Pressure ulcers in cancer palliative care patients

Review Pressure ulcers in cancer palliative care patients Palliative Medicine 24(7) 669–673 ! The Author(s) 2010 Reprints and permissions: sagepub.c...
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Review

Pressure ulcers in cancer palliative care patients

Palliative Medicine 24(7) 669–673 ! The Author(s) 2010 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216310376119 pmj.sagepub.com

I Hendrichova Antea Formad, Rome, Italy M Castelli Antea Formad, Rome, Italy C Mastroianni Antea Formad, Rome, Italy M Piredda Universita` Campus Bio Medico, Rome, Italy F Mirabella Istituto Superiore di Sanita`, Rome, Italy L Surdo Antea Formad, Rome, Italy MG De Marinis Universita` Campus Bio Medico, Rome, Italy T Heath Serenity Palliative Care Consultancy Service, Melbourne, Australia G Casale Antea Formad, Rome, Italy

Abstract Terminally ill cancer patients are considered at high risk for pressure ulcers because of their clinical condition. However, in Italy, data about pressure ulcers and their prevalence are insufficient. This paper reports a study on pressure ulcers incidence and prevalence in a population of oncology patients cared for in an Italian palliative care service. A retrospective analysis of 414 clinical records of patients admitted over 6 months showed a prevalence of pressure ulcers of 22.9% and an incidence of 6.7%. Karnofsky Performance Scale Index scores, age and length of the stay were significantly related to the pressure sore development. These results support the need to focus attention on pressure ulcers prevention and treatment in terminally ill cancer patients, and to further define specific guidelines aimed at warranting patients’ comfort and quality of life. Keywords Pressure ulcers, palliative care, terminally ill cancer patients, wound care

Introduction In Italy, every year about 170,000 people die as a result of malignancies.1 Cancer is one of the most common diagnoses, which leads to referral to palliative care services. The primary aim of palliative care is to promote quality of life of terminally ill patients and their families. Thus, palliative care provides support by focusing on symptoms’ management and control, neither hastening nor postponing death.2 Pressure ulcers represent an important problem in palliative care because they intensify the suffering of the patients, reduce their quality of life, and increase the healthcare costs. Recently, pressure ulcers have also Corresponding author: C Mastroianni, Antea Formad, Rome, 00100, Italy Email: [email protected]

been shown to be a clinical predictor of decreased survival in women with advanced cancer.3 The National Pressure Ulcers Advisory Panel in 2007 defined the pressure ulcer 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’. Factors that may contribute to pressure ulcers include advanced age, poor nutritional state, impaired sensory perception, decreased ability to walk, or immobility.4 All these factors are often present in terminally ill patients.5 Moreover, in cancer patients, the use of opioids and sedative drugs that inhibit spontaneous movements may increase the risk of development of pressure ulcers.

670 Usually, the performance status of patients referred to palliative care is lower than 50%. Such a score suggests that all these patients should be considered at high risk of developing a pressure ulcer, because on these scales a score of 40% indicates that the patient spends most of the time in bed, and a score of 30% indicates increasing debility and a requirement for total care. In palliative care, performance status is measured with the Karnofsky Performance Scale (KPS) Index or with the Palliative Performance Scale (PPS) which are used interchangeably.6 Within palliative care, these scales are also commonly used instead of the Braden Scale (BS), a measure specifically aimed at evaluating the risk of developing pressure ulcers, as the PPS shows a significant relationship with the BS.7 The main aim of palliative wound care is not wound healing, but symptoms control. Thus, palliative wound care is the evolving body of knowledge and skills that takes a holistic approach to relieving suffering and improving the quality of life of patients and families living with chronic wounds, irrespective of whether the wound is healable or not.8 However, the strategies commonly employed for the prevention and treatment of pressure ulcers in terminally ill patients can hinder their comfort. For instance, position changes might be uncomfortable and hard for patients with dyspnoea, pain, or nausea.4,9 Therefore, treatments should avoid deterioration of pressure ulcers and focus on pain control and management of infections, smell, exudates, and bleeding.10 The issue of unavoidability of pressure ulcers in terminally ill patients remains open because of insufficient data on the actual numbers of ulcers, their causes, the implementation of guidelines, and their efficacy.11 Prevalence of pressure ulcers in palliative care varies from 17 to 47%.5,12,13 These data refer to terminally ill patients with several diseases, while little is known about ulcer incidence and prevalence in cancer patients.11,14 In Italy, data about the prevalence of pressure ulcers refer only to the general patient population in hospital (18.3%) and home care (32.19%) settings.15 Thus, to date, no data are available about palliative care cancer patients. This study aims to contribute to the knowledge base about pressure ulcers in palliative care through the description of prevalence and incidence of pressure ulcers in terminally ill cancer patients in an Italian palliative care service.

Method A descriptive study was conducted by retrospective analysis of clinical records of cancer patients cared for by ‘Antea Associazione’, a palliative care service

Palliative Medicine 24(7) in Rome (Italy). All cancer patients admitted during the period from 1 January 2008 to 30 June 2008 were included in the study. The information retrieved from the clinical records referred to sex, age, diagnosis, KPS index at admission, length of stay, and presence of pressure ulcers. A pressure ulcer was considered present if it was graded ‘stage 1’ or higher according to the most widespread classification in Europe.16 A KPS index lower than 50% is one of the criteria for admission in an Italian palliative care setting; hence, all patients included in the study were considered to be at high risk of developing pressure ulcers. Accordingly, individualized prevention strategies were used for all of them. We used higher specification foam mattresses for all patients and an active support surface for patients at higher risk of pressure ulcers development, where frequent manual repositioning was not possible. Whenever possible, we regularly turned and repositioned all individuals at risk of developing pressure ulcers and created an awareness about repositioning in all persons involved in the care. We observed the skin regularly and used skin emollients to hydrate dry skin to reduce the risk of skin damage. Prevention was performed by adapting to the palliative care priorities the recommendations of general guidelines,17 as specific guidelines for palliative wound care were unavailable. However, the strategies actually performed were not documented in clinical records, and hence it was not possible to correlate the data on the care delivered to the individual patients and their wound development or healing. We considered prevalence as all occurrences of pressure ulcers for the period of study, including both pre-existing and new cases, and incidence as all new cases of pressure ulcers in the same period of study.18,19 Descriptive measures (frequency, percentage, mean, and standard deviation) of sex, age, diagnosis, KPS index, and length of stay were calculated. The Student’s t-test was used to compare the means of independent samples and 2 was used to compare the frequencies.

Results Clinical records of 414 cancer patients cared for in the palliative care service during a period of 6 months were analysed. The sample included 206 (49.7%) male and 208 (50.3%) female patients with a mean age of 74 years (Table 1). In the sample, 65% of patients came from their homes and 35% came from another healthcare service. They were cared for in the palliative care service for a

Hendrichova et al.

671

Table 1. Group distribution for sex and age

Mean age Sex

M F

Total

Group 1

Group 2

Group 3

Group 4

Group 5

Total

73 159 (49.8%) 160 (50.2%)

79 13 (48.1%) 14 (51.9%)

75 31 (51.7%) 29 (48.3%)

79 5 (62.5%) 3 (37.5%)

77 49 (51.6%) 46 (48.4%)

74 206 (49.7%) 208 (50.3%)

319 (77%)

27 (6.5%)

60 (14.5%)

8 (8.4%)

95 (22.9%)

414

Table 2. Karnofsky Performance Scale (KPS) index score at admission for different groups KPS Group Group Group Group Group

1 2 3 4 5

10

20

30

40

50

Total

6 0 1 0 1

25 (8%) 1 (4 %) 9 (15%) 0 (0%) 10 (11%)

190 (60%) 18 (67 %) 46 (77%) 8 (100%) 72 (76%)

92 (29%) 7 (26 %) 4 (7%) 0 (0%) 11 (12%)

6 1 0 0 1

319 27 60 8 95

(2%) (0%) (2%) (0%) (1%)

(2%) (4%) (0%) (0%) (1%)

Total

414

Table 3. Length of stay for patient groups

Length of stay (mean of days)

Group 1

Group 2

Group 3

Group 4

Group 5

37

57

28

52

38

mean of 38 days. The death rate during the 6-month period was 85%; 11% of the patients were discharged, and 4% remained in palliative care at the end of the study. Furthermore, 30% of the patients were diagnosed with gastrointestinal cancer, 29% with lung-pleura cancer, 19% with urogenital cancer, 6% with breast cancer, 3% with haematological malignancies, 2% with head and neck cancer, and 10% with other cancers (Table 4). Sample classification was based on that performed by Henoch and Gustafsson,12 depending on the presence or absence of pressure ulcers, and adapted to illustrate rates of healing. Thus, patients in the sample were stratified into five groups. Group 1 included patients without pressure ulcers (n ¼ 319; 77%); Group 2 comprised patients who developed pressure ulcers during palliative care (n ¼ 27; 6.5%)and in whom ulcers did not heal; Group 3 consisted of patients with pressure ulcers at admission without healing (n ¼ 60; 14.5%); Group 4 were patients with pressure ulcers at admission that healed during palliative care (n ¼ 8; 8.4%); and Group 5 included all patients with pressure ulcers (n ¼ 95; 22.9%).

The prevalence of pressure ulcers during the study period was 22.9% (Group 5) and the incidence was 6.7% (Group 2). Among all the patients who developed new pressure ulcers (Group 2), 15 (53.5%) developed them in the last 6 days before death. Scores of KPS index were distributed with significant difference (p < 0.001) between patients who had pressure ulcers when admitted (Groups 3 and 4) and those without pressure ulcers at admission (Groups 1 and 2). The KPS indices 20 and 30 were frequent in patients with pressure ulcers at admission (Table 2). Patients who developed pressure ulcers were significantly older than those who did not develop them (mean age: 79.9 (SD ¼ 6.8) years vs. 73.4 (SD ¼ 11.5) years; p < 0.0001). There were no significant differences of sex distribution between the groups (Table 1). Patients who developed pressure ulcers were cared for a significantly greater number of days (57.2 days vs. 37.4 days; p ¼ 0.027) than those who did not develop ulcers (Table 3). Only in 8 out of 95 cases (8.4%), 5 females and 3 males, did the ulcers heal (Group 4 vs. all the other groups). There were no significant differences in the distribution of cancer diagnoses among the five groups (Table 4).

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Table 4. Distribution of cancer diagnoses for patient groups

Group Group Group Group Group Total

1 2 3 4 5

Other

Head and neck cancer

Thorax cancer

Gastro-intestinal cancer

Breast cancer

Urogenital Cancer

Haematological malignancies

Total

32(10%) 2(7%) 7(12%) 2(25%) 11(12%) 43(10%)

7(2%) 2 (7%) 1(2%) 0 3(3%) 10(2%)

96(30%) 7(26 %) 16(27%) 3(37%) 26(27%) 122(29%)

95(30%) 11(41%) 19(32%) 1(13%) 31(33%) 126(30%)

19(6%) 1(4%) 4(7%) 1(13%) 6(6%) 25(6%)

59(18%) 4(15%) 13(22%) 1(13%) 18(19%) 77(19%)

11(3%) 0 0 0 0 11(3%)

319 27 60 8 95 414

Discussion This is the first study to describe the prevalence and incidence of pressure ulcers in a sample of cancer patients in palliative care in Italy. The prevalence of pressure ulcers was 22.9% and incidence was 6.7%. These data are consistent with the results from previous studies conducted in palliative care,12 which also included patients with non-cancer diagnoses and employed different methods.6 In Italy, the reported prevalence of pressure ulcers in acute care hospitals was 18.3%;15 thus, the higher prevalence found in our sample confirms the importance of management of pressure ulcers in palliative care, because of the vulnerability of terminally ill cancer patients. In this study, new cases of pressure ulcers occurred regardless of prevention strategies. Patients at higher risk of pressure ulcers were those with a KPS index of 30 or lower, and those older patients. In addition, the risk for pressure ulcers in our sample increased with the length of stay. These results suggest that a number of systemic alterations (such as impaired tissue perfusion, coagulation, etc.) present in terminally ill patients might hinder healing and cause irreversible skin damage which is neither preventable nor treatable.20 Data related to the 27 patients (55.6%) who developed pressure ulcers in the last 6 days before death can be explained from a physiological point of view, because of the serious tissue injures in the last hours of life. Usually, some days before death, circulatory problems emerge and body systems begin to shut down.21 Therefore, pressure ulcers can be considered as visual biomarkers indicating that the critical illness has completely overwhelmed the organism.20 There were no significant differences in age, KPS index, and length of stay among the eight patients whose ulcers healed and the rest of the patients. It is unclear whether pressure ulcers in palliative care can be prevented and treated, or whether they should be considered unavoidable because of progressive and irreversible worsening of the health condition of terminally ill cancer patients.

Available guidelines for the management of pressure ulcers do not specifically address patients at the end of life. Some of their recommendations, such as repositioning patients, that could cause pain or be limited by nausea or inability to lie on one side, may be conflicting with palliative care priorities. Other interventions, such as the use of skin protectors, pressure reducing mattress and pillows, and advanced wound dressings can be used to enhance the primary aims of wound palliative care. The strategies employed to attain specific aims, such as minimizing odour and the excess of exudates, controlling pain, avoiding infections, stabilizing the wound, and lessening dressing changes, might be used by adapting general recommendations to the individual patient. Assessment of patient condition should drive the decision-making for palliative wound care, the primary aim of which is patient comfort.11,22 In some instances, to accept that a new ulcer will occur may be the best choice for the wellbeing of the patient. Very often, family members may consider the development of pressure ulcers to be a result of the inadequate care provided by the health staff or their own failure when the patient is cared for at home.23 However, the occurrence of pressure ulcers cannot be always interpreted as a consequence of poor care, because, notwithstanding intensive programs of prevention and treatment, new ulcers can develop or worsen their condition.20 Educational interventions for patients and family should focus on the primary goals of management of pressure ulcers in palliative care. The attention given to patients’ comfort and symptom control can make it acceptable that a patient may die with a pressure ulcer, without blaming its occurrence on poor care. Some study limitations should be acknowledged. A retrospective method was used for data collection. This might lead to bias owing to difficulties in checking the quality and completeness of the data documented in clinical records. Furthermore, data about the presence of risk factors for the development of pressure ulcers and about the prevention strategies actually performed were neither collected systematically nor related to the

Hendrichova et al. prevalence and incidence of pressure sores. Moreover, this was a single site study, and hence its results cannot be widely generalized.

Conclusions Pressure ulcers are often perceived as a failure of care provided,20 even when patients who developed pressure ulcers have been included in intensive ulcer prevention programs.11 Compromised physiological conditions of patients in palliative care require careful attention to wound prevention and treatment to avoid further suffering. Results from this study hint that, in terminally ill cancer patients, low performance status, advanced age, and length of stay are important risk factors for the development of pressure ulcers. The state of the knowledge suggests that in a number of terminally ill patients their occurrence is unavoidable, regardless of careful implementation of the available guidelines for prevention and treatment. Pressure ulcers in palliative care warrant further research on their causes. Specific studies are needed to develop prevention and treatment strategies.6,11 In addition, perspective studies would strengthen the available results. Finally, it is important to develop specific guidelines and measure associated outcomes.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References 1. Istat (Istituto nazionale di statistica) 2009 Stime preliminari della mortalita` per causa nelle regioni italiane. Periodo di riferimento: anno 2007. Diffuso 25 giugno 2009, http://www.istat.it/dati/dataset/20090625_00/ (accessed 12 August 2009) 2. World Health Organization. Palliative care. Geneva: WHO, 2002. 3. Maida V, Ennis M, Kuziemsky C and Corban J. Wounds and survival in cancer patients. Eur J Cancer 2009; 45: 3237–3244. 4. Calosso A and Zanetti E. (a cura di) Linee guida integrali dell’AHRQ (Agency for Health Research and Quality) per la prevenzione e il trattamento delle lesioni da decubito. Pavia: Edizioni AISLeC, 2003. 5. Bale S, Finlay I and Harding KG. Pressure sore prevention in a hospice. J Wound Care 1995; 4: 465–468.

673 6. Reifsnyder JA and Magee HS. Development of pressure ulcers in patients receiving home hospice care. Wounds 2005; 17: 74–79. 7. Maida V, Lau F, Downing M and Yang J. Correlation between Braden Scale and Palliative Performance Scale in advanced illness. Int Wound J 2008; 5: 585–590. 8. Ferris FD, Al Khateib AA, Fromantin I, et al. Palliative wound care: managing chronic wounds across life’s continuum: a consensus statement from the international palliative wound care initiative. J Palliat Med 2007; 10(1): 37–39. 9. Hatcliffe S and Dawe R. Monitoring pressure sores in a palliative care setting. Int J Palliat Nurse 1996; 2(4): 182–186. 10. McDonald A and Lesage P. Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. J Palliat Med 2006; 9(2): 285–295. 11. Bernardo M. Lesioni da decubito in medicina palliative. RICP 2007; 2: 36–45. 12. Henoch I and Gustafsson M. Pressure ulcers in palliative care: development of a hospice pressure ulcer risk assessment scale. Int J Palliat Nurs 2003; 9(11): 474–484. 13. Chaplin J. Pressure sore risk assessment in palliative care. J Tissue Viability 2000; 10(1): 27–31. 14. DeConno F, Ventafridda V and Saitta L. Skin problems in advanced and terminal cancer patients. J Pain Symptom Manage 1991; 6(4): 247–256. 15. A.I.S.Le.C. (Associazione Italiana per lo studio delle Lesioni Cutanee) Ausilie presidi per la prevenzione e trattamento delle lesioni da decubito, Pavia: MA.RO, 1998. 16. EPUAP (European Pressure Ulcer Advisory Panel). Pressure ulcer treatment guidelines, 1998, http://www. epuap.org/gltreatment.html (accessed 11 August 2009). 17. NPUAP-EPUAP (National Pressure Ulcer Advisory Panel - European Pressure Ulcer Advisory Panel). New guidelines on pressure ulcer prevention, 2009, http:// www.epuap.org/guidelines/Final_quick_prevention.pdf (accessed 12 August 2009). 18. Maida V, Lau F, Downing M and Jang J. Correlation between Braden scale and Palliative Performance Scale in advanced illness. Int Wound J 2008; 5(4): 585–590. 19. Maida V, Corbo M, Dolzhykov M, Ennis M, Irani S and Trozzolo L. Wounds in advanced illness: a prevalence and incidence study based on a prospective case series. Int Wound J 2008; 5: 305–314. 20. Hughes RG, Bakos AD, O’Mara A and Kovner CT. Palliative Wound Care at the End of Life. Home Health Care Management & Practice 2005;17(3): 196–202. 21. Weissman DE. Syndrome of imminent death. Fast Fact and Concept #3, 2nd ed. End-of-Life Palliative Education Resource Center, 2005, www.eperc.mcw.edu. 22. Alvarez OM, Kalinski C, Nusbaum J, et al. Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds. J Palliat Med 2007; 10(5): 1161–1189. 23. Reifsnyder J, Hoplamazian LM and Maxwell TL. Preventing and treating pressure ulcers in hospice patients. Caring 2004; 23(11): 30–37.

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