological shut down of body systems 10-

14 days before death



Risk Factors for Pressure Injury in Hospice Patients

• Advanced age

– Skin drier, fragile, easily injured

– Thinner skin more vulnerable to pressure injury

• Protein-calorie malnutrition

– 50-85% of older individuals in LTC

– Lean body mass decreased; associated with PI development

– Catabolism common in older patient group

– Unintentional weight loss increases risk of developing PI by 147%



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Wounds at Life’s End• Affect up to 35% of patients at life’s end

• ~ 50% of these wounds are pressure injuries

• ~ 20% are ischemic wounds (PAD)

Heel Pressure Injury

DTI

Arterial Insufficiency

PAD

Wounds at Life’s End (con’t.)• ~ 30% mixture of various wound etiologies

– Malignant fungating wounds

– Fistulae

– Radiotherapy skin reactions

– Surgical wounds turned to chronic wounds

– Venous insufficiency/lymphedema

– Diabetic neuropathic wounds

– Skin tears

– ~ 2 million patients in hospice care

– Approximately 700,000 people

need palliative wound care each year



Fungating Wound

Phlebolymphedema

Venous Insufficiency

and

Lymphedema

in the same leg

Skin Tear

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End of Life Considerations

• May involve short periods of overwhelming illness (acute)

• Or slow deterioration lasting months to years (chronic)

• In both cases, the skin becomes particularly vulnerable to

breakdown

• Witkowski and Parish concluded that skin breakdown is

often unavoidable at this point



Wound Care at Life’s End

• May be component of palliative care

• Focus on alleviating symptoms

• Pain

• Wound odor

• Exudate control

• If not addressed adequately, can lessen

quality of life even more



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Prolonging Life• Medical technologies & life-sustaining interventions common

• Sustain life often beyond ability of skin to maintain its integrity

• Skin failure & pressure injuries in

older adults & the terminally ill

is not always preventable!!!

• May lead to what is termed:

� “Permissible Pressure Ulcer”

� “Skin failure”

� “Unavoidable Pressure Ulcer”

� “Kennedy Terminal Ulcer”



SKIN CHANGES AT LIFE'S END

SCALE

&

THE KENNEDY TERMINAL ULCER

WITHIN THE CONCEPT OF

PALLIATIVE CARE

Pamela ScarboroughPT, DPT, MS, CDE, CWS, CEEAA

Director of Public Policy & Education

American Medical Technologies

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Background

Organ dysfunction

•Acute critical illness

•Trauma

•At life’s end

Organ shut down

•Injury / interference with

systems

•May lead to death

SKIN:

Decreased ability to utilize nutrients to sustain normal functionCopyright © 2016 Gordian Medical, Inc. dba American


S.C.A.L.E.



• Skin Changes At Life’s End

• Expert panel published paper in 2008

• Current understanding of complex skin changes at life’s end

limited

What we do know:

“Not all pressure ulcers are avoidable”

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SCALE

Observable Skin Changes

At Life’s End

Current

UnderstandingPhenomenon

Limited

Additional Research Needed

Better Education: Clinicians, Laypeople,

Policy Makers

Conclusions from SCALE Expert Panel



Skin Barrier Failure

• Largest organ

• Fails like other organs

• Acute, chronic, or end-stage skin failure



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Skin breakdown inevitable for some

Healing often not be realistic goal

New pressure ulcers may occur in this venerable

population

Intervention in accordance with

individuals wishes

NPUAP supports concept of unavoidable pressure injury in the context of

multisystem organ failure in pts receiving palliative care



Robust section on

prevention and

treatment of

pressure

injuries in patients

receiving palliative

care

Aging Changes Skin

• 80% of adults older than 65 suffer one or more chronic

conditions

• Drug therapies contribute to fragility of skin

• Advanced age, comorbidities, medications, environmental

factors and lifestyle contribute to overall condition of skin

• Making skin unable to tolerate the collective magnitude

of insults at life’s end

• Outcome=Skin Failure



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Skin Deterioration

• In the failing individual, skin deterioration is often

the most outward manifestation of overall faltering

physiology

• Jane Fore, MD



Skin Failure

Langemo and Brown define

“skin failure” as:

• an event in which the skin

and underlying tissue die due

to hypoperfusion that occurs

concurrent with severe

dysfunction or failure of the

organ systems.



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Multiple Organ Failure and

Skin Failure

Multiple/Multi-Organ Failure (MOF)

is considered a

terminal stage of many diseases that occur as

the body wastes away…”

Multiple/Multi-Organ Failure (MOF)

is considered a

terminal stage of many diseases that occur as

the body wastes away…”



Organ Failure Stratification

Acute

ChronicEnd-Stage

Skin Barrier

Failure



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Acute Skin Failure

• Hypoperfusion to

skin & underlying

tissue

• Concurrent with

critical illness

• ICU/Acute care

setting



Chronic Skin Failure

• Hypoperfusion concurrent with ongoing, chronic

disease states

• Occurs in a more steady fashion

• Usually older with multiple co-morbidities

Internal organ systems increasingly

& irreversibly lose their ability to

function as the end of life nears



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Chronic Skin Failure

Loss of fat & muscle

mass

Loss of fat & muscle

mass

Decreased mobility

Decreased mobility

Skin & underlying

tissue changes

Skin & underlying

tissue changes

Chronic illness

Older population

Multiple co-morbidities

Decline in mentation

& function

Malnutrition



End-Stage Organ Decompensation & Failure

• Large and unusual presentations of skin failure

• Body shunts blood to vital organs

• Widespread & deep tissue destruction over stressed areas can appear in a matter of hours

– Sacrum

– Heels

– Posterior calf muscles

– Arms

– Elbows



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End-Stage Skin Failure

• Skin and underlying tissue die due to hypoperfusion

concurrent with end of life

• Challenges to maintaining skin integrity

• Transition from acute to chronic to end-stage - not easily

observable continuum



Kennedy or End of Life Wounds

• Large ulcers in a butterfly or pear shape

• Rapid onset

• Progresses to full thickness wounds

• Often precursor to multi-organ failure

• End of life ulcer

• Exact cause unknown

• Usually appear 2-6 weeks before deathCopyright © 2016 Gordian Medical, Inc. dba American


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Avoidable vs. Unavoidable

Pressure Ulcers•

• It is important to consider that the skin is a major

organ and can fail just as other organs of the body

fail (e.g., heart, kidney, liver failure)

• The unavoidable pressure ulcer has been defined

by CMS as a category of wound that is not

preventable due to the resident’s fragile and

declining physical condition, such as when there is

multi-system organ failure or end-of-life conditions



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CMS:

Considered to be an Unavoidable Pressure Ulcers in the LTC Setting

F314

• Resident developed a pressure ulcer even

though the facility:

– Evaluated the resident’s clinical condition and

risk factors

– Defined and implemented interventions that

are consistent with resident needs, goals, and

recognized standards of practice

– Monitored and evaluated the impact of the

interventions

– Revised interventions as appropriateCopyright © 2016 Gordian Medical, Inc. dba American


Unavoidable

Pressure

Ulcer

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PALLIATIVE PRESSURE INJURY PREVENTION

STRATEGIES



Practical Pointers

Care of Fragile Skin• Avoid soap

• Use a pH-balanced cleanser

• Apply moisturizers

• Organic coconut oil

• Apply a moisture barrier

• Protect skin from incontinence

• Clean skin very well after bouts

of incontinence

• Particularly fecesCopyright © 2016 Gordian Medical, Inc. dba American


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INTERVENTIONS

to Mitigate Chronic Skin Failure

Well documented multidisciplinary interventions:

-Nutritional support

-Hydration

-Medical management

-Skin hygiene

-Functional rehabilitation

-Pressure redistributing surface selection



Pressure Distribution

• Reposition and turn the individual at periodic intervals, in

accordance with the individual’s wishes, comfort and

tolerance.

• Strength of Evidence = C

• Strength of Recommendation = ��



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Repositioning & Early Mobilization for

Individuals Receiving Palliative Care (con’t.)

• Strive to reposition individual receiving palliative care at

least every 4 hours on a

pressure redistributing mattress

such as viscoelastic foam, or

every 2 hours on a regular

mattress.

SoE= B; SoR = ��

• Document turning and repositioning, as well as the

factors influencing these decisions (e.g., individual

wishes or medical needs).

• (SoE=C; SoR = ��) Copyright © 2016 Gordian Medical, Inc. dba American


Repositioning and Early Mobilization

for Individuals Receiving Palliative Care

• Pre-medicate the individual 20 to 30 minutes prior to a

scheduled position change for individuals who experience

significant pain on movement. (SoE=C; SoR=��)

• Consider the individual’s choices

in turning, including whether

she/he has a position of comfort,

after explaining the rationale for

turning. (SoE=C; SoR= ��)

• Consider changing the support surface to improve pressure

redistribution and comfort. (SoE = C; SoR = ��)



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Nutrition and Hydration

• Strive to maintain adequate nutrition and

hydration compatible with the individual’s

condition and wishes.

• Adequate nutritional support is often not

attainable when the individual is unable or

refuses to eat, based on certain disease

states. (SoE = C; SoR = ��)

• Offer nutritional protein supplements when

ulcer healing is the goal. (SoE = C; SoR = ��)



PALLIATIVE WOUND CARE PRINCIPLES



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Clinicians should strive to distinguish:

Healable Wounds

Maintenance Wounds

Nonhealable Wounds

• Have adequate blood supply

• Can heal if underlying causes addressed

• Healing potential• Patient/resident or health system barriers

compromising healing• Patient/residents may be nonadherent to treatment • Patients/residents may have resource limitations

• Includes palliative wounds

• Cannot heal due to irreversible causes/illnesses

• Critical ischemia

• Non treatable malignancy

Maintenance and Nonhealable

Wounds

• Consider conservative approach to treatment

– I.e. conservative debridement of slough

• Bacterial reduction through antisepsis and moisture

reduction

• Focus should be on patient-centered concerns

• Especially pain and optimizing ADLs



• Wound on many people at life’s end

heal

• Please give them a chance

• Prevent the increased quality of life

decline that chronic wounds bring

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Wound Bed Preparation ModelPerson with a

chronic wound

Treat the causePatient/Family

Centered Concerns

Local Wound Care

Sibbald: 2011,2014, 2015

Determine Healability: Healable, Maintenance, Nonhealable, Palliative

Edge EffectMoisture

ManagementInfection

InflammationDebridement Periwound

Skin

1. Focus on Preventing and Relieving Suffering

• Focused on preventing and relieving suffering of the

individual with life-threatening illness and his or her

significant others through:

– Identification, assessment and relief of distressing physical,

psychosocial and spiritual issues, and pain while neither

hastening nor prolonging death



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2. Goals of care

• Goals of care should be established in collaboration with the

individual and his or her significant others.

• To the extent possible, allow the individual to direct care.



Goals for Palliative Wound Care

Prevent wound from getting larger

Prevent new pressure injuries

Prevent infection

Manage odor & exudate

Assess & treat pain/ discomfort



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3. NOT Lack of Care

• Palliative pressure ulcer care is not ‘lack of care’, but care

focus on comfort and limiting the extent or impact of the

wound

• Prevention of new pressure ulcers remains important;

however, during the period of active dying, comfort and/or

the individual’s preference may override implementation of

active prevention strategies.



General Principles

for Pressure Ulcer Management

• Manage and control individual’s symptoms

• Promote best quality of life

• Neither hasten nor prolong death process

• Collaborative goals for care with individual & family

• Where possible allow individual to direct care

• Focus on comfort

• Limit impact of wound on quality of life

• Implement current wound care interventions that meet the standards of care with caveats for palliative/hospice care (e.g. Dakin's solution for longer than 2-3 days)



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Practical Pointers

• Encourage turning & repositioning to the extent possible

• Protect heels

• Assess treat, reassess wound associated pain

• Medications

• Appropriate wound care

• Nonadherent dressings

• Skin sealants

• Nonpharmacologic techniques



52

Framework

Functional

Wound

Environment

Debridement

Infection / Inflammation

Control

Moisture Regulation

Migrating Wound Edges

Periwound

Skin

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Palliative Care

When Healing is NOT the Goal

• Individual receiving palliative care whose body systems are shutting down often lacks the physiological resources necessary for complete healing of the pressure ulcer.

• As such, the goal of care may be to maintain or improve the status of the pressure ulcer rather than heal it.



Treatment Goals for Palliative Care

• Set treatment goals consistent with the

values and goals of the

individual, while

considering input from

the individual’s

significant others.

• SoE = C;

• SoR = ��



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Treatment Goals (con’t)

• Set a goal to enhance quality of life, even if the pressure ulcer

cannot be healed or treatment does not lead to

closure/healing.

• SoE = C; SoR = ��

• Assess the individual initially and at any change in their

condition to re-evaluate the plan of care.

• SoE = C; SoR = ��



Pressure Ulcer Assessment

in Palliative Care

• Assess the pressure ulcer initially and with each

dressing change, but at least weekly (unless

death is imminent), and document findings.

• SoE = C; SoR = ��)

• Monitor the pressure ulcer in order to continue

to meet the goals of comfort and reduction in

wound pain, addressing wound symptoms

that impact quality of life such as malodor and

exudate.

• SoE = C; SoR = ��Copyright © 2016 Gordian Medical, Inc. dba American


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• Manage malodor through:

– regular wound cleansing;

– assessment & management of infection;

– debridement of devitalized tissue,

– consider the individual’s wishes and goals of care

– SoE = C; SoR = ��

• Consider use of topical metronidazole to effectively control pressure

ulcer odor associated with anaerobic bacteria and protozoal

infections (SoE = C; SoR = ��)

• Consider use of charcoal or activated charcoal dressings to help

control odor. (SoE = C; SoR = ��)

• Consider use of external odor absorbers or odor maskers for the

room (e.g., activated charcoal, kitty litter, vinegar, vanilla, coffee

beans, burning candle, and potpourri). (SoE = C; SoR = ��)

• Pamela addition = Essential oils utilizing diffuser

Control Wound Odor



Pain Assessment and Management

• Do not under treat pain in individuals receiving palliative

care.

• SoE = C; SoR = ��

• Select a wound dressing that requires less frequent changing

and is less likely to cause pain.

• SoE = C; SoR = ��



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Patient and Risk Assessment

• Complete a comprehensive assessment of

the individual.

• SoE = C; SoR = ��

• Consider using the Marie Curie Centre

Hunters Hill Risk Assessment Tool, specific

to adult individuals in palliative care.

• SoE = C; SoR = ��



Complementary Therapies

• May be of benefit in management of wound pain

• Include:

– Relaxation techniques

• Music

• Reading to patient

• Breathing

– Massage

– Visualization

– Imagery

– Distraction

• These techniques help in reduce pain or pain response by breaking the anxiety-pain cycle



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Closing Thoughts

• Limited studies on woundsat life’s end

• Prevalence ~ 1-million hospice patients

• Millions of frail elderly

• More coming

• Awareness of risks for pressure injury

• Develop as robust wound prevention and care program as possible



References• http://www.aoa.gov

• http://www.agingstats.gov

• http://www.frailcare.org/

• http://npuap.org

• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance.

Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Perth, Australia;

2014

• Langemo DK, Black J, National Pressure Ulcer Advisory Panel. Pressure ulcers in individuals receiving palliative care: a National

Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2010;23(2):59-72. - See more at:

http://www.annalsoflongtermcare.com/article/palliative-care-pressure-ulcers-long-term-care#sthash.yJw6Qlih.dpuf

• The Institute for the Future. (2003). Health & Health Care 2010 The Forecast, The Challenge (2nd Ed.). Princeton, NJ: Jossey-

Bass.

• Waldrop J, Doughty D. Wound-healing physiology In: Bryant RA. Acute and Chronic Wounds: Nursing Management. 2nd ed. St

Louis, Mo: Mosby, Inc. 2000: 31-34.

• Cordrey R, Lee ACW. Integumentary System Aging Changes and Wounds; In FOCUS: Geriatric Physical Therapy 2006; An

independent Home Study Course for Individual Continuing Education, March-August 2006. American Physical Therapy

Association.

• Wysocki AB. Anatomy and Physiology of Skin and Soft Tissue. In: Bryant RA. Acute and Chronic Wounds: Current Management

Concepts. 3rd ed. St Louis, Mo: Mosby, Inc. 2007: 39-55.

• Reddy M. Skin and Wound Care: Important Considerations in the Older Adult: Advances in Skin & Wound Care, Vol 21, No

9:424-438, 2008.

• Chen TM, Fife CE. Never Say Never: Is it realistic to declare zero tolerance on pressure ulcers. Advance for Long Term Care

Management; January/February 2009, 18-20. Copyright © 2016 Gordian Medical, Inc. dba American


8/31/2016

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References• Langermo DK, Brown G; Skin Fails Too: Acute, Chronic and End-Stage Skin Failure. Adv in Skin & Wound Care, Vol 19,

No 4, 206-211, May 2006.

• Brem H, Nierman DM, Nelson JE. Pressure ulcers in the chronically critically ill patient. Crit Care Clin 2002;18:683-94.

• Nelson JE. Palliative care of the chronically critically ill patient. Crit Care Clin 2002; 18:659-81.

• Shannon ML, Lehman CA. Protecting the skin of the elderly patient in the intensive care unit. Crit Care Nurs Clin

North Am 1996;8(1):17-28.

• Sibbald, GR, Krasner DL, Alvarez O., et al. Skin Changes at Life’s End (SCALE): Preliminary Consensus Statement,

September 2008.

• Langemo D, Anderson J, Hanson D, et al PEARLS IN PALLIATION: Understanding palliative wound care . Nursing2009

Critical Care, September 2008 , Volume 3 Number 5, Pages 56 - 56.

• Langemo D, Anderson J, Hanson D, Thompson P, Hunter S. Understanding palliative wound care. Nursing.

2007;37(1):65-66.

• Chrisman, C. A. Care of chronic wounds in palliative care and end-of-life patients. International Wound Journal. 2010;

7(4): 214-235.

• Tippett, AW; Wounds at the End of Life; Wounds. 2005; 17(4):91-98 HMP Communications.



QUESTIONS?

Copyright © 2012 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com

For more information about this or other educational

activities, please contact [email protected]



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