By: Phyllis Gabbart, APN Nurse Practitioner for Hospice of Southern Illinois
Quality wound care in hospice is a challenge. As patients decline, the advanced disease can compromise the body’s largest organ – the skin. For individuals at the end of life, care of wounds is most often focused on supporting the individual for comfort rather than cure.
What are the most common types of wounds in hospice care?
Pressure wounds are defined as localized injuries to the skin or underlying tissues, usually over a bony area, such as the hip or tailbone. In hospice care, these are the most common wounds. Multiple factors contribute to pressure wound formation in the terminally ill individual, but the overlying cause is skin failure. Skin failure occurs when underlying tissues become necrotic and die due to poor circulation. Additionally, skin failure may occur concurrently with other organ system failures. In patients with skin failure near the end of life, even the most vigilant care and treatment may not prevent skin breakdown. Therefore, the goal in these situations is to manage pain and other distressing symptoms.
Malignant fungating wounds occur when cancer infiltrates or metastasizes into the skin, blood vessels, or lymph vessels. For example, these wounds may occur in those with advanced breast cancer, head and neck cancer, or melanoma. Often, they are accompanied by symptoms of odor, pain, bleeding, and tissue necrosis (tissue death). Due to their painful nature, comprehensive wound management is essential in these cases. Early identification of these wounds can provide relief from pain at the end of life.
Skin tears are particularly common wounds in hospice care. As a result of friction or shearing, these traumatic wounds occur primarily on the extremities of older adults. These forces can cause the separation of the outer layer of skin (epidermis) from the middle layer of skin (dermis). Additionally, they may even extend into underlying structures to become full-thickness wounds. As a person ages, the skin loses elasticity, becomes thinner, and loses underlying fat cells. Skin tears can occur with minimal trauma due to the natural aging process of the skin.
Ulcers– Venous and arterial skin ulcers can occur as a result of poor circulation, usually in the lower extremities. These wounds often become chronic and unable to heal at end of life. Diabetic ulcers are wounds that occur mostly on the feet of diabetics. These wounds are most commonly due to neuropathy and peripheral vascular disease. As with venous and arterial ulcers, diabetic ulcers can become chronic and non-healing. The goals for the treatment of these wounds are to manage symptoms to improve comfort, well-being, and quality of life.
How does the hospice team help care for wounds?
As with all areas of hospice care, an interdisciplinary team approach is necessary for the management of wound care. Nurses perform a comprehensive assessment of skin on a routine basis, monitoring for the presence of new skin impairments as well as performing preventive interventions on areas at risk for breakdown. Other team members such as home health aides thoroughly inspect the skin during bathing and normal hygiene care, communicating concerns to the nurses. Patient and family education is also important, not only for actual wound care but also for preventative care. Together, the patient and family will discuss the goals of care. A mutually agreed-upon plan of care is put in place and updated as needed.
Can preventative methods help avoid wounds?
A complete and comprehensive assessment of the hospice patient is key to developing an effective preventive plan of care. The following are helpful in preventing skin breakdown:
- Risk assessment
- Providing meticulous skincare
- Good positioning
- Reducing friction and shear
- Using pressure-redistribution support surfaces
- Supporting nutrition and hydration
- Managing skin moisture
Despite best practices in preventive methods, some skin changes at the end of life may be unavoidable. The focus turns to relieving suffering and providing the best quality of life for each individual to live with dignity, respect, and as much independence as possible.