This article updated on 16 August 2022, discusses pressure sores in palliative care.
With all our attention recently focused on the big threat of Covid-19, the little things that don’t appear to be a problem could sneak up on us.
A reader raised her concerns about the way her mother died and the very poor management of her mother’s pressure sores, which caused much suffering for her mother as she died. Through the research her daughter has done since, she has found much of her mother’s pain and therefore suffering could have been avoided.
A pressure sore happens when there is constant pressure on a part of the body – for example, the base of the spine or back of the heel, that doesn’t move much because the person is confined to a space, usually a bed or a chair.
They can also be called bed sores, decubitus ulcers or just ‘ulcers’.
People who are dying are very vulnerable to pressure sores in palliative care, as are the bed-ridden elderly, because of their lack of movement.
As the tissue with the pressure on it continues to break down, the area involved gets larger and the eroded area can reach through to the bone. A staging system is used to describe the severity of pressure sores, with 1 being low and 4 being severe.
Modern hospitals and aged care managers are increasingly alert to prevention strategies.
This is the reason people who are immobile are rolled over frequently by staff in hospitals and nursing homes, often at two hourly intervals. If a dying person is being cared for at home, this is one of the most important reasons for regular visits from nursing staff, who are trained in how to do this, without hurting themselves.
In September 2019, the NSW coroner reported on the case of Sylvia Confos, who died as the result of a poorly managed sacral ulcer in a nursing home. This is an ulcer at the base of the spine.
Sylvia’s family were unaware of the ulcer.
A specialist who reviewed the case for the coroner’s court said appropriate plans were put in place to treat the wound by the nursing home. However the coroner:
- noted a number of deficits, including in keeping of wound charts
- was critical of non-communication with the family
- noted the wound care policy was not sufficiently adhered to
- said that clinicians should always be talking to families about decisions, whether palliative or curative, and at every change in condition.
The coroner reported that notes on Mrs Confos positioning and repositioning were incomplete, even though they should have been filled in by staff and that her mattress was not the right one for her condition.
The nursing home’s policy was to take photos of the wounds to send to experts but this wasn’t done consistently.
The coroner said Mrs Confos was a vulnerable resident due to her age and co-morbidities, but because of her dementia, she was not able to make decisions about her treatment, or communicate effectively.
“And so the Home owed an obligation to her to ensure that a family member responsible for her would be aware of relevant medical conditions and treatment and be in a position to make decisions,” she said.
Sometimes staff thought other staff were communicating with the family. Mrs Confos’ GP thought the nursing home was communicating with the family.
“The impression I formed from the evidence is that there was no one person who accepted responsibility for notifying the family, and that there was an assumption that someone else would do it,” the coroner noted.
As a result of this case, the nursing home concerned has introduced a Pressure Ulcer Healing Chart, with its scoring system.
The nursing home’s improvements to its practice include:
- improved charting of ulcers
- introduction of a wound care schedule.
- wound deterioration guidelines requiring more than monthly photos
- guidelines about GP review of wounds
- guidelines about notifying families
- more alert systems in the electronic medical record to prompt clinicians to attend to various obligations
- changes so it would not be possible for someone to assess a wound from stage 2 to 4, or from 4 to 2, for example, without an alert
- multi-disciplinary case conferences to occur annually or more frequently as required.
- family conferences to occur once a month if required.
This is a handy consciousness raising for all of us likely to have to consider the care of someone dying, or even just bedridden.
To read the coroner’s report on Mrs Confos’ case, go to: http://www.coroners.justice.nsw.gov.au/Documents/Findings%20Confos%20Final%20v2.pdf
For the NSW pressure point prevalence survey report, go to:
To see My Health, Alberta, Canada’s great guide to pressure sores, for the lay person, go to:
And to look a bit deeper into issues facing the elderly see our article on elder abuse.