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More on Pressure Ulcers and the Standard of Care

Byrne, Joseph MD; Olshansky, Kenneth MD

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To the Editor:

Dr Kenneth Olshansky's guest editorial, "A New Look at Pressure Ulcers and the Standard of Care,"1 justly challenges us to improve our prevention and treatment of pressure ulcers. However, his analogy to the prevention of airplane crashes is dangerous, both in terms of patient and family expectations and medical-legal liability. Unlike airplanes, every patient ultimately dies ("crashes"), and no one would expect to fly an 80- to 90-year-old airplane with a failing engine (heart) or fuselage (skin) for which no repair parts were available.

Just as we acknowledge end-stage renal failure and endstage heart failure, we need to accept that the skin, the body's largest organ, can also reach an end stage where breakdown is inevitable and healing is impossible. Aging alone brings a decrease in dermal vascularity and collagen density and an increase in fragmentation of elastin.2 Adding to that are the multiple organ-system failures found in many of our patients, as well as the cofactors of quadriplegia, coma, and urinary and fecal incontinence. Cancer patients and patients with chronic infections may be in states of catabolism that impair protein synthesis. Many patients with nonhealing wounds are immunocompromised.

If we hold out to patients and attorneys the concept that every pressure ulcer can be either prevented or healed, then we invite their response that every ulcer is "someone's fault" and that they should identify the person or institution responsible and sue for monetary damages.

We should strive for continuous quality improvement in care of patients with pressure ulcers. However, we need to emphasize to patients, families, and attorneys that despite our best efforts, some patients will die with or from pressures ulcers. For these patients, the approach should be that of palliative care, where we should use our wound care skills to minimize pain and maximize quality of life.

Joseph Byrne, MD

Medical Director,

St Joseph Hospital Center for Wound Care,

Fayetteville, NY


1. Olshansky K. A new look at pressure ulcers and the standard of care. Adv Skin Wound Care 2005;18:176.
2. Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care. Wayne, PA: HMP Communications; 2001:266.

In response:

I thank Dr Byrne for responding to my editorial. This issue is so important, and I appreciate Advances in Skin & Wound Care for giving it the attention that it deserves.

Dr Byrne makes some important points with which I totally agree. Every pressure ulcer is not preventable, healable, or due to neglect. As he notes, the changes of aging skin and the effects of cancer and immunosuppression are certainly factors that increase the risks for developing pressure ulcers. I also agree that despite our best efforts, some patients will develop and die from pressure ulcers.

I would, however, like to respond to some of his other comments.

Dr Byrne questions my analogy to the prevention of airline crashes. I strongly believe that our patients and their families should place on us the same high expectations as they do on the airlines. In my experience not all-but almost all-pressure ulcers could have been prevented. The analogy to airline crashes, then, is very valid. If an airline crash occurs, the Federal Aviation Administration and the National Transportation Safety Board do an extensive investigation to determine the root cause of the crash. Safety standards for the airlines are some of the highest in any industry, and the end result for the flying public is quite extraordinary.

When our patients develop pressure ulcers, we blame their risk factors instead of conducting an extensive investigation to determine the root cause so it does not happen again. How many times have we heard ourselves say, "The reason our patients developed pressure ulcers is because we did not adequately relieve their pressure." We, as health care professionals, should be the ones demanding more accountability in our hospitals and nursing homes to improve quality. Our patients and families deserve that and should expect it.

Dr Byrne also brings up the issue of end-stage breakdown of the skin, which he says is inevitable and makes healing impossible. If "end-stage skin failure" is a real entity, why do these patients develop pressure ulcers over the same bony prominences as patients without "skin failure"? The bottom line is that we all take care of high-risk patients and have no control over the severity of their illnesses. However, we do have control over how well we take care of them. It is not fair, in this day and age of high-tech medicine, specialty beds, and highly trained health care professionals, to always blame our patients' risk factors.

The point I want to make is that to improve quality, we must begin to approach patient safety like the airlines have done. The old excuses are no longer valid.

In summary, I am sure both Dr Byrne and I want to do what is best for our patients. My clinical experience tells me that most pressure ulcers are preventable, and until we accept that fact and recognize our responsibility, the standard of care will not improve.

Kenneth Olshansky, MD

Clinical Professor of Plastic Surgery,

Medical College of Virginia/Virginia

Commonwealth University,

Richmond, VA

© 2005 Lippincott Williams & Wilkins, Inc.