Palliative Care of Pressure Ulcers in Long-Term Care

Pressure ulcers are highly prevalent among older adults and elders receiving palliative care in numerous care settings. A palliative care approach to wounds involves a comprehensive assessment of existing wounds and prevention of new wounds. Treatment of wounds and their associated complications is typically driven by symptom management to improve patient comfort and quality of life. While much is known about palliative wound care in general, evidence to guide palliative care of pressure ulcers, specifically in older adults residing in long-term care (LTC) settings, is severely lacking. Many LTC facilities may follow the evidence-based guidelines developed by the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel. Although these organizations make specific recommendations to palliative care providers, scientific evidence should be strengthened and expanded upon. This article reviews the current body of medical literature on the palliative care of pressure ulcers in older adults, particularly those in LTC settings; examines how the medical literature compares with clinical practice guidelines; and identifies gaps where further research is needed.

Key words: Palliative care, pressure ulcers, wound care.
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In recent years, palliative care has become increasingly more common due to the rising number of older adults who are living with chronic and debilitating illnesses.¹ Approximately 300 million individuals—about 3% of the world population—receive palliative care or end-of-life care each year.² The World Health Organization defines palliative care as an “approach that improves the quality of life in patients and their families facing the problems associated with life-threatening illnesses.”³ The major tenets of palliative care include: providing pain and symptom control with respect to a patient’s individual needs, spiritual and cultural preferences, and level of psychosocial distress; facilitating open and inclusive decision-making conversations among healthcare providers, patients, and their families about the benefits and burdens of treatment; coordinating continuous care across healthcare settings; and providing practical and emotional support and resources to patients and families throughout life-threatening illness and during the dying process.¹ 

Healthcare providers may take a palliative approach in the care of elderly persons who have advanced and chronic illnesses and reside in hospital settings or in long-term care (LTC) settings, including home care, skilled nursing facilities, and hospice programs. In this population, pressure ulcers are common due to age-related changes, skin failure, diminished ability to heal, malnutrition, dehydration, and periods of prolonged inactivity or limited mobility.⁴ In these patients for whom the primary goal of wound therapy is not curative, palliative care is driven by a holistic approach that seeks to improve quality of life by alleviating physical symptoms and limiting negative psychological effects.⁵ Much is known in the medical literature about palliative wound care in general; however, there are numerous gaps in the evidence base about palliative care of pressure ulcers, specifically in the vulnerable elderly LTC population. This article reviews the available literature in the PubMed/MEDLINE, Scopus, Cochrane, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases on caring for pressure ulcers in older adults. The search revealed numerous gaps in research when attempting to extrapolate the findings to elders with these wounds who are receiving palliative care across different LTC settings.

Incidence, Prevalence, and Risk Factors of Pressure Ulcers in Long-Term Care 

Pressure ulcers are defined by the National Pressure Ulcer Advisory Panel (NPUAP) as “localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction.”⁵ These wounds, which are highly associated with an increased risk of morbidity and mortality, vary greatly in incidence and prevalence across and within sites of care. 

As reported by White-Chu and colleagues,⁶ a national survey conducted by the Centers for Disease Control and Prevention in 2004 reported that 159,000 (11%) nursing home residents had a pressure ulcer. Nenna⁷ reported that surveys performed between 1990 and 2000 showed the prevalence of pressure ulcers in the hospice care setting to be between 14% and 28%. A more recent study by Reifsnyder and Magee⁸ in 2005 examined the incidence of new pressure ulcers in 980 home-hospice patients, finding that 10% of patients had developed a pressure ulcer within their first 6 months of care. The patients who developed pressure ulcers tended to be significantly older, have lower scores on the Karnofsky Performance Scale and the Palliative Performance Scale (PPS), and tended to have noncancer diagnoses. Most of the wounds were found on the sacrum, followed by the heel. In this study there was increased incidence among African Americans, which was attributed to the increased prevalence of diabetes in this ethnic group.⁸ 

Horn and colleagues⁹ analyzed the findings of the National Pressure Ulcer Long-Term Care Study, a retrospective cohort study conducted between 1996 and 1997 in 95 US-based LTC facilities. They found that in addition to history of ulcers and advanced age, significant weight loss, eating disorders, use of catheters, and use of positioning devices increased the likelihood of pressure ulcers. 

Facets of Palliative Care Assessment 

Many LTC facilities follow the evidence-based clinical practice guidelines for pressure ulcer assessment, prevention, and treatment that are outlined by the NPUAP and the European Pressure Ulcer Advisory Panel (EPUAP).^10,11 They advise risk assessment of ulcer development, skin assessment for existing wounds, and a pain assessment. However, as there are often adverse negative stressors associated with pressure ulcers, such as shame, social isolation, and sleep disturbances, a complete palliative care assessment should also assess patients’ quality of life from psychological, spiritual, and emotional viewpoints based on an individualized account of patients’ values, culture, wishes, and needs.^2,7,12 Doing so would ideally encompass the concepts of dignity and comfort that are vital to palliative care⁷; therefore, continual assessment of quality of life is an essential measure.¹³ Additionally, there are limitations and special considerations when applying these clinical practice guidelines to assess pressure ulcers in a palliative care setting.

Risk Assessment  

Proper assessment of potential or actual skin breakdown is vital in all patients. This review identified that the Hunters Hill Marie Curie Centre Pressure Sore Risk Assessment Tool is the only validated pressure ulcer risk assessment tool specifically designed for use in the palliative care setting.¹⁴ The tool should be used weekly or when a change occurs in the patient’s condition. It assesses for seven subscales of pressure sore risk: sensation, mobility, moisture, activity in bed, nutrition/weight change, skin condition, and friction/shear. With a possible score range of 7 to 28 points, the scoring method can predict four thresholds of risk: low (7-11), medium (12-17), high (18-21), and very high (>22). Chaplin¹⁴ evaluated the reliability of the tool in a study of 291 patients in a specialist palliative care unit by experienced palliative care nurses.

A study by Maida and colleagues¹⁵ describes the significant correlation between the Braden Scale (BS) and the PPS in patients with advanced illness. The BS is a commonly used pressure ulcer risk assessment tool that is intended for use in the general population. It is comprised of six subscales that assess for the following: a patient’s sensory perception; the skin’s exposure to moisture; activity level; mobility; nutritional status; and friction and shear.¹⁶ The BS has shown sensitivities ranging from 70% to 100% and specificities ranging from 64% to 90%. The PPS is used to assess the functional status of palliative care patients and has five dimensions: patient’s ambulation; activity level and evidence of disease; self-care; oral intake; and level of consciousness.¹⁷ The PPS has 11 levels, measuring from PPS at 0% to PPS at 100% using increments of 10%. A patient with a PPS score of 0% is dead, whereas a patient with a PPS score of 100% is mobile and healthy. In Maida and colleagues’ analysis of 644 patients who were referred for a hospital-based palliative care program, each patient had the BS and PPS performed within 24 hours of referral. The results indicated that in care settings where the BS is not routinely used, the PPS could be considered a viable alternative tool for assessing pressure ulcer risk in older adults receiving palliative care.¹⁵

Wound Assessment

Systematic and detailed assessments of existing wounds should be performed periodically; however, the process of wound assessment remains a clinical challenge for palliative care providers, as there are no best practice guidelines to standardize terminology, reliability, and key wound parameters of the various wound assessment tools. Outside of the palliative care setting, weekly wound assessments are typically warranted, but within palliative care, frequency of assessments should be individualized to each patient.¹² The NPUAP and the EPUAP have established a pressure ulcer classification system that is recognized by nearly all LTC facilities. Stages range from I to IV, with stage I indicating nonblanchable erythema with intact skin to stage IV representing a full-thickness wound with tissue loss and exposed bone, tendon, or muscle.⁵ There is no reverse staging; thus, once a pressure ulcer has reached stage IV, it will always be designated at stage IV regardless of healing.⁵

To assess nonhealing wounds, Keast and colleagues¹⁸ developed an assessment tool called MEASURE, which is an acronym for Measure (length, width, depth, and area), Exudate (quantity and quality-odor), Appearance (wound bed), Suffering (pain), Undermining, Re-evaluate (wound treatment effectiveness), and Edge (condition of edge and surrounding skin). By using this tool, the provider not only assesses healing of the wound, but also assesses for clinical outcomes, including controlling exudates, minimizing odor, and managing pain, all of which impact quality of life. These quality-of-life outcomes are discussed in further detail in the Wound Treatment Considerations section.

Pain Assessment  

A major goal of palliative care is pain management; therefore it is essential to perform regular pain assessments. According to Langemo,¹² “Although millions of individuals experience acute and chronic wound pain, under-treatment remains prevalent, with many individuals with pressure ulcers experiencing moderate to severe pain during wound care, dressing changes, and debridement.” 

There are a number of recognized, validated pain measurement scales that can be used to assess pain—none of which are designed specifically for palliative care patients—including the Visual Analogue Scale for Pain (VAS Pain); Numeric Box Scale; the Faces Rating Scale (FRS); Face, Legs, Activity, Cry, and Consolability (FLACC) scale; the McGill Pain Questionnaire (MPQ); and Visual Rating Scale.^13,19 A literature review by De Laat and colleagues²⁰ found that the MPQ, VAS Pain, and FRS were valid and reliable to diagnose pressure ulcer pain. In patients who have cognitive impairment and difficulty expressing pain verbally, a tool such as the FLACC scale can be used to assess pain according to specific behaviors, such as withdrawal, grimacing, and crying out, as well as other facial expressions, body movements, and vocalizations. Other pain indicators may include changes in normal activities, such as refusing food or changes in rest patterns, and changes in mental status, such as crying or irritability.²

In a 2007 United Kingdom-based study, Price and colleagues¹⁹ developed an original holistic approach to assess chronic wound pain, known as the Wound Pain Management Model, which takes into account the location, intensity, and duration of pain. Moreover, the model involves listening to the ways in which patients describe pain and its impact on activities of daily living, facilitating the development of a treatment plan to optimize patients’ quality of life. Effective communication and ongoing reassessment are fundamental in this wound pain assessment model.¹⁹

Quality of Life Assessment  

In line with the palliative care mission, a social worker and healthcare provider should conduct a psychosocial assessment that aims to optimize quality of life. The domains of this assessment can include, but are not limited to, an evaluation of lifestyle goals and values, spiritual needs, cognitive function, communication ability, learning style, social functioning and support, and the patient’s and family’s willingness and ability to adhere to an individualized treatment plan.⁷ When reviewing the literature, only one tool was found—the Cardiff Wound Impact Schedule (CWIS) questionnaire—that assesses the impact of chronic wounds on quality of life.²¹ The CWIS was tested in a United Kingdom–based study using a three-step process in patients with leg ulcers and diabetic foot ulcers, measuring three quality-of-life domains: (1) physical symptoms and daily living; (2) social life; and (3) well-being. There were no significant differences in scores between the two wound types, indicating that the tool has high internal consistency, reproducibility, and validity.²¹ The results of this study suggest that the CWIS may be used to assess quality of life in the palliative care of older adults with pressure ulcers, the results of which could then be used to determine appropriate management. A discussion of psychosocial interventions is provided later in the article.

Palliative Care Principles of Wound Care and Prevention 

The goals of palliative wound care are stabilization of existing wounds, prevention of new wounds (if possible), and symptom management of complications to improve patient comfort, well-being, and quality of life.⁷ This can be achieved by a holistic and integrated approach based on evidence-based principles of traditional wound care. The EPUAP/NPUAP clinical practice guidelines¹⁰ provide general recommendations for three major areas of wound prevention: repositioning, support surfaces, and nutrition. What follows is a brief discussion of each tenet and the issues that arise when trying to apply them in the palliative care setting.

Immobility and Repositioning  

Older adults receiving palliative care in LTC settings often have prolonged periods of immobility, which increases the likelihood of localized tissue ischemia from inactivity and pressure.¹² The NPUAP guidelines advise repositioning for all persons at risk of pressure ulcers, the frequency and techniques of which should be individualized to achieve maximal comfort, dignity, and functionality.¹⁰

Although frequent repositioning of patients is considered essential to pressure ulcer prevention protocols, there is little evidence supporting its efficacy. In severely debilitated older adults and in those with contractions, distribution of pressure away from bony prominences cannot always be achieved.²² Rich and colleagues²³ performed a cohort study involving 269 elderly bed-bound hip fracture patients from nine Maryland and Pennsylvania hospitals. Results showed that repositioning patients at least every 2 hours was not associated with a decreased incidence of pressure ulcers, suggesting that manual repositioning at this frequency may not effectively prevent pressure ulcers. In palliative care patients, it is acceptable to discontinue frequent turning schedules if the patient refuses or if frequent repositioning will lead to increased pain and sleep disturbance. 

Many older adults in palliative care have difficulty with breathing when laying flat in bed, so some healthcare providers may remedy this problem by elevating the head of the patient’s bed. However, this can increase friction and shear forces on the skin over the sacrum. When the head of the bed is elevated more than 30 degrees, blood vessels can be occluded, increasing the risk of tissue damage and necrosis.²⁴ However, if the patient’s ability to breathe improves with the head of the bed elevated, the risk of skin damage may be an acceptable trade-off.^12,25

Support Surfaces  

Not all support surfaces are well suited to every care setting. According to the NPUAP guidelines, selection of a surface to reduce tissue pressure over bony prominences should take into account the patient’s level of mobility in bed, his or her comfort, and other environmental conditions.¹⁰ Generally, support surfaces can be divided into two groups: dynamic, in which electricity powers the surface and alters the level of support through inflation and deflation of air or movement of fluid; and static, in which inflation is maintained at a constant level and pressure is reduced by spreading body weight over a larger area.²⁶ Support surfaces include mattresses; overlays, which can be filled with air, water, gel, foam, or a combination of these materials and then applied to the top of the mattress; and specialty beds, which are designed to provide pressure relief by eliminating shear and moisture on the body. 

In a randomized controlled trial involving 239 older adults aged 65 years and older with fractured hips, Donnelly and colleagues²⁷ examined whether differences exist between complete offloading and standard care with regard to the number of new heel pressure ulcers and the number or severity of new pressure ulcers on other areas of their bodies. Patients were randomly allocated to receive heel elevation plus pressure-redistributing support surface (complete offloading) or pressure-redistributing support alone (standard). In the control group, 26% of patients (n=31) developed pressure ulcers compared with 7% (n=8) in the intervention group (P<.001), suggesting that offloading reduces the incidence of heel ulcers. 

In 2012, McInnes and colleagues²⁸ reported the findings of a systematic Cochrane database review and a meta-analysis of 53 trials (randomized controlled trials and quasi-randomized trials), involving a total of 16,285 patients, to assess the impact of various support surfaces in preventing pressure ulcers of any grade, in any patient group, and in any setting. The authors concluded that there is strong evidence to support the efficacy of higher-specification foam mattresses (vs standard foam mattresses) and sheepskins in pressure ulcer prevention; however, there is insufficient evidence to draw conclusions on the value of seat cushions, limb protectors, and various constant low-pressure devices. They noted that more clinical trials are warranted to address these gaps in research, but the findings suggest that in the palliative care setting, it should always be taken into consideration if bed and sitting support surfaces are therapeutic and comfortable to the patient.

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.

Moisture  

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.

Cleansing  

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  

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

Adjunctive Therapy  

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.

Malodor and Exudate  

Wound odor and heavy exudates can distress patients by causing embarrassment, depression, and social isolation, leading to a poor quality of life. Odor can be controlled by properly cleaning the wound, appropriately disposing of the used dressings, adequately debriding necrotic tissue, and using antibiotic therapy and specific dressings. Topical metronidazole has been shown to be effective in reducing odor by eradicating anaerobes.^7,42 Topical metronidazole gel (0.75%-0.80%) may be used directly on the wound once per day for 5 to 7 days or more often as needed, and metronidazole tablets can be crushed and placed onto the ulcer bed.² When the primary goal is to control exudate, with a secondary goal of controlling odor, a proper dressing must be chosen that will not dry out the ulcer bed.¹³ Activated charcoal dressings applied to wounds significantly control odor but only if the dressing is fit as a sealed unit and if the wound is kept dry.⁴² There are currently no studies that assess the odor-absorbing capacity of activated charcoal dressings for pressure ulcers,²⁰ but in other care settings, these dressings have been shown to control odor and to remove fluids and toxins that can impair healing. One randomized control trial of 120 patients showed that activated charcoal dressings were better tolerated than the hydrocolloid dressings used in a control group, even though outcomes were similar between groups.⁴³ Healthcare providers should also be sensitive to patients who may be experiencing embarrassment or discomfort due to malodor by using other external odor-control methods, such as placing a pan of clay cat litter under the bed to absorb odors or using a jar of vinegar or coffee beans or a vanilla-scented candle to mask malodor.³⁶  

In addition to odor, if wound exudate is not controlled, it can lead to maceration, breakdown, and itching. It is important to control or eliminate wound exudates by matching dressings to the amount of exudate¹²; therefore, the healthcare provider should communicate with the patient in finding the appropriate comfortable dressing with maximum benefit for palliative management of the wound.¹³ Further, as Draper⁴² concluded in a comprehensive review, the development of new dressings and techniques for controlling malodor and exudate, particularly in fungating wounds, is greatly needed.

Infection  

Open wounds are at risk of bacterial infection, which can delay healing and lead to other potential complications.¹³ Traditional signs of infection (eg, pain, erythema, edema) may be absent; thus, care providers should be alert to other signs of infection, such as serous exudate, delayed healing, discoloration of granulation tissue, malodor, wound breakdown, fever, and elevated white blood cell count.^44,45 Superficial bacterial colonization of wounds is universal, and all pressure ulcers contain bacteria, but concern is warranted when the colony level reaches 10⁵ or 10⁶ organisms per gram.⁴⁵ Experts agree that swab cultures on the wound surface should not be performed because they typically do not reflect the cause of infection.⁴⁵ Rather, a more targeted laboratory work-up can help clinicians make a more accurate diagnosis, ensuring optimum treatment of infected open wounds. Testing may include swabbing for deep pus, a tissue biopsy, or a blood culture.⁴⁶ 

Oral antibiotics, topical sulfa silverdiazine, and silver-impregnated dressings are used frequently in wound care and have all demonstrated varying degrees of efficacy in reducing bacterial burden in pressure ulcers.^36,45 Due to the emergence of antibiotic resistance, the use of honey has come back into practice for the management of wounds. In a 5-week randomized clinical trial, 26 patients (total of 50 pressure ulcers at stage II or III) were treated either with honey dressing or with ethoxy-diaminoacridine plus nitrofurazone. The researchers found that the honey dressing healed pressure ulcers at approximately four times the rate of healing in the comparison group.⁴⁷ 

Pain  

Pressure ulcers can often be painful, especially in more advanced stages. In a systematic review of the literature, Gorecki and colleagues⁴⁸ identified 15 studies that addressed the impact of pain on quality of life in older patients, and they concluded that pain was the most significant consequence of having a pressure ulcer and that it affected every aspect of patients’ lives. Proper pain assessment is vital to understanding its etiology.¹³ If pain is predictable, such as the pain associated with a debridement procedure or dressing change, it may be admissible to administer an opioid before the procedure.⁴⁴ However, because pressure ulcer pain often does not respond well to systemic pain medications, localized pain management tends to be more effective and better tolerated by patients. 

One randomized double-blind pilot study set out to determine the effectiveness of topical diamorphine gel on pressure ulcer pain in hospice patients.⁴⁹ Pain scores improved significantly with the use of diamorphine gel over the placebo, leading to the conclusion that diamorphine gel appears to be an effective option in controlling pressure ulcer pain in palliative care patients; however, a larger study is needed to confirm these results and to assess for side effects. 

A literature review by De Laat and colleagues²⁰ led the authors to support local pain relief for patients with pressure ulcers. They found that the use of a eutectic mixture of local anesthetic cream, which consists of lidocaine and prilocaine in an oil-in-water emulsion, was effective in reducing pain caused by chronic wounds. However, lidocaine-prilocaine cream is indicated for local analgesia for normal, intact skin and has not been well studied in older adults, particularly in those with open wounds; therefore, this is an area where further clinical trials may be warranted.⁵⁰

Complementary therapies may reduce anxiety and detract attention from pain caused by wounds. A review by Naylor⁵¹ identified possible therapies, including relaxation, music, massage, aromatherapy, visualization, and guided imagery. Breathing techniques, television, music, or conversation may also create distraction during painful dressing changes. However, Naylor reported that these therapies tend to be underused, inappropriately administered, and lack scientific evidence to support their efficacy. Moreover, patients are more likely to initiate these therapies rather than the healthcare provider,⁵¹ suggesting that such techniques should not be overlooked, especially in the palliative care setting.  

Psychosocial Issues  

The psychosocial effects of pressure ulcer-related odor, exudate, and pain can be severe, leading to embarrassment, chronic tiredness, self-imposed social isolation, depression, and anxiety. The literature strongly supports the need for frequent assessment and intervention to manage these adverse social effects of pressure ulcers.^{13,19,21,44,45,48} The NPUAP and the AHPR recommend initial and routine psychosocial assessments that consist of consultation with individual patients and their families to discuss preferences, goals, and abilities; the objective of these discussions is to promote patient adherence to the pressure ulcer treatment plan.^36,38 The psychosocial assessments may evaluate mental status, learning ability, depression, polypharmacy (ie, risk of overmedication), values, lifestyle, sexuality, and culture, among other factors. Once treatment goals are set in alignment with these domains, it is important to routinely follow up with patients and arrange interventions (ie, counseling, educational resources) as necessary. 

Conclusion 

Older adults and elders residing in LTC settings represent an especially vulnerable population in which poor nutrition, immobility, loss of cognitive function, and incontinence often lead to unavoidable pressure ulcers. The aims of palliative wound care in this population include stabilization of existing wounds and prevention of new wounds, if possible. A comprehensive assessment using a multidisciplinary and holistic approach that incorporates patients’ and their family’s preferences and values will lead to individualized treatment goals. When prevention is unsuccessful or unrealistic, symptomatic management of complications should be undertaken and strive to improve patient comfort, well-being, and quality of life. Healthcare providers would be well served by integrating palliative care goals as they assess, plan, and evaluate treatment of pressure ulcers in any care setting. Further evidence-based chronic wound care research is needed that supports quality of life and encourages partnerships with patients and their families.