Sarah stared at the wet sheets again. Three a.m. Her mother hadn’t moved. The catheter had leaked. Again. She pulled the soaked bedding away from her mother’s fragile skin and felt tears burn behind her eyes. When the hospital discharge nurse mentioned the PureWick™ System, it sounded like an answer to prayer—a simple external device that would wick away urine without the need for traditional catheters or constant brief changes.
No more midnight sheet changes. No more struggling to roll her barely-conscious mother from side to side. Just place the soft wick against the body, turn on the gentle suction, and let the device handle what Sarah’s exhausted hands and aching back could barely manage anymore.
Thousands of families hear this same promise every year. The PureWick™ System, an external catheter designed for women, uses a soft, absorbent wick placed between the legs and connected to a suction canister. In hospitals, where nurses check patients every two hours and monitor for complications around the clock, the device serves a legitimate purpose for short-term incontinence management. But home is different from the hospital. Hospice is different. What works under professional surveillance for days often fails—sometimes catastrophically—when families use it for weeks or months with minimal oversight.
Understanding the PureWick™ System
What Is It and How Does It Work?
The PureWick™ Female External Catheter sits outside the body, fitting between the labia and against the perineal area. Its soft, flexible wick material draws urine away from skin through low-pressure suction connected to a collection canister. Replace the wick every 8 to 12 hours. Clean the area. Insert a fresh wick. The marketing materials show smiling elderly women and relieved caregivers.
The appeal is obvious. Unlike indwelling Foley catheters that are threaded through the urethra into the bladder, this device remains external. No insertion. No violation of bodily space. The manufacturers highlight a reduction in catheter-associated urinary tract infections compared with internal catheters, positioning the PureWick™ as a safer, more dignified alternative.
Why Hospitals Recommend It
Hospital nurses caring for four to six patients can check the PureWick™ placement every two hours during rounds. They assess skin integrity. They reposition patients on schedule. They notice when urine output changes color or develops an odor. They document intake and output meticulously. They replace wicks on time because supply rooms stock them, and shift changes bring fresh eyes to bedside assessments.
Hospitals use the PureWick™ System for short stays—post-surgical recovery, acute illness management, and brief rehabilitation periods. Professional monitoring catches complications early. Staffing ratios ensure someone notices problems before they escalate.
The Hospice Reality: Why This Changes Everything
Compromised Immune Systems in Hospice Patients
Mrs. Chen qualified for hospice because metastatic cancer had spread from her colon to her liver, lungs, and bones. Her body couldn’t fight off the common cold, much less aggressive bacterial infections. Every hospice-eligible patient shares this vulnerability—their immune systems are failing because their bodies are dying.
Terminal illness doesn’t just attack one organ. Cancer ravages the entire immune response. End-stage heart failure starves tissues of oxygen needed for healing. Advanced dementia accompanies malnutrition that depletes infection-fighting white blood cells. COPD patients on hospice struggle with every breath while their bodies lose the strength to battle even minor infections.
Healing capacity vanishes. What might cause mild irritation in a healthy adult becomes a serious wound in a hospice patient. A small urinary tract infection that a younger person’s body would clear in days can progress to sepsis and death within 48 hours in someone already dying.
Skin Integrity: The Body’s Largest Organ Under Siege
Skin is dying too. Poor circulation means inadequate blood flow to surface tissues. Decreased mobility creates constant pressure on bony prominences. Malnutrition robs skin of protein needed to maintain elasticity and strength. Incontinence introduces moisture and bacteria that accelerate breakdown.
The hospice patient’s skin is paper-thin. Transparent. Easily torn. Press your finger against healthy skin, and it blanches white, then pinks back up immediately as blood returns. Press a hospice patient’s skin, and sometimes it stays white. Or worse, it stays red—a warning sign that capillaries underneath have already ruptured and tissue damage has begun.
Friction from any medical device applied to this fragile tissue risks injury. Add moisture from urine. Add suction to pull the tissue against the synthetic material. The math is brutal.
What Hospice Nurses See: Real Complications from Continuous Use
Infection Nightmares
On day four, the urine in Mr. Patterson’s collection canister appeared cloudy. Day six, his temperature climbed to 101.3°F, and he moaned when anyone touched his lower abdomen. By day eight, his hospice nurse arrived to find him barely responsive, his breathing rapid and shallow. The infection that started with bacteria colonizing the constantly moist tissue around the PureWick™ had traveled up the urethra into the bladder and was now attacking his kidneys.
Urinary tract infections develop quickly in environments with constant moisture. Worse, when a hospice patient experiences diarrhea—common with many terminal illnesses—fecal bacteria contaminate the PureWick™ wick and the suction literally draws that contamination toward the urethral opening. One hospice nurse described it bluntly: “Infection nightmare if the patient has diarrhea. It just sucks it all up into the urethra.”
These aren’t mild infections. In hospice patients, a UTI can trigger delirium, accelerate decline, and cause suffering that no amount of antibiotics can fully resolve when the immune system has already surrendered.
Skin Breakdown That Happens Fast
The progression is predictable. Hour 12: mild redness where the wick contacts tissue. Hour 24: The redness doesn’t blanch when pressed. Hour 36: swelling appears as tissues become inflamed. Hour 48: The outer layer of skin begins to separate. Hour 72: open wounds.
“I’ve seen severe irritation and swelling,” one experienced hospice nurse reported. Another described “a lot of skin breakdown with patients using it.” The suction that pulls urine away also pulls delicate tissue against the synthetic wick material. Continuous contact, moisture, and friction equal tissue destruction.
Chemical irritation compounds the mechanical damage. Urine contains urea, ammonia, and other compounds that burn skin during prolonged exposure. Adult briefs at least absorb and lock away moisture. The PureWick™ keeps tissue in constant contact with whatever urine the suction doesn’t immediately remove.
The Hidden Problem: Urinary Retention
The PureWick™ System wicks away urine released by the body. It does nothing to relieve the urine trapped in a distended bladder. One nurse shared a striking example: “Does not help with urinary retention. Just had a patient today with a PureWick™ System admitted to the inpatient unit, and a Foley was inserted with 925ml output!”
Nine hundred twenty-five milliliters. That’s nearly a liter of urine her bladder had been unable to empty. The patient suffered from pressure and discomfort, while her family believed the external catheter was solving the problem. It wasn’t. External devices can’t address retention—they only manage what the body successfully voids.
Why 24/7 Use Causes Harm
The 12-Hour Rule That Gets Ignored
The manufacturer recommends changing the PureWick™ wick every 8 to 12 hours. That’s twice daily, minimum. Each change requires removing the device, thoroughly cleaning and drying the skin, inspecting for breakdown, and applying a fresh wick.
Families don’t do this. “Most caregivers think they are to be left on 24/7, 365 days a year,” one hospice nurse observed. Another noted, “Families just leave them in. They leak.”
The appeal of the PureWick™ System is that it appears to eliminate the need for work. Set it and forget it. But safe use demands more work than families anticipate—work that exhausted caregivers, already stretched impossibly thin, simply cannot sustain week after week.
What Happens When Families Don’t Change Them
Bacteria begin colonizing the moist wick within 6 to 8 hours. By hour 12, bacterial counts multiply exponentially. By hour 24, the wick has become a breeding ground pressed directly against mucous membranes and skin. By hour 48, infection is almost inevitable.
Skin maceration—the medical term for tissue that’s been waterlogged until it breaks down—accelerates with each additional hour of moisture exposure. The outer skin layer softens. It separates from the underlying tissue. It tears with minimal friction. What started as a convenience becomes a stage 2 pressure ulcer, then stage 3, with alarming speed.
“The family won’t change them out,” a hospital infection control team member confirmed when explaining why her facility banned the PureWick™ System. Medical devices are only as safe as the humans using them. When those humans are family caregivers managing impossible burdens alone, device safety collapses.
The Psychological Impact on Dementia Patients
Mrs. Rodriguez had advanced Alzheimer’s. She couldn’t communicate verbally anymore, just agitated sounds and frightened eyes. When her daughter applied the PureWick™ System, Mrs. Rodriguez’s anxiety spiked. She reached down repeatedly, trying to remove the strange object. She cried out. She couldn’t understand why something was touching her in such an intimate area or what the pulling sensation meant.
“The psychological impact on a dementia patient who now has some strange apparatus suctioning somewhere no one is supposed to be touching” causes genuine distress, one nurse explained. Patients without cognitive impairment can understand explanations. Dementia patients cannot. They only know something foreign is invading their personal space, causing sensations they can’t comprehend, and no amount of reassurance penetrates the confusion.
Dignity disappears. Agency vanishes. Comfort becomes impossible when the solution meant to help instead creates fear.
The Ripple Effect: Unintended Consequences
Reduced Repositioning and Movement
Sarah checked on her mother less frequently once the PureWick™ was in place. No more wet briefs to change every few hours meant fewer reasons to disturb her mother’s rest. She stopped turning her mother every two hours because, honestly, there wasn’t an obvious immediate need anymore.
The false sense of security is dangerous. “Families think they don’t need to move a bed-bound patient because of it, and that causes even more breakdown,” a hospice nurse warned. Patients still need repositioning every two hours to prevent pressure ulcers on heels, hips, shoulders, and the back of the head. The PureWick™ doesn’t eliminate this need. But families believe it does, and immobile patients develop wounds that could have been prevented.
Pressure ulcers compound the problems the PureWick™ already creates. Now there are multiple wound sites. Multiple infection risks. Escalating pain. Accelerating decline.
Cost Burden on Families
Each PureWick™ wick costs approximately $8 to $12. Change it twice daily as recommended, and that’s $16 to $24 per day. Over a month, that’s $480 to $720 just for wicks. Add the cost of renting or purchasing a suction device, and families face expenses that most hospice benefits don’t cover.
“Not covered by hospice,” multiple nurses confirmed. The financial burden falls entirely on families already strained by medical bills, lost income from work, and end-of-life expenses. When promised convenience comes with a price tag that families can barely afford, the stress multiplies.
Some families push wicks beyond the recommended 12-hour maximum, trying to stretch supplies. This further increases the risk of infection and skin breakdown. Economic pressure drives unsafe practices.
If Families Insist: Safer Use Guidelines
The 8-to-12-Hour On, 12-to-16-Hour Off Protocol
Intermittent use gives skin recovery time. Apply the PureWick™ System for 8 to 12 hours—perhaps overnight when caregivers need sleep—then remove it for 12 to 16 hours. During “off” hours, use traditional incontinence briefs with frequent changes and thorough skin care between changes.
Create a rotation schedule. Document it. Post it where all caregivers can see it. 8:00 p.m.: Apply PureWick™ after evening care. 8:00 a.m.: Remove device, provide full skin care, apply barrier cream. Use briefs throughout the day. Repeat.
This isn’t as convenient. But it’s safer. Tissue gets air exposure. Moisture breaks are essential for preventing maceration. Pressure relief from the device itself allows blood flow to return to compressed areas.
Observable Signs of Trouble
Infection Warning Signs:
Cloudy urine or a strong, foul odor that wasn’t present before
Fever above 100.4°F or increased confusion and agitation beyond baseline
Patient crying out when urinating or showing signs of abdominal discomfort
Increased lethargy or sudden decline in responsiveness
Skin Breakdown Indicators:
Redness that remains even after pressing the skin with a finger (non-blanching erythema)
Tissue that feels warmer than the surrounding areas or shows visible swelling
Skin tears, blisters, or any open areas where the wick contacts tissue
Patient wincing, moaning, or pulling away when the area is touched or cleaned
Call the hospice nurse immediately if any of these signs appear. Don’t wait for the next scheduled visit. Early intervention can prevent minor irritation from progressing to serious complications.
Proper Skin Care Between Uses
When removing the PureWick™ wick, cleanse the entire perineal area with warm water and a pH-balanced, fragrance-free cleanser. Pat dry gently—never rub, which increases friction damage. Allow the area to air-dry completely for 5 to 10 minutes, if the patient’s condition allows.
Apply a barrier cream containing zinc oxide or dimethicone to protect skin from moisture during the next application period. Position the patient to relieve pressure on the areas where the device sits. Even 15 minutes lying on the opposite side improves circulation and tissue oxygenation.
Inspect carefully during every device change. Look for color changes, texture differences, increased warmth, or patient discomfort. Photograph of areas to track whether they’re worsening over time. Documentation protects both the patient and the caregiver.
For Hospice Providers: Education as Prevention
Proactive Conversations About Home Medical Devices
Admission assessments should include direct questions: “Are you currently using or considering any medical devices for incontinence management? Has the hospital or any provider recommended equipment that hospice hasn’t discussed with you?” Create space for families to mention the PureWick™ System before problems develop.
When families express interest in devices like PureWick™, seize the teaching opportunity. Explain the differences between hospital monitoring and home reality. Address expectations honestly. Provide written education about risks alongside any discussions of potential benefits.
Addressing the “Hospital Said It Was Fine” Challenge
“But the hospital said it was great and really helped Mom” is a refrain hospice nurses hear constantly. The challenge isn’t contradicting hospital staff but explaining context.
Hospital registered nurses monitor patients every two hours during 12-hour shifts, then go home while fresh nurses take over. That’s four to six sets of professional eyes on each patient every 24 hours, plus aide assistance for repositioning and care. Home is one exhausted caregiver—or two, if the family is fortunate—managing everything 24/7 without breaks, without professional training, without backup when complications emerge.
Professional monitoring gaps mean problems that would be caught within hours in a hospital can progress for days at home before the hospice nurse’s next scheduled visit. This isn’t about hospitals being wrong. It’s about environments being fundamentally different, creating different risk profiles for the same device.
Documentation and Informed Decision-Making
When families insist on using the PureWick™ System despite education about risks, document thoroughly. Record exactly what information was provided—the good, the bad, and the ugly. Note the family’s stated reasons for choosing to proceed. Specify the rotation schedule recommended. Clarify warning signs the family should monitor. Establish clear boundaries for who is responsible for device management and skin monitoring.
Ongoing monitoring requirements must be explicit. Increase the frequency of nursing visits when families use high-risk devices, if possible. Document skin assessments meticulously at every visit. Photograph areas of concern. When a breakdown occurs, documentation protects everyone by showing that education was provided and that risks were explained before the problem developed.
Learning About Devices Outside Hospice’s Purview
The PureWick™ System represents a broader issue: families increasingly use medical devices, tools, and systems that hospice agencies neither provide nor reimburse. Providers must stay informed about these products because patients will use them regardless of whether hospice supplies them.
Identify common device families purchased independently—external catheters, specialized positioning equipment and home monitoring technology. Create educational resources addressing safe use, realistic expectations, and complication recognition for each. Make these resources available during admission and throughout the hospice journey.
Staff education matters too. Interdisciplinary team members need training on devices they’ll encounter in patient homes, even if hospice doesn’t supply them. Regular case reviews where nurses share experiences with various home medical equipment build collective knowledge and improve patient safety across the agency.
Conclusion: When Convenience Doesn’t Always Mean Comfort
The PureWick™ System promises simplicity during impossibly complex times. Families want to believe in solutions that ease suffering and reduce caregiver burden. That desire is human, understandable, and worthy of compassion rather than criticism.
Yet convenience and safety don’t always align, particularly when fragile, dying bodies respond differently to interventions than manufacturers and hospital providers anticipate. The skin of a hospice patient is not the skin of a post-surgical patient who will heal and go home in four days. The immune system of someone with weeks to live cannot fight infections as well as the immune system of someone with years ahead. Home monitoring by exhausted family members cannot replicate hospital surveillance by rotating professional staff.
Knowledge empowers better choices. When families understand that continuous use risks infections their loved one’s body cannot fight, that a 24/7 application causes skin breakdown that increases suffering, and that dementia patients may experience genuine psychological distress from the device, they can make truly informed decisions. When hospice providers commit to learning about devices beyond their formal supply catalog and to educating families about realistic risks and benefits, they fulfill their ethical obligation to prevent harm, even when they don’t control every aspect of patient care.
The conversation about the PureWick™ System isn’t about forbidding its use. It’s about ensuring that families who choose it understand what safer use looks like—intermittent application with vigilant monitoring—and recognize the warning signs that require immediate intervention. It’s about hospice professionals acknowledging their responsibility to educate about the good, the bad, and the ugly of devices families may encounter, even when those devices fall outside standard hospice protocols.
Dignity in dying means more than physical comfort. It means informed choice. It means caregivers are equipped with accurate information rather than marketing promises. It means patients are protected from well-intentioned interventions that create more suffering than they relieve.
When convenience doesn’t guarantee comfort, honesty becomes the greatest kindness we can offer.
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Compassion Crossing Academy — Free and paid online courses are available to teach caregivers, nurses, social workers, chaplains, end-of-life advocates, and educators, including death doulas, how to confidently coordinate complex care.
The Death Deck is often a wonderful conversation starter.
Compassion Crossing, LLC, via Peter M. Abraham, BSN, RN, EOLD, offers on-site services in Madison County, KY, as well as in the seven nearby counties—Clark, Estill, Fayette, Garrard, Jackson, Jessamine, and Rockcastle—and provides virtual options when no local provider is available.
Hospice Buddy: Although Jamie Haberman, RN, CHPN, isn’t a certified end-of-life doula, her virtual services are highly valuable.
Currently, no official organization regulates end-of-life doulas (EOLDs). Remember that some EOLDs listed in directories may no longer be practicing, so it’s important to verify their current status.
End-of-Life Doula Schools
Before you consider a death doula school, please volunteer with a local hospice provider as a “companion volunteer” to gain experience with strangers who are dying, as well as with family and staff dynamics. The author also recommends reading the article Economic rant: The death doula crisis we aren’t talking enough about, as most death doula schools do not emphasize that being a death doula is a calling rather than a career.
The following are end-of-life (aka death doula) schools for those interested in becoming an end-of-life doula:
Compassion Crossing Academy: Although it isn’t a dedicated death-doula school, it offers unique classes that can help death doulas expand their practice. It serves as an important resource for individuals looking to deepen their understanding and grow in this meaningful profession.
Remember that there is no official accrediting body for end-of-life doula programs. Certification simply shows you’ve completed an unaccredited course and received a certificate of completion. It’s advisable to have discovery sessions with any death doula school you’re considering — even if it isn’t listed here — to see if it meets your needs. Also, ask questions and reach out to references, such as former students, to assess whether the school provided a solid foundation for launching your own death doula practice.
