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Unavoidable pressure ulcers at the end of life and nurse understanding

02 February 2020
Volume 4 · Issue 1



prevention of pressure ulcers (PUs) in end-of-life care is often problematic because both PUs and interventions to prevent them can cause suffering. The primary aim of this study was to identify and describe the different ways in which nurses understood unavoidable PUs in late palliative care. A second aim was to explore the expediency of the different levels of understanding.


a qualitative interview study with a phenomenographic approach was carried out. The study participants were nurses and healthcare assistants who worked in nursing homes or in specialist palliative inpatient care units run by private providers, non-profit foundations, municipalities and county councils. A phenomenographic analysis of the interview data was undertaken.


all participants shared a fundamental understanding that the prevention of PUs is highly worthwhile in end-of-life care. Within this common view, practitioners' understanding of whether PUs could be prevented differed in four main ways, and were divided into categories:

A: unavoidable PUs do not exist. All can be prevented if all interventions are applied, and all patients are at the same risk for developing PUs in end-of-life care; B: unavoidable PUs do not exist, but some patients do not participate in prevention interventions, which makes prevention difficult. The risk of developing pressure ulcers in end-of-life care varies between patients; C: some PUs are unavoidable because some patients do not participate in prevention interventions; the risk of developing pressure ulcers in end-of-life care differs between patients. D: some PUs are unavoidable, depending on the pathophysiological processes in the dying body. The risk of developing pressure ulcers in end-of-life care differs between patients.


it is paramount to communicate to nurses that not all PUs can be prevented in dying patients, to lessen the burden of ethical stress for the nurses.

During 2014, a national state of the science conference was held in the US to explore the issue of unavoidable pressure ulcers (PU; also known as pressure injuries). The group reached a consensus that unavoidable pressure ulcers do occur and that terminally ill patients who become immobile, malnourished and/or cachexic are at an increased risk of developing unavoidable PUs.

The definition of an unavoidable PU is:

‘One that develops even though the provider has evaluated the patient's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with the patient's needs and goals, and [are] formulated with recognised standards of practice; monitored and evaluated the impact of interventions; and revised these approaches as appropriate’ 1

PUs are fairly common in end-of-life care in Sweden. End-of-life care can be categorised as either general palliative care or specialist palliative care. General palliative care is defined as care given to patients with needs that can be met by staff with a basic knowledge of palliative care. Specialist palliative care is given to patients who have complicated symptoms or specific needs. It is provided by a multiprofessional team with specialist knowledge and competence in palliative care.

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