Home Health & Hospice Week

Just because a patient is on hospice care doesn't mean the burden is off providers to prevent and treat pressure ulcers.

"The hospice surveyor guidance doesn't include anything specific about pressure ulcer prevention or treatment," says Lynn Serra, a consultant with Beth Carpenter and Associates in Lake Barrington, Ill.

Even so, hospices that don't provide and document essential skin-care services could earn less than optimal patient or survey outcomes -- or find themselves caught in the cross-hairs of a lawsuit brought by a grieving family upset by a patient's pressure ulcer.

Best practice: Hospice staff should identify if the patient has existing pressure ulcers or is at risk for developing them -- and then implement strategies that are like those "you might find in non-palliative settings," says  JoAnne Reifsnyder, program director for health policy at Jefferson University in Philadelphia, Penn.

"It's hard to differentiate between palliative and curative approaches for wounds," points out Marygrace Lomboy. "If a patient needs a wound vac due to wound drainage, that's appropriate," says Lomboy, a nurse practitioner with Hospice of Lancaster  County in Pennsylvania. Wound debridement to prevent bacteria from invading the wound, adding to the drainage or potential for infection, is also appropriate, she adds. Lomboy notes, in fact, that her hospice sees patients' wounds heal at times.

Staff at Hospice of Lancaster County have set up a palliative care wound protocol as a basis for nurses to follow, but they also highly individualize each patient's care plan.

The protocol includes assessment and goes into how to identify skin tears, abrasions, and deep tissue injury, among other skin problems. The protocol also focuses on using advanced wound care products, such as hydrogels, foams, and alginates. These products promote patient comfort and can remain in place for three to five days, says Lomboy. The hospice doesn't use wet-to-dry dressings.

As part of the protocol, hospice caregivers educate the patient's family about how to reposition patients and use pillows to "float heels and support limbs -- and to keep bony prominences from direct contact with each other. We make it a point to tell families not to use doughnut devices."

Families learn to try to reposition bed-bound patients every two hours. "We teach chair-bound patients to shift their weight every 15 minutes," adds Lomboy. The staff cautions patients and family members against elevating the head of the patient's bed more than 30 degrees "as that's hard on the [patient's] sacrum and bottom."

Staff also teach family caregivers to use bed linens as a draw sheet to lift the patient up in bed or to transfer or turn him. The hospice protocol includes protecting patients' skin from incontinence episodes with calmoseptine, a moisture barrier cream, says Lomboy.

Devices can help: Hospices can and do use overlays and mattresses that help to relieve pressure, notes Reifsnyder. "You can put a static overlay on the bed for a person who is at low to moderate risk for skin breakdown, or an alternating pressure mattress for a person at higher risk, so that passively pressure is being relieved periodically."

In addition to providing breakthrough pain medication prior to wound-dressing changes, if needed, Lancaster hospice uses some "interesting palliative care approaches for wound pain," says Lomboy.

Example: The pharmacy developed a topical spray that contains morphine, ketamine, and bipivicaine. "And we have a morphine gel that we can put in the wound bed," Lomboy says.

To combat odor, hospice care staff may get an order for metronidazole (Flagyl) and clindamycin (Cleocin) powder to put in the wound. "And we put charcoal or kitty litter under the bed -- and essential oils like lavender near the bed. Sometimes controlling odor is a matter of controlling the drainage withan advanced wound care product." Lomboy says.

If the patient refuses repositioning or basic wound care, assess what's going on, advises Serra. You may be able to counter the resistance with education. For example, "did the person remember his grandfather had a difficult wound that got worse with treatment?"

Other possibilities: "Is the person depressed, angry, or in pain? Does he not have enough meaningful activities to engage him in a quality life?" If the latter is the case, hospice staff can bring in music therapy, pet therapy, and volunteers to visit, Serra suggests.

The best possible care can't prevent every pressure ulcer at end of life. Lomboy points to "a lot of different studies saying that from 19 to 25 percent of palliative care patients will have some type of bedsore when they die. That's a big piece of the population -- and not all of it's related to poor care."

Yet sometimes families "feel a tremendous amount of guilt and emotional suffering when their loved one develops a pressure ulcer," Lomboy observes. In such cases, she explains to the family that the skin is the largest organ in the body and can fail when the person is near death. "We may see the Kennedy ulcer in the sacrum develop 24 to 48 hours before the person dies," she adds. "And that's basically a result of organ failure."

Education pays: "We care for a lot of Amish people and they do a fabulous job of taking care of their family members," Lomboy notes. And the Amish caregivers said that learning that the skin can fail no matter what "lifted a big burden for them."