8/31/2016
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PALLIATIVE WOUND CARE:
BALANCING THE BURDENS &
BENEFITS FOR PATIENTS ON
HOSPICE CARE
Pamela ScarboroughPT, DPT, CDE, CWS, CEEAA
Director of Public Policy and Education
America Medical Technologies
DisclaimerThe information presented herein is provided for educational and
informational purposes only and to promote the safe-and-
effective use of the wound care products provided. It is for the
attendees’ general knowledge and is not a substitute for legal or
medical advice. Although every effort has been made to provide
accurate information herein, laws change frequently and vary
from state to state. The material provided herein is not
comprehensive for all legal and medical developments and may
contain errors or omissions. If you need advice regarding a
specific medical or legal situation, please consult a medical or
legal professional. Gordian Medical, Inc. dba American Medical
Technologies shall not be liable for any errors or omissions in this
information.Copyright © 2016 Gordian Medical, Inc. dba American
Medical Technologies. www.amtwoundcare.com
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• This program will discuss ideas and treatments for preventing
pressure injuries in patients/residents on palliative/hospice
care.
• In addition, the presentation will review appropriate goals
and interventions for palliative wound care for patients who
are receiving hospice care.
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Article Available for You
Guidelines for Wound Management in Palliative Care
• Basic wound care article.
• Contains good palliative wound care principles.
• Author out of New Zealand so some products are different
than those in U.S.
• Great section on Guide to Wound Dressings for those who are
not wound specialists or just starting wound care as part of
their practice.
• Excellent supplement to this talk.
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This Article Has Been Provided for You to
Download
• White paper from the National Pressure Ulcer Advisory Panel
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Promotes Quality of Life
Palliative Care
Affirms Life
Treats the Person
Supports the Family
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Palliative Care’s Overreaching Goal
• “Goal is MUCH MORE than comfort in dying;
• Palliative care is about living, through meticulous attention to
control of pain and other symptoms, supporting emotional,
spiritual, and cultural needs, and maximizing functional
status.”
• Credit: Nse. Punithavathi Inbanathan
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National Pressure Ulcer Advisory Panel
• “The goals of palliative wound care are comfort for the
individual and limiting the impact of the wound on quality of
life, without the overt intent of healing.”
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Pressure Injury (PI) Risk in Individuals with
Advanced or Terminal Disease
• These patients are at significant risk for pressure injury
• Stage 3 and 4 pressure injuries common
• Majority of PI in hospice occur ~2 weeks before death
• Correlates with physiological shut down of body systems 10-
14 days before death
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Risk Factors for Pressure Injury in Hospice Patients
• Advanced age
– Skin drier, fragile, easily injured
– Thinner skin more vulnerable to pressure injury
• Protein-calorie malnutrition
– 50-85% of older individuals in LTC
– Lean body mass decreased; associated with PI development
– Catabolism common in older patient group
– Unintentional weight loss increases risk of developing PI by 147%
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Wounds at Life’s End• Affect up to 35% of patients at life’s end
• ~ 50% of these wounds are pressure injuries
• ~ 20% are ischemic wounds (PAD)
Heel Pressure Injury
DTI
Arterial Insufficiency
PAD
Wounds at Life’s End (con’t.)• ~ 30% mixture of various wound etiologies
– Malignant fungating wounds
– Fistulae
– Radiotherapy skin reactions
– Surgical wounds turned to chronic wounds
– Venous insufficiency/lymphedema
– Diabetic neuropathic wounds
– Skin tears
– ~ 2 million patients in hospice care
– Approximately 700,000 people
need palliative wound care each year
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Fungating Wound
Phlebolymphedema
Venous Insufficiency
and
Lymphedema
in the same leg
Skin Tear
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End of Life Considerations
• May involve short periods of overwhelming illness (acute)
• Or slow deterioration lasting months to years (chronic)
• In both cases, the skin becomes particularly vulnerable to
breakdown
• Witkowski and Parish concluded that skin breakdown is
often unavoidable at this point
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Wound Care at Life’s End
• May be component of palliative care
• Focus on alleviating symptoms
• Pain
• Wound odor
• Exudate control
• If not addressed adequately, can lessen
quality of life even more
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Prolonging Life• Medical technologies & life-sustaining interventions common
• Sustain life often beyond ability of skin to maintain its integrity
• Skin failure & pressure injuries in
older adults & the terminally ill
is not always preventable!!!
• May lead to what is termed:
� “Permissible Pressure Ulcer”
� “Skin failure”
� “Unavoidable Pressure Ulcer”
� “Kennedy Terminal Ulcer”
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SKIN CHANGES AT LIFE'S END
SCALE
&
THE KENNEDY TERMINAL ULCER
WITHIN THE CONCEPT OF
PALLIATIVE CARE
Pamela ScarboroughPT, DPT, MS, CDE, CWS, CEEAA
Director of Public Policy & Education
American Medical Technologies
8/31/2016
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Background
Organ dysfunction
•Acute critical illness
•Trauma
•At life’s end
Organ shut down
•Injury / interference with
systems
•May lead to death
SKIN:
Decreased ability to utilize nutrients to sustain normal functionCopyright © 2016 Gordian Medical, Inc. dba American
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S.C.A.L.E.
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• Skin Changes At Life’s End
• Expert panel published paper in 2008
• Current understanding of complex skin changes at life’s end
limited
What we do know:
“Not all pressure ulcers are avoidable”
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SCALE
Observable Skin Changes
At Life’s End
Current
UnderstandingPhenomenon
Limited
Additional Research Needed
Better Education: Clinicians, Laypeople,
Policy Makers
Conclusions from SCALE Expert Panel
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Skin Barrier Failure
• Largest organ
• Fails like other organs
• Acute, chronic, or end-stage skin failure
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Skin breakdown inevitable for some
Healing often not be realistic goal
New pressure ulcers may occur in this venerable
population
Intervention in accordance with
individuals wishes
NPUAP supports concept of unavoidable pressure injury in the context of
multisystem organ failure in pts receiving palliative care
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Robust section on
prevention and
treatment of
pressure
injuries in patients
receiving palliative
care
Aging Changes Skin
• 80% of adults older than 65 suffer one or more chronic
conditions
• Drug therapies contribute to fragility of skin
• Advanced age, comorbidities, medications, environmental
factors and lifestyle contribute to overall condition of skin
• Making skin unable to tolerate the collective magnitude
of insults at life’s end
• Outcome=Skin Failure
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Skin Deterioration
• In the failing individual, skin deterioration is often
the most outward manifestation of overall faltering
physiology
• Jane Fore, MD
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Skin Failure
Langemo and Brown define
“skin failure” as:
• an event in which the skin
and underlying tissue die due
to hypoperfusion that occurs
concurrent with severe
dysfunction or failure of the
organ systems.
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Multiple Organ Failure and
Skin Failure
Multiple/Multi-Organ Failure (MOF)
is considered a
terminal stage of many diseases that occur as
the body wastes away…”
Multiple/Multi-Organ Failure (MOF)
is considered a
terminal stage of many diseases that occur as
the body wastes away…”
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Organ Failure Stratification
Acute
ChronicEnd-Stage
Skin Barrier
Failure
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Acute Skin Failure
• Hypoperfusion to
skin & underlying
tissue
• Concurrent with
critical illness
• ICU/Acute care
setting
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Chronic Skin Failure
• Hypoperfusion concurrent with ongoing, chronic
disease states
• Occurs in a more steady fashion
• Usually older with multiple co-morbidities
Internal organ systems increasingly
& irreversibly lose their ability to
function as the end of life nears
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Chronic Skin Failure
Loss of fat & muscle
mass
Loss of fat & muscle
mass
Decreased mobility
Decreased mobility
Skin & underlying
tissue changes
Skin & underlying
tissue changes
Chronic illness
Older population
Multiple co-morbidities
Decline in mentation
& function
Malnutrition
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End-Stage Organ Decompensation & Failure
• Large and unusual presentations of skin failure
• Body shunts blood to vital organs
• Widespread & deep tissue destruction over stressed areas can appear in a matter of hours
– Sacrum
– Heels
– Posterior calf muscles
– Arms
– Elbows
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End-Stage Skin Failure
• Skin and underlying tissue die due to hypoperfusion
concurrent with end of life
• Challenges to maintaining skin integrity
• Transition from acute to chronic to end-stage - not easily
observable continuum
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Kennedy or End of Life Wounds
• Large ulcers in a butterfly or pear shape
• Rapid onset
• Progresses to full thickness wounds
• Often precursor to multi-organ failure
• End of life ulcer
• Exact cause unknown
• Usually appear 2-6 weeks before deathCopyright © 2016 Gordian Medical, Inc. dba American
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Avoidable vs. Unavoidable
Pressure Ulcers•
• It is important to consider that the skin is a major
organ and can fail just as other organs of the body
fail (e.g., heart, kidney, liver failure)
• The unavoidable pressure ulcer has been defined
by CMS as a category of wound that is not
preventable due to the resident’s fragile and
declining physical condition, such as when there is
multi-system organ failure or end-of-life conditions
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CMS:
Considered to be an Unavoidable Pressure Ulcers in the LTC Setting
F314
• Resident developed a pressure ulcer even
though the facility:
– Evaluated the resident’s clinical condition and
risk factors
– Defined and implemented interventions that
are consistent with resident needs, goals, and
recognized standards of practice
– Monitored and evaluated the impact of the
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– Revised interventions as appropriateCopyright © 2016 Gordian Medical, Inc. dba American
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Unavoidable
Pressure
Ulcer
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PALLIATIVE PRESSURE INJURY PREVENTION
STRATEGIES
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Practical Pointers
Care of Fragile Skin• Avoid soap
• Use a pH-balanced cleanser
• Apply moisturizers
• Organic coconut oil
• Apply a moisture barrier
• Protect skin from incontinence
• Clean skin very well after bouts
of incontinence
• Particularly fecesCopyright © 2016 Gordian Medical, Inc. dba American
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INTERVENTIONS
to Mitigate Chronic Skin Failure
Well documented multidisciplinary interventions:
-Nutritional support
-Hydration
-Medical management
-Skin hygiene
-Functional rehabilitation
-Pressure redistributing surface selection
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Pressure Distribution
• Reposition and turn the individual at periodic intervals, in
accordance with the individual’s wishes, comfort and
tolerance.
• Strength of Evidence = C
• Strength of Recommendation = ��������
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Repositioning & Early Mobilization for
Individuals Receiving Palliative Care (con’t.)
• Strive to reposition individual receiving palliative care at
least every 4 hours on a
pressure redistributing mattress
such as viscoelastic foam, or
every 2 hours on a regular
mattress.
SoE= B; SoR = ����
• Document turning and repositioning, as well as the
factors influencing these decisions (e.g., individual
wishes or medical needs).
• (SoE=C; SoR = ��������) Copyright © 2016 Gordian Medical, Inc. dba American
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Repositioning and Early Mobilization
for Individuals Receiving Palliative Care
• Pre-medicate the individual 20 to 30 minutes prior to a
scheduled position change for individuals who experience
significant pain on movement. (SoE=C; SoR=����)
• Consider the individual’s choices
in turning, including whether
she/he has a position of comfort,
after explaining the rationale for
turning. (SoE=C; SoR= ��������)
• Consider changing the support surface to improve pressure
redistribution and comfort. (SoE = C; SoR = ����)
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Nutrition and Hydration
• Strive to maintain adequate nutrition and
hydration compatible with the individual’s
condition and wishes.
• Adequate nutritional support is often not
attainable when the individual is unable or
refuses to eat, based on certain disease
states. (SoE = C; SoR = ��������)
• Offer nutritional protein supplements when
ulcer healing is the goal. (SoE = C; SoR = ��������)
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PALLIATIVE WOUND CARE PRINCIPLES
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Clinicians should strive to distinguish:
Healable Wounds
Maintenance Wounds
Nonhealable Wounds
• Have adequate blood supply
• Can heal if underlying causes addressed
• Healing potential• Patient/resident or health system barriers
compromising healing• Patient/residents may be nonadherent to treatment • Patients/residents may have resource limitations
• Includes palliative wounds
• Cannot heal due to irreversible causes/illnesses
• Critical ischemia
• Non treatable malignancy
Maintenance and Nonhealable
Wounds
• Consider conservative approach to treatment
– I.e. conservative debridement of slough
• Bacterial reduction through antisepsis and moisture
reduction
• Focus should be on patient-centered concerns
• Especially pain and optimizing ADLs
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• Wound on many people at life’s end
heal
• Please give them a chance
• Prevent the increased quality of life
decline that chronic wounds bring
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Wound Bed Preparation ModelPerson with a
chronic wound
Treat the causePatient/Family
Centered Concerns
Local Wound Care
Sibbald: 2011,2014, 2015
Determine Healability: Healable, Maintenance, Nonhealable, Palliative
Edge EffectMoisture
ManagementInfection
InflammationDebridement Periwound
Skin
1. Focus on Preventing and Relieving Suffering
• Focused on preventing and relieving suffering of the
individual with life-threatening illness and his or her
significant others through:
– Identification, assessment and relief of distressing physical,
psychosocial and spiritual issues, and pain while neither
hastening nor prolonging death
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2. Goals of care
• Goals of care should be established in collaboration with the
individual and his or her significant others.
• To the extent possible, allow the individual to direct care.
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Goals for Palliative Wound Care
Prevent wound from getting larger
Prevent new pressure injuries
Prevent infection
Manage odor & exudate
Assess & treat pain/ discomfort
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3. NOT Lack of Care
• Palliative pressure ulcer care is not ‘lack of care’, but care
focus on comfort and limiting the extent or impact of the
wound
• Prevention of new pressure ulcers remains important;
however, during the period of active dying, comfort and/or
the individual’s preference may override implementation of
active prevention strategies.
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General Principles
for Pressure Ulcer Management
• Manage and control individual’s symptoms
• Promote best quality of life
• Neither hasten nor prolong death process
• Collaborative goals for care with individual & family
• Where possible allow individual to direct care
• Focus on comfort
• Limit impact of wound on quality of life
• Implement current wound care interventions that meet the standards of care with caveats for palliative/hospice care (e.g. Dakin's solution for longer than 2-3 days)
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Practical Pointers
• Encourage turning & repositioning to the extent possible
• Protect heels
• Assess treat, reassess wound associated pain
• Medications
• Appropriate wound care
• Nonadherent dressings
• Skin sealants
• Nonpharmacologic techniques
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Framework
Functional
Wound
Environment
Debridement
Infection / Inflammation
Control
Moisture Regulation
Migrating Wound Edges
Periwound
Skin
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Palliative Care
When Healing is NOT the Goal
• Individual receiving palliative care whose body systems are shutting down often lacks the physiological resources necessary for complete healing of the pressure ulcer.
• As such, the goal of care may be to maintain or improve the status of the pressure ulcer rather than heal it.
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Treatment Goals for Palliative Care
• Set treatment goals consistent with the
values and goals of the
individual, while
considering input from
the individual’s
significant others.
• SoE = C;
• SoR = ��������
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Treatment Goals (con’t)
• Set a goal to enhance quality of life, even if the pressure ulcer
cannot be healed or treatment does not lead to
closure/healing.
• SoE = C; SoR = ����
• Assess the individual initially and at any change in their
condition to re-evaluate the plan of care.
• SoE = C; SoR = ��������
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Pressure Ulcer Assessment
in Palliative Care
• Assess the pressure ulcer initially and with each
dressing change, but at least weekly (unless
death is imminent), and document findings.
• SoE = C; SoR = ��������)
• Monitor the pressure ulcer in order to continue
to meet the goals of comfort and reduction in
wound pain, addressing wound symptoms
that impact quality of life such as malodor and
exudate.
• SoE = C; SoR = ��������Copyright © 2016 Gordian Medical, Inc. dba American
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• Manage malodor through:
– regular wound cleansing;
– assessment & management of infection;
– debridement of devitalized tissue,
– consider the individual’s wishes and goals of care
– SoE = C; SoR = ��������
• Consider use of topical metronidazole to effectively control pressure
ulcer odor associated with anaerobic bacteria and protozoal
infections (SoE = C; SoR = ����)
• Consider use of charcoal or activated charcoal dressings to help
control odor. (SoE = C; SoR = ����)
• Consider use of external odor absorbers or odor maskers for the
room (e.g., activated charcoal, kitty litter, vinegar, vanilla, coffee
beans, burning candle, and potpourri). (SoE = C; SoR = ����)
• Pamela addition = Essential oils utilizing diffuser
Control Wound Odor
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Pain Assessment and Management
• Do not under treat pain in individuals receiving palliative
care.
• SoE = C; SoR = ��
• Select a wound dressing that requires less frequent changing
and is less likely to cause pain.
• SoE = C; SoR = ��
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Patient and Risk Assessment
• Complete a comprehensive assessment of
the individual.
• SoE = C; SoR = ��
• Consider using the Marie Curie Centre
Hunters Hill Risk Assessment Tool, specific
to adult individuals in palliative care.
• SoE = C; SoR = ����
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Complementary Therapies
• May be of benefit in management of wound pain
• Include:
– Relaxation techniques
• Music
• Reading to patient
• Breathing
– Massage
– Visualization
– Imagery
– Distraction
• These techniques help in reduce pain or pain response by breaking the anxiety-pain cycle
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Closing Thoughts
• Limited studies on woundsat life’s end
• Prevalence ~ 1-million hospice patients
• Millions of frail elderly
• More coming
• Awareness of risks for pressure injury
• Develop as robust wound prevention and care program as possible
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References• http://www.aoa.gov
• http://www.agingstats.gov
• http://www.frailcare.org/
• http://npuap.org
• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance.
Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Perth, Australia;
2014
• Langemo DK, Black J, National Pressure Ulcer Advisory Panel. Pressure ulcers in individuals receiving palliative care: a National
Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2010;23(2):59-72. - See more at:
http://www.annalsoflongtermcare.com/article/palliative-care-pressure-ulcers-long-term-care#sthash.yJw6Qlih.dpuf
• The Institute for the Future. (2003). Health & Health Care 2010 The Forecast, The Challenge (2nd Ed.). Princeton, NJ: Jossey-
Bass.
• Waldrop J, Doughty D. Wound-healing physiology In: Bryant RA. Acute and Chronic Wounds: Nursing Management. 2nd ed. St
Louis, Mo: Mosby, Inc. 2000: 31-34.
• Cordrey R, Lee ACW. Integumentary System Aging Changes and Wounds; In FOCUS: Geriatric Physical Therapy 2006; An
independent Home Study Course for Individual Continuing Education, March-August 2006. American Physical Therapy
Association.
• Wysocki AB. Anatomy and Physiology of Skin and Soft Tissue. In: Bryant RA. Acute and Chronic Wounds: Current Management
Concepts. 3rd ed. St Louis, Mo: Mosby, Inc. 2007: 39-55.
• Reddy M. Skin and Wound Care: Important Considerations in the Older Adult: Advances in Skin & Wound Care, Vol 21, No
9:424-438, 2008.
• Chen TM, Fife CE. Never Say Never: Is it realistic to declare zero tolerance on pressure ulcers. Advance for Long Term Care
Management; January/February 2009, 18-20. Copyright © 2016 Gordian Medical, Inc. dba American
Medical Technologies. www.amtwoundcare.com
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References• Langermo DK, Brown G; Skin Fails Too: Acute, Chronic and End-Stage Skin Failure. Adv in Skin & Wound Care, Vol 19,
No 4, 206-211, May 2006.
• Brem H, Nierman DM, Nelson JE. Pressure ulcers in the chronically critically ill patient. Crit Care Clin 2002;18:683-94.
• Nelson JE. Palliative care of the chronically critically ill patient. Crit Care Clin 2002; 18:659-81.
• Shannon ML, Lehman CA. Protecting the skin of the elderly patient in the intensive care unit. Crit Care Nurs Clin
North Am 1996;8(1):17-28.
• Sibbald, GR, Krasner DL, Alvarez O., et al. Skin Changes at Life’s End (SCALE): Preliminary Consensus Statement,
September 2008.
• Langemo D, Anderson J, Hanson D, et al PEARLS IN PALLIATION: Understanding palliative wound care . Nursing2009
Critical Care, September 2008 , Volume 3 Number 5, Pages 56 - 56.
• Langemo D, Anderson J, Hanson D, Thompson P, Hunter S. Understanding palliative wound care. Nursing.
2007;37(1):65-66.
• Chrisman, C. A. Care of chronic wounds in palliative care and end-of-life patients. International Wound Journal. 2010;
7(4): 214-235.
• Tippett, AW; Wounds at the End of Life; Wounds. 2005; 17(4):91-98 HMP Communications.
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QUESTIONS?
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