Introduction

As a family member, caregiver, or , understanding end-of-life is crucial for providing the best possible comfort and quality of life for terminally ill patients. In the final stages of life, various types of wounds, such as pressure ulcers, ischemic wounds, and skin changes at life's end (SCALE), can impact the patient's well-being. Knowledge about preventing and managing these wounds is essential to ensure the patient's comfort and dignity. This article aims to provide comprehensive education on the types of wounds, prevention strategies, and the value of comfort-focused care in the last weeks of life, addressing the needs of family members, , and hospice nurses.

Types of Wounds

Different types of wounds may occur at the end of life, depending on the underlying cause and the stage of the dying process. Some of the most common ones are:

Pressure Ulcers are wounds caused by prolonged pressure on the skin, usually over bony areas. They can range from mild redness to deep tissue damage. Pressure ulcers are often preventable with proper positioning, mobility, skincare, and nutrition. However, some pressure ulcers may be unavoidable at the end of life, as the skin becomes more fragile and blood circulation decreases. In this case, aims to prevent infection, control odor, and manage pain and drainage.

Ischemic Wounds: These are wounds caused by reduced blood flow to the skin, usually due to vascular diseases or heart failure. They can appear as dry, black, or gangrenous areas on the extremities, such as the feet or toes. Ischemic wounds are often painful and difficult to heal. Wound care aims to improve blood circulation, if possible, and prevent infection and further tissue damage.

Skin Changes at Life's End (SCALE): These changes occur due to the dying process, such as skin discoloration, , or breakdown. They are not caused by pressure or ischemia but by the failure of multiple organ systems. They can appear as purple or maroon areas on the sacrum or other body parts and develop rapidly within hours or days before death. SCALE is not preventable or treatable, and wound care aims to provide comfort and dignity to the patient and family.

Part 1: Education for Family Members caring for a Terminally Ill Loved one

Understanding the Importance of Preventing Wounds at End of Life

As a family member supporting a loved one in , it's essential to be mindful of wound prevention to ensure their comfort and quality of life during this time. Wounds can cause unnecessary pain and discomfort, and preventing them is an essential aspect of . Here are some tips to help prevent wounds at the end of life:

  1. Positioning and Mobility: Frequent changes in position are crucial to prevent pressure ulcers. Help your loved one change positions regularly, using pillows or cushions to relieve pressure on bony areas.
  2. Skin Inspection: Regularly inspect your loved one's skin for signs of redness, irritation, or breakdown. Inform the hospice team immediately if you notice any changes.
  3. Proper Nutrition and Hydration: Adequate nutrition and hydration are essential for maintaining healthy skin. Ensure your loved one is getting the proper nutrients and staying hydrated.
  4. Moisturizing: To prevent dryness and cracking, keep the skin moisturized. Use a gentle, fragrance-free lotion recommended by the hospice team.
  5. Gentle Cleaning: Use mild, non-irritating cleansers when bathing your loved one. Pat the skin dry instead of rubbing to avoid skin damage.
  6. Comfort Medications before Wound Care: If wound care is necessary, administer comfort medications at least 30 minutes before the procedure to help reduce pain and discomfort.

Since the skin is the largest organ of the body and a terminally ill patient often does not and is not able to maintain proper nutrition and hydration, the terminally ill are at elevated risk for wounds. The risk is so high that, at times, even providing the absolute best care will still result in your loved one having too many wounds, including wounds that get worse over time, especially as your loved one approaches death.

The National Pressure Ulcer Advisory Panel reports that more than 50% of patients experience skin failure 2 to 6 weeks before death.

Understanding the Value of Comfort over Wound Care in the Last Weeks of Life

In the last two weeks of life, the focus shifts to providing comfort and maintaining the highest possible quality of life. While wound care is essential in certain situations, it's essential to consider the comfort level and benefits for the patient during this time. Here's why comfort may take precedence over wound care:

  1. Pain and Discomfort: Wound care procedures, especially in the terminal stage, can be painful and distressing for the patient. The discomfort caused may outweigh the potential benefits of wound treatment.
  2. Focusing on Moments that Matter: In the final weeks, time with your loved one becomes even more precious. Prioritizing comfort allows you to make the most of your time together.
  3. Dignity and Peace: Comfort-focused care helps maintain your loved one's dignity and offers them a peaceful and serene environment.

Remember, the hospice team supports you and your loved one throughout this journey. If you have any questions or concerns about wound care, comfort measures, or anything related to hospice care, don't hesitate to contact the team.

Part 2: Education for Nurses on End-of-Life Wound Care

Understanding the Common Occurrence of Wounds at End of Life

As nurses, we play a vital role in educating families about the common occurrence of wounds at the end of life. The combination of poor nutrition, declining health, and limited mobility in terminally ill patients puts them at higher risk for developing wounds. Some specific points to discuss with families include:

  1. Skin as the Largest Organ: Emphasize that the skin is the body's largest organ and can be vulnerable when the patient's health is compromised.
  2. Nutrition and Skin Health: Poor nutrition affects the skin's ability to heal and increases the risk of pressure ulcers and other wounds.
  3. Immobility and Pressure Ulcers: Immobility can lead to pressure ulcers in areas where the body's weight rests for extended periods.

Understanding Kennedy Ulcers at the End of Life

Kennedy ulcers, or terminal ulcers, are a specific type of wound that can occur in patients nearing the end of life. These wounds are often deep, painful, and challenging to treat. Education about Kennedy ulcers includes:

  1. Identification and Symptoms: Describe how Kennedy ulcers may appear suddenly and worsen rapidly, leading to skin breakdown and necrosis.
  2. Emphasizing Comfort Measures: As with other end-of-life wounds, prioritize comfort over aggressive wound care for Kennedy ulcers due to their tendency to cause significant discomfort.

In my experience as a , the onset of a Kennedy ulcer is often a clue the patient has two weeks or less to live.

Best Practices for Nurses Performing End-of-Life Wound Care

As nurses, we must approach wound care with and sensitivity, always considering the patient's comfort and dignity. Here are some best practices to follow when performing wound care for someone at the end of life:

  1. Assessment and Communication: Assess the wound carefully and communicate with the hospice team to ensure appropriate care planning.
  2. : Administer comfort medications at least 30 minutes before wound care to alleviate pain and minimize distress.
  3. Gentle and Effective Cleaning: Use gentle cleansing techniques and appropriate wound dressings to promote healing and prevent infection.
  4. Family Involvement: Involve family members in the wound care process, explaining the procedure and ensuring their understanding and support.
  5. Emotional Support: Provide emotional support to the patient and their family, acknowledging their challenges.

As experienced hospice nurses, we understand the complexities of end-of-life wound care. Our primary focus is always on ensuring our patients' highest comfort level and quality of life during their final journey.

Conclusion

End-of-life wound care requires a compassionate and holistic approach to prioritize the patient's comfort and dignity. Family members and are vital in preventing and identifying wounds, ensuring the patient's skin integrity and overall well-being. For hospice nurses, understanding the common occurrence of wounds, including specific types such as Kennedy ulcers, and following best practices for wound care is essential to provide quality care. By emphasizing the value of comfort over aggressive wound treatment in the last weeks of life, we can ensure that patients receive the support and care they need to maintain the highest possible quality of life. Together, we can work towards enhancing the end-of-life journey for terminally ill patients, focusing on empathy, , and personalized care.

Resources

Wound Care: Enhancing Healthcare for the Aging Population

The Peter Abraham Wound Care Scholarship

Pressure Injury – Formerly Known As Pressure Ulcer

Wound Bed Preparation – TIME Mnemonic

SCALE wounds: Unavoidable pressure injury (PDF)

Bates Jenson Wound Assessment Tool (PDF)

FRAIL Palliative Wound Care: Palliative Wound Care And Healing Probability Assessment Tool (PDF)

Payne‐Martin Classification System for Skin Tears (PDF)

Pressure Injury Prevention Points (PDF)

Eldercare Locator: a nationwide service that connects older Americans and their caregivers with trustworthy local support resources

Surviving Caregiving with Dignity, Love, and Kindness

Caregivers.com | Simplifying the Search for In-Home Care

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My Aging Parent Needs Help!: 7-Step Guide to Caregiving with No Regrets, More Compassion, and Going from Overwhelmed to Organized [Includes Tips for Caregiver Burnout]

Take Back Your Life: A Caregiver's Guide to Finding Freedom in the Midst of Overwhelm

The Conscious Caregiver: A Mindful Approach to Caring for Your Loved One Without Losing Yourself

Dear Caregiver, It's Your Life Too: 71 Self-Care Tips To Manage Stress, Avoid Burnout, And Find Joy Again While Caring For A Loved One

Everything Happens for a Reason: And Other Lies I've Loved

The Art of Dying

Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death.”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side, A Guide for Caring for the Dying at Home

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