A woman in her early 60s left the hospital with a stage 4 pressure ulcer about the size of a grapefruit on her sacrum.
“It was very deep, and they tried for two years to heal it,” recalls Lynn Borkenhagen, DNP, CNP, ACHPN, a hospice and palliative care nurse practitioner who works with the Mayo Care Transitions/Palliative Care Homebound Program in Rochester, MN.
The woman had chronic obstructive pulmonary disease (COPD) and a mitral valve replacement that failed. She spent two months in the ICU and needed heart surgery again, Borkenhagen says.
“When she came out of the ICU, the goal was to heal her wound, so we followed her along for several months to optimize her heart functioning and promote wound healing,” she says. “We got a plastic surgeon involved and put every effort we could into healing the wound.”
But when they performed a CT scan to check the progress, they were surprised to see that the wound had gotten even larger and there likely was bone infection, Borkenhagen says.
The woman’s treatment while in palliative care had reached an impasse. “We needed to sit down and talk,” she says.
Borkenhagen first gathered together the cardiologist, plastic surgeon, and pulmonologist and asked them for honest feedback.
“We asked the plastic surgeon about any further treatments to heal her wound,” she says. “He was very emotional and said, ‘I have absolutely nothing more to offer her. There’s nothing more we can do — this will not heal.’”
The cardiologist said that the woman would not be eligible for a heart valve replacement if her wound wouldn’t heal, and without it she was facing certain death.
With this information, Borkenhagen had a difficult talk with the patient. She told her how the medical team had done everything they could to heal her wound, and nothing was working. Then she said, “I’m so sorry I don’t have better news. Based on your CT scan, it would appear that your wound is getting worse.”
Then Borkenhagen asked the patient what she understood about her heart condition and, also, what was most important to her once they stopped trying to treat the wound.
“She wanted to go to a family reunion on the East Coast and said, ‘Please, make this happen,’” Borkenhagen says.
The woman had limited mobility, so it took considerable effort to make her comfortable for safe traveling on an airplane. But the team stabilized her wound and heart and had her travel with family to the reunion. The patient returned safely and died at home eight weeks later, she says.
The woman’s death was the way she wanted it, and she was glad that she could make a decision — to travel to the reunion — about something that was important to her, Borkenhagen adds.
“She wore a cute red dress to the family reunion and looked great,” she says.
A hospice and palliative care nurse practitioner recalls the case of a patient with a pressure ulcer that would not heal.
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