Palliative Care of Pressure Ulcers in Long-Term Care: Page 2 of 3
Nutrition and Hydration
Malnutrition, which is highly common in the palliative care setting, is known to increase the likelihood of pressure ulcer formation and can be a reason why wounds fail to heal or become worse.12 For this reason, the EPUAP/NPUAP guidelines advise assessing the nutritional status of all patients at risk of pressure ulcers, regardless of their healthcare setting.10 For patients deemed at risk of nutritional problems, the guidelines generally advise following relevant and evidence-based guidelines for enteral nutrition and hydration.10 In older adults with advanced illness, data are limited on the effectiveness of nutritional supplements, and as Shepherd29 notes, more research is needed to evaluate the effects of different food types on aspects of wound healing. Based on current evidence, the EPUAP/NPUAP guidelines advise that patients with nutritional and pressure ulcer risk because of acute or chronic diseases or a surgical intervention receive high-protein mixed oral nutritional supplements, tube feeding, or both in addition to the their usual diet.10 There is, however, evidence that the use of tube feeding either by parenteral or enteral means does not assist wound healing. A review by Finucane and colleagues30 found that tube feeding was not associated with healing of pressure ulcers in patients with advanced dementia. Based on these findings, it can be concluded that nutritional assessment is indicated in palliative care older adults, but options to improve nutrition may be limited in this population and require further study.
The importance of water in nutritional status should not be overlooked, as it has been demonstrated that dehydration may increase the risk of pressure ulcer incidence and delay healing.31 Older adults may refuse to drink water due to decreased thirst or fear of incontinent episodes. To encourage greater water consumption, care providers can avoid serving water at night to prevent nocturia; serve water that is fresh and chilled, as opposed to stagnant water that has been sitting in bedside pitchers; and serve water with no-calorie flavorings or slices of fruit to make it more appealing. To prevent dehydration in palliative care patients who have difficulty with drinking due to dysphagia or other limitations, an effort should be made to correct the underlying cause if possible, provide assistance, and carefully monitor and record fluid intake.31 It is important to note that these are general recommendations, but the role of hydration in the prevention of pressure ulcers has not been systematically analyzed.32
Wound Treatment Considerations
As palliative wound treatment is generally not curative, a localized, noninvasive, and pain-minimizing approach to moisture control, cleansing, and debridement of wounds is advised. Several adjunctive therapies may assist in palliative wound treatment, but they require further study. What follows is a brief overview of the literature findings with regard to palliative treatment of pressure ulcers.
Patients who lay down for prolonged periods of time may be exposed to excess perspiration, wound exudates, and urine and/or feces due to incontinence, which increases skin friction and inhibits epidermal moisture transmission, placing them at high risk of skin breakdown and maceration. In incontinent adults, it may be necessary to contain urine with a catheter and feces with a tube.2,12 As described earlier in the section about support surfaces, it may also be necessary to switch patients to a specialty mattress that wicks away moisture from the body to prevent new pressure ulcers and the progression of existing pressure ulcers.
Wound cleansing at dressing changes is widely considered to be an important component of pressure ulcer care, as it removes dead tissue and foreign bodies from wounds, but this recommendation is supported largely by expert opinion rather than direct scientific evidence, according to NPUAP clinical guidelines11; therefore, clinicians and manufacturers may support certain solutions and methods of application over others. A recent Cochrane systematic review found only three small randomized controlled trials determining the effect of wound cleansing solutions and wound cleansing techniques on the rate of pressure ulcer healing.33 None of the studies compared cleansing with no cleansing. One of the studies reported a statistically significant improvement in healing when pressure ulcers were cleansed with a saline spray containing aloe vera, silver chloride, and decyl glucoside, rather than an isotonic saline solution (P=.025); however, because the data were scant, the researchers concluded there is no good trial evidence to support use of any particular wound cleansing solution or technique for pressure ulcers.33
Debridement is a method of treatment used to remove necrotic tissue and slough from wounds, which inhibit healing, support bacterial growth, and mask signs of infection.6,7,34 There are five methods of debridement: surgical or sharp, which uses a scalpel and scissors; autolytic, which uses hydrocolloids and hydrogels; enzymatic, which uses streptokinase or streptodornase preparations or bacterial-derived collagenases; mechanical, which uses methods like hydrotherapy and wound irrigation; and biological, which uses larval or maggot therapy.35 Chemical methods of debridement with agents like hypochlorite were used in the past but have fallen out of favor because they can be painful and damage underlying tissue.35 Some methods of debridement are more aggressive (eg, surgical and mechanical) than others (eg, autolytic or biological), posing an increased risk of pain and bleeding. In the palliative care setting, many factors should be taken into account when weighing the risks versus benefits of debridement options. Factors include potential for healing, type and amount of necrotic tissue, absence or presence of infection, and the patient’s tolerance level.7
There are many studies on the debridement of diabetic foot ulcers, but there are few that focus on optimal debridement technique of pressure ulcers in palliative care. A study by Sherman34 evaluated the efficacy and safety of maggots versus conventional therapy in a cohort of
103 patients (total of 145 pressure ulcers). At the facility, conventional therapy using topical antimicrobial therapy and debridement was the standard of care. Fifty patients received maggot therapy with disinfected fly larva (Phaenicia sericata) to the wound along with a hydrocolloid pad placed on the surrounding skin. The pad was topped with a porous sheet of lightweight fabric to create a kind of cage to contain the maggots around the wound. A lightweight gauze pad was placed on top of the porous sheet to absorb drainage. The maggots remained in place for two 48-hour periods each week. Within 3 weeks of maggot therapy, necrotic tissue decreased by 0.8 cm2 per week (P=.003) and total wound surface area decreased by 1.2 cm2 per week (P=.001), demonstrating that maggot-treated wounds were debrided more quickly and completely than conventionally treated wounds. Overall, patients readily accepted maggot therapy, with discomfort reported by only 4% of patients. Maggot therapy may be an advisable option in the palliative care of older adults with pressure ulcers when compared with other forms of debridement that may increase bleeding or pain.7,34
The NPUAP recommends autolytic debridement when complete wound healing is not a primary goal.36,37 It is advised in palliative care because it is relatively easy, in-expensive, noninvasive, and painless compared with other methods. The Agency for Healthcare Policy and Research (AHPR) clinical practice guidelines advise autolytic debridement in patients who cannot tolerate other forms of debridement and in whom the wound is unlikely to become infected.38 This method of debridement makes use of natural bodily functions, by which endogenous proteolytic enzymes break down necrotic tissue. An occlusive and moisture-retentive dressing, such as hydrogel (water- or glycerin-based) may quicken the body’s natural process and may help soothe pain.36 Autolytic debridement also has the benefits of decreased frequency of dressing changes and of odor and exudate containment.37
In addition to local wound care for pressure ulcers, several adjunctive therapies may be employed, such as vacuum-assisted closure (VAC) therapy and electromagnetic therapy (EMT). VAC therapy uses the controlled negative pressure of a vacuum to promote healing by sucking infectious materials and other fluids out of the wound, whereas EMT seeks to promote healing by using electrodes to produce an electromagnetic field across the wound.
One study documented higher efficacy of VAC therapy (compared with alginate and hydrocolloid dressings) in accelerating healing of many wound types, including pressure ulcers.39 There are no randomized controlled trials of VAC usage in palliative care, but one case report has been published.40 This report describes the case of a 62-year-old woman with a cellulitis blister that burst, causing a copious amount of odorous exudates. Due to her advanced disease, deteriorating renal function, and desire to be cared for in the hospice setting, VAC therapy was initiated to contain the exudate and reduce the pain of dressing changes. The patient reported that the dressing changes facilitated with VAC therapy were no more painful than conventional dressing changes, and by reducing the frequency of daily dressing changes to every 3 days, her quality of life increased. She also found the machine to be unobtrusive and the dressing comfortable once in place. The ability to control the odorous exudates seemed to ease her. This case report illustrates how VAC therapy may be a useful adjunctive therapy in the management of pressure ulcers in a palliative care setting.
A 2010 Cochrane systematic review summarized the results of two small randomized controlled trials that evaluated EMT.41 Based on the findings, the authors concluded that there is no reliable evidence to show EMT to be beneficial for the treatment of pressure ulcers.They also indicated that, due to the few trials available for analysis, the possibility of benefit or harm with this treatment cannot be ruled out.41 Neither study reported adverse effects of EMT, but both had methodological limitations and small sample sizes. Pending further research, EMT may be a possible adjunct therapy.
Managing Complications of Pressure Ulcers
Pressure ulcers not only increase morbidity and mortality in older adults, but can also have numerous complications that can diminish quality of life, including malodor, exudates, pain, infection, and psychosocial effects. A palliative care approach to managing these complications should seek to improve patient comfort and well-being both physically and psychologically.