Management of pressure ulcers in palliative care patients: nurses' view

Objective: to understand the management of pressure ulcers in palliative care patients from the perspective of nurses. Methods: qualitative study, in which 17 care nurses participated through semi-structured interviews. Data were submitted to thematic categorical analysis. Results: two categories were listed: Nursing management of pressure ulcers in palliative care patients and Outcome of pressure ulcers in palliative care patients. Their management occurs by means of individualized assistance and may vary according to the different moments in which the individual is and should be malleable. The possibility of three outcomes was also observed: complete healing, clinical improvement and clinical stabilization. Conclusion: despite all the frailty of these patients in palliative care, it was perceived that the clinical improvement of the lesions occurs, although it is a slow path, by means of handling the lesions in an individualized manner and focused on the search for comfort. Descriptors: Nursing Care; Nursing; Palliative Care; Pressure Ulcer; Wound Healing. 1Universidade Estadual do Ceará. Fortaleza, CE, Brasil. 2Centro Universitário Fametro. Fortaleza, CE, Brasil. 3Hospital São José de Doenças Infecciosas. Fortaleza, CE, Brasil. Autor correspondente: Sarah Vieira Figueiredo Av. Dr. Silas Munguba, 1700 – Itaperi, CEP: 60714-903. Fortaleza, CE, Brasil. E-mail: sarahvfigueiredo@gmail.com EDITOR CHEFE: Ana Fatima Carvalho Fernandes EDITOR ASSOCIADO: Francisca Diana da Silva Negreiros Sarah Vieira Figueiredo1 Sherida Karanini Paz de Oliveira1 Anne Kayline Soares Teixeira1 Luciana Catunda Gomes de Menezes2 Ilvana Lima Verde Gomes1 Ydinara Luttianna Paz de Oliveira3 Como citar este artigo: Figueiredo SV, Oliveira SKP, Teixeira AKS, Menezes LCG, Gomes ILV, Oliveira YLP. Management of pressure ulcers in palliative care patients: nurses' view. Rev Rene. 2021;22:e62774. DOI: https://doi.org/10.15253/2175-6783.20212262774 Figueiredo SV, Oliveira SKP, Teixeira AKS, Menezes LCG, Gomes ILV, Oliveira YLP Rev Rene. 2021;22:e62774. 2 Introdução O aumento dos processos de adoecimentos fora de possibilidades curativas atuais acrescido das discussões sobre a terminalidade da vida e da busca de um cuidado de saúde humanizado e de qualidade têm possibilitado que os cuidados paliativos venham ganhando considerável relevância em todo o mundo(1). A origem da palavra paliar vem do latim palliare que se relaciona com o termo proteção ou cobrir com um manto, uma capa. Assim, a abordagem paliativa busca a real promoção de um conforto pleno aos pacientes, de maneira individual e completa(2). Assim, na busca de uma assistência integral diante de um adoecimento ameaçador à vida, o olhar deve ser dado às múltiplas dimensões do ser: físicas, psicológicas, espirituais e sociais. Nesse sentido, destaca-se a importância dos cuidados com a pele desses pacientes, pois esta constitui o maior órgão do corpo humano e que também está vulnerável devido à falha dos múltiplos sistemas orgânicos. Ao levar em consideração fatores relacionados com o estado clínico e físico, tais como a presença de comorbidades e a restrição de mobilidade, os pacientes em cuidados paliativos constituem o grupo de maior risco para o surgimento das lesões por pressão(3-5). A lesão por pressão causa dor e desconforto e, dessa forma, afeta negativamente a qualidade de vida desses pacientes e de seus familiares. Logo, a equipe deve estar atenta às complicações que podem advir das lesões, bem como desenvolver estratégias de busca por prevenção, controle dos sintomas e alívio do sofrimento(6). A literatura é clara quando destaca as peculiaridades da pele de pessoas em cuidados paliativos, por ser mais vulnerável e frágil, bem como o contexto diferenciado de cuidado na prevenção e no tratamento(1,5,7-8). Assim, faz-se mister a realização de um maior número de pesquisas sobre a temática. Apesar da necessidade de um plano de cuidados interdisciplinar para subsidiar a assistência às pessoas com lesão por pressão, cumpre destacar que o enfermeiro é o membro da equipe de saúde que exerce o manejo de forma mais direta a esses pacientes e de forma contínua, especialmente com a pele. Portanto, é imprescindível apoiar suas práticas em evidências científicas, com vistas a um cuidado de qualidade e seguro(9). Desse modo, tem sido exigido dos profissionais enfermeiros, cada vez mais, um olhar atento e dirigido às demandas específicas de pacientes que lidam com o final da vida, na medida em que este processo precisa ser vivido com plena dignidade, satisfação e conforto(10). Ante o exposto, levantou-se o seguinte questionamento: como os enfermeiros têm realizado o manejo das lesões por pressão em pacientes sob cuidados paliativos? Assim, espera-se, com base nos resultados apresentados, contribuir para o fomento às discussões nesse sentido, com o intuito de promover maior conforto a esses pacientes e a seus familiares. A presente pesquisa teve como objetivo compreender o manejo da lesão por pressão em pacientes sob cuidados paliativos na perspectiva de enfermeiros.


Introduction
The increase in illness processes beyond current curative possibilities plus the discussions about the terminality of life and the search for humanized and quality health care have made palliative care considerably relevant worldwide (1) .
The origin of the word palliate comes from the Latin palliare, which is related to the term protection or covering with a mantle, a cloak. Thus, the palliative approach seeks the real promotion of full comfort to patients, individually and completely (2) . Thus, in the search for integral assistance in the face of a life-threatening illness, the gaze must be given to the multiple dimensions of the being: physical, psychological, spiritual, and social.
In this sense, the importance of skin care for these patients is highlighted, since it constitutes the largest organ of the human body and is also vulnerable due to the failure of multiple organ systems. Taking into consideration factors related to clinical and physical status, such as the presence of comorbidities and mobility restriction, palliative care patients constitute the group at highest risk for the onset of pressure ulcers (3)(4)(5) .
Pressure ulcers cause pain and discomfort and thus negatively affect the quality of life of these patients and their families. Therefore, the team should be aware of the complications that may arise from the lesions, as well as develop strategies to seek prevention, control of symptoms and relief of suffering (6) .
The literature is clear when it highlights the peculiarities of the skin of people in palliative care, for being more vulnerable and fragile, as well as the different context of care in prevention and treatment (1,5,(7)(8) . Thus, it is necessary to carry out more research on the subject.
Despite the need for an interdisciplinary care plan to support the assistance to people with pressure ulcers, it should be noted that nurses are the health team members who manage these patients more directly and continuously, especially with the skin. Therefore, it is essential to support their practices in scientific evidence, aiming at a quality and safe care (9) .
Thus, nursing professionals have been increasingly required an attentive and directed look at the specific demands of patients dealing with the end of life, since this process needs to be lived with full dignity, satisfaction and comfort (10) . Given the above, the following question was raised: how have nurses performed the management of pressure ulcers in patients under palliative care?
Thus, it is expected, based on the results presented, to contribute to the promotion of discussions in this regard, in order to promote greater comfort for these patients and their families. The present research aimed to understand the management of pressure ulcers in palliative care patients from the perspective of nurses.

Methods
Qualitative study conducted in a public health service of secondary level reference in the care of chronically ill patients with level 3 hospital accreditation title (maximum score achieved, after evaluation as to quality standards, safety, integrated management and organizational culture) by the National Accreditation Organization, in Fortaleza, CE, Brazil. The study sector was the Adult Special Care Unit due to the high prevalence of patients in follow-up by the institutional palliative care team. In order to guarantee the validity of the methodological aspects this research followed the recommendations of the Consolidated Criteria for Reporting Qualitative Research (COREQ).
It was developed in the period from December 2018 to May 2019. The population consisted of 22 nurses of that unit and all were invited, but only 17 agreed to participate and met the inclusion criteria, which were: being a nurse and having experience with patients under palliative care for at least six months (minimum time that is expected for the professional to achieve experience to provide the information sought in this research). Excluded were those who were on vacation, sick leave, leave of absence or any inability to attend the service during data collection; and those who exercised only management activities in the unit, since the present research was aimed at prioritizing the care practice of nurses before the public under study.
A semi-structured, individualized interview was carried out with an average duration of 15 minutes using a script composed of two parts: Characterization of health professionals (gender, age, time of education, time working in palliative care, post-graduation; participation in courses, lectures or training in palliative care and/or pressure injury; reading of documents on palliative care and/or pressure injury) and Open questions about the research theme (Talk about your practice in pressure injury care of patients under palliative care; What comfort measures have been performed by you and your nursing team for patients with pressure injuries under palliative care?).
Throughout the data collection, pre-analyses of the statements were made continuously, aiming, based on the depth, the degree of recurrence and divergence of the information provided, to delimit the moment of finalization. It is noteworthy that all interviews were recorded with digital equipment and transcribed in full.
The transcribed empirical material was analyzed by means of Bardin's Categorical Thematic Analysis, following the steps: 1) pre-analysis; 2) exploration of the material; 3) treatment of results, inference and interpretation (11) . Thus, two thematic categories were listed, namely: 1) Nursing management of pressure ulcers in palliative care patients and 2) Outcome of pressure ulcers in palliative care patients.
The research respected all the norms of Resolution 466/2012 of the National Health Council, such as subject autonomy, beneficence, non-maleficence, justice, and anonymity (the interviews were coded with the letter "E" for "Nurse" for their designation in the alphanumeric sequence from 1 to 17). All nurses signed the Informed Consent Form in two copies, one given to the participant and the other kept by the researcher and consented to the recording of the interview. The consent of the unit management and hospital direction was requested, and the project received approval from the Research Ethics Committee of the hospital (opinion no. 3,222,859/2019 and Certificate of Ethical Appreciation Submission no. 04375818.1.0000.5684).

Results
Seventeen nurses participated in the research and only one (5.9%) was male, mean age was 37.94 years, ranging from 24 to 54 years and 12 were married or had a stable union (70.6%). Regarding the time of training, 16 participants had graduated in nursing more than eight years ago (94.1%) and only two had no graduate courses (11.8%).
About palliative care, the time of experience varied from one to nine years, and most had more than five years of experience with this profile of patients (70.6%). In addition, 14 participants had already received training (82.4%), courses or lectures about this care approach and 12 sought to update themselves through reading (70.6%). Regarding pressure ulcers, it was unanimous (100.0%) the involvement of all in improvement events, in addition to the search for more knowledge through studies by the majority (88.2%). These aspects reveal a profile of nurses with experience in the theme, which brought many contributions, discussed in the following categories.

Nursing management of pressure ulcers in palliative care patients
It was possible to notice in the participants' reports that, although prevention strategies are instituted, the development of pressure ulcers in palliative care patients may happen, depending on the limitations and frailty of everyone. Thus, the importance of an adequate treatment of injuries was highlighted, since the promotion of comfort, including physical comfort, is an inherent aspect of palliative care, as ex-posed in the speech: ...Palliative care is that we give comfort ...
if the patient has a stage 3 lesion, which is cavitary, it will cause pain to the patient, so we will take care of the pain, reducing the patient's pain by taking care of the lesion (E17).
Thus, in the management of these lesions, the nurses highlighted some aspects of their clinical practice for a better care, because, according to the partici-

Nursing Interventions
Speeches of the participants

Indicator management
When the injury appears, it is notified (E6).

Multi-professional teamwork
The whole team gets into the process, which is nutrition, doctor, everybody, the whole team and so usually our injuries improve significantly (E4).   Figure 1 highlights important care to be given to this public that deals with a life-threatening process of illness. The nurses showed no effort to generate greater comfort to patients whose suffering is accentuated with the onset of pressure ulcers. As for the care evidenced, an aspect pointed out concerns the choice of products to be used in the treatment of the lesions, depending on the availability in the service and on the individual needs of each patient. The pants, there is a concern that the lesions do not evolve with clinical worsening: And then we are careful to do the proper cleaning, dressing and care, so that this wound does not get bigger and other wounds do not appear (E6).
Thus, Figure 1 was elaborated, emphasizing the main aspects highlighted by nurses regarding PU management in palliative care patients.
participants commented on three main dressings because they are available in larger quantities for use in the service, namely: papain, Essential Fatty Acids and silver sulfadiazine.
Analgesia was highlighted as an important ally in care. Therefore, nurses constantly interact with medical professionals aiming at a better therapeutic plan for pain control. Among the strategies in this sense, it was evident the analgesia established in the medi-cal prescription before the beginning of the bath and dressing, on average 30 minutes before these procedures.
The participants highlighted their experiences, revealing the answers they found after their interventions, aspects that are presented in the following category.

Outcome of pressure ulcers in palliative care patients
Regarding the clinical evolution of injuries in treatment, several participants pointed out the improvement of such injuries, even without expectations from the team due to the fragility of patients, being, therefore, "surprised" many times. However, this process of improvement of ulcers, when it occurs, ha-  It was perceived that the nurses talked about three possibilities for the evolution of pressure ulcers, namely: Complete Healing (total closure of the treated lesion occurs), Clinical Improvement (although the lesion does not heal completely, there is for an improvement of the wound and the patient's physical con-ppens more slowly, according to the nurses' report, as a result of the physical limitations of individuals, especially when they are already experiencing the process of terminality: Due to their condition, we have a slower response, not such a fast response, and then we use the products, but we do Thus, Figure 2 presents the process of pressure ulcers evolution (outcome), according to the speeches of the participants, in order to make clearer the perception about the clinical characteristics, according to their speeches. dition, besides relief of suffering) and Clinical Stabilization (corresponds to situations in which the lesion does not regress in its stage, but also does not increase or worsen, remaining the same for long periods). The latter was highlighted as a positive aspect by nurses when dealing with patients in palliative care.

Discussion
As limitations of the study, we highlight the inclusion of only care nurses, and the absence of nursing managers and other professionals. Thus, it points out the need for further studies on the subject and that there is still much to be discussed from different perspectives.
Regarding the experience of nursing professionals regarding the treatment and outcome of pressure ulcers in this population, no other studies with this specific approach were found. Thus, it is believed that the data obtained will favor a better discussion on the subject, spreading knowledge and stimulating the development of strategies, aiming at a better promotion of comfort to these patients.
Corroborating the findings presented, one author states that even with properly instituted prevention strategies, the appearance of pressure ulcers may occur, becoming a significant problem for patients in palliative care. Thus, although it is not possible to prevent all injuries in these patients, adequate care and treatment is essential when the skin loses its integrity (8) .
Treatment initially requires a correct and comprehensive assessment of the patient (their physical and psychosocial aspects, as well as their wishes and those of their family) and the wound. This is followed by management according to the principles of wound care: cleaning, infection management, debridement, pain management, and dressing selection (12) .
The choice of dressing is an essential aspect for discussion in stomal therapy, as it contributes to the formation of an ideal microenvironment for healing. Therefore, it is essential that nurses have knowledge about the phases of healing and wound assessment and recognize the most appropriate dressings for each situation. Thus, the selection of the ideal dressing should occur consciously and specifically for each patient, and the search for less discomfort is fundamental (13) .
In this context, the scarcity of material resour-ces, also evidenced in another study, was presented by the nurses participating in the research as a negative aspect of care, since the absence of adequate covers may hinder the proper management of the lesion (14) . This problem becomes even more relevant when it comes to palliative care patients, since it is believed that the dressings used must meet the needs of this public. In addition, they must have attributes that allow longer changing time to reduce patient manipulation, which generates pain, as well as provide an appropriate local environment for faster healing and relief of suffering.
Regarding therapeutic decision making, it was found that nurses do not distinguish between patients in palliative care or not, performing the conduct based on the individuality of each patient and the characteristics of the lesions. In addition, debridement was a technique often addressed by nurses as important in the management and healing of the wound.
Authors corroborate, stating that in the assistance to patients in palliative care with pressure ulcers, one should seek, as a priority, the promotion of comfort. Therefore, debridement of devitalized tissue may occur, taking into consideration the patient's wishes and objectives (8,15) . Regarding the suffering of family members, evidenced in the speeches of the participants, the important relationship established by nurses is highlighted, in order to promote comfort to them, based on the guidelines established about the lesions, that is, how they are being treated and their daily evolution.
In fact, pressure ulcers generate several repercussions for patients, their families and healthcare institutions, besides being sources of discomfort, pain, emotional suffering and increase the risk of other complications, influencing the length of hospital stay and morbidity and mortality (16) .
According to the National Pressure Injury Advisory Panel (NPIAP) guidelines, the pain process generated by pressure injuries can be severe and continuous (15) . In this sense, it was unanimous among nurses that pain relief is essential. The pain happens due to the presence of the pressure ulcers and due to the patient's movement in bed, during bathing and when dressing.
It should be noted that wound manipulation, cleansing, debridement and dressing change is a painful process for patients. Thus, an analgesic regimen of at least 20-30 minutes (maximum 60 minutes) before the start of these procedures is suggested (15) .
Another aspect identified for the promotion of comfort in the treatment of pressure ulcers refers to the frequency of dressings, performed whenever necessary, aiming to minimize odors and discomfort from saturation of diapers and dressings, plus procedures related to intimate hygiene. This care shows the importance of promoting the dignity of patients in palliative care. Performing body hygiene is an important measure to generate comfort, contributing to a better appearance and well-being of patients (17) .
The nurses' view on the importance of effective communication between the team was observed, aiming at quality care and an individualized therapeutic plan, because it is a care that involves multiple aspects of the individual. Thus, effective communication between physicians, physical therapists, nurses, nutritionists, surgeons and social workers contributes to the improvement of more than 50.0% of injuries, even when the main focus is not the cure, as is the case of patients in palliative care (12) .
In addition, nurses said they are always in contact with the Stomal Therapy team by requesting opinions for better guidance of conducts. The Stomal Therapy service plays a key role in hospital services, aiming at the expansion of better care to patients through innovations in care and strategies that aim for excellence, decreased length of hospital stays and costs (14) . Thus, this team reveals to be an important pillar, especially in view of the peculiarities existing in the context of palliative care.
Although it is often believed that the healing of pressure ulcers is difficult, it cannot be said that in all individuals in palliative care these pressure ulcers do not heal (15) . It is inappropriate to assure that they are untreatable, or to ignore them in this profile of patients at the end of their lives (18) . Like the findings presented, other studies found the same outcomes in a population in which the majority presented complete healing, followed by clinical improvement of the lesion, maintenance of staging and clinical worsening (3,19) .
Other research has also found positive responses in care of injuries in palliative care patients. This is a study of 124 patients in home care in Italy with a total of 156 pressure ulcers (34% stage 1, 55.8% stage 2, 9.6% stage 3 and 0.6% stage 4). It was observed that healing of these lesions may be a realistic goal in these patients, especially those up to stage 2 (18) .
It is worth pointing out that palliative care patients with pressure ulcers should not be confused with those individuals who have palliative lesions, such as those of the oncologic type with no therapeutic options. The difference is that, according to the clinical practice presented, in palliative care patients with pressure ulcers, cure is possible and has revealed the presence of relief in the suffering of these patients and their families.
Therefore, health professionals need to understand the patient's clinical condition, since the focus of care can change. In situations of near terminality, the team needs to reflect on this, so as not to expend ineffective efforts in the treatment of situations that can no longer be cured (4) .
Therefore, the nurse's decision must be based on the individuality and needs of the patient, since his choices regarding the management of pressure ulcers should primarily provide relief and comfort at a given time and clinical evolution of the disease process. Therefore, the management of patients in palliative approach may vary according to the different moments that that individual is at and must be malleable.

Conclusion
Based on the discussions presented, it was possible to understand the experiences and the percep-tion of nursing assistants related to the management of pressure ulcers in patients under palliative care. It is a care permeated by challenges, being highlighted different approaches of nursing interventions, such as: selection of appropriate dressings, debridement, pain relief and comfort, among others. Despite all the fragility of these patients, it was perceived that the clinical improvement of pressure ulcers occurs, despite being a slow path through qualified nursing care focused on the specific needs of the patient.

Collaborations
Figueiredo SV, Oliveira SKP, Teixeira AKS, Menezes LCG, Gomes ILV, and Oliveira YLP contributed to the conception and design, data analysis and interpretation, writing of the article, relevant critical review of the intellectual content, and final approval of the version to be published.