When a patient is dying, the skin, like other body organs, becomes particularly vulnerable to breakdown; in fact, skin breakdown may be unavoidable.1 Pressure ulcers-typically Stage I or II sacral ulcers-are the most common form of skin breakdown in dying patients, developing from 2 to 6 weeks before death.2-3
Cancer patients are at risk for skin breakdown because the body is in a state of catabolism or wasting. Decreased oral intake, a hallmark of the dying process,4 can occur weeks to months before death, along with a diminished swallowing reflex. Poor nutrition in dying patients contributes to pressure ulcer development and impaired wound healing. Because they have difficulty swallowing, dying patients can easily become dehydrated-another factor that weakens tissue and makes it less resistant to the forces of pressure, friction, and shear.
Older age, compromised mobility, and sedentary lifestyle are the three primary factors associated with pressure ulcer development at the end of life.2 The administration of opioids or sedatives, although generally necessary, can complicate matters by impeding spontaneous movement.
Patient care pointers
Palliative wound care focuses on preventing the wound from getting larger or becoming infected, and managing odor and exudate. Here are some pointers:
* Practice meticulous skin care. Avoid soap, which is drying; use a pH-balanced cleaner instead. Apply moisturizers, particularly in high-risk areas such as the elbows. If the patient is incontinent, use a low-pH skin cleaner and apply a moisture barrier to the skin. Protect the skin from maceration, which further reduces the skin's ability to withstand friction, shear, and pressure.5
* Encourage repositioning to the extent possible. Although turning is recommended every 2 hours, repositioning efforts may be limited in some patients. Protect vulnerable heels by suspending them over a pillow or using heel protectors.
* Minimize or eliminate friction and shear forces as much as possible. Many dying patients have im paired ventilation, but elevating the head of bed increases friction and shear forces on the skin over the sacrum. Use a pressure-reducing mattress or mattress overlay.
* Minimize wound pain. Medications and appropriate wound care help minimize pain. Administer breakthrough pain medications 20 to 30 minutes before wound care, and use nonpharmacologic techniques such as distraction.
* Clean wounds gently. Use minimal mechanical force (4 to 15 psi irrigation) and warmed, noncytotoxic agents for wound cleaning. Moisten dressings before removing them. Minimize odor by removing necrotic wound tissue, using an antimicrobial dressing (silver or cadexomer iodine), or applying a topical agent such as metronidazole.6 Match the dressing to the amount of exudate and odor.
Peaceful endings
By integrating palliative care concepts with chronic wound management strategies, you can honor your patient's wishes at the end of his life and keep him as comfortable as possible.
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