Pressure Ulcers in Hospitals: Ethics, Law, and Patient Care

Background: Understanding Pressure Ulcers

Bedsores, also known as pressure ulcers, are lesions primarily caused when soft tissues are pressed against bone for a prolonged period of time, restricting blood flow to the affected area. These injuries commonly occur when a patient is immobile or confined to a recovery bed for an extended period. They are most frequently found on the hips, elbows, knees, ankles, and even the back of the head. Current research shows that pressure ulcers are exacerbated by other conditions such as diabetes, perspiration, incontinence, infection, and medications that impair the circulatory system.

Pressure ulcers are particularly serious in older patients — especially those who use a wheelchair or who do not move or exercise regularly. Bedsores are often fatal even when treated aggressively and are one of the leading causes of death from complications in many developed countries, second only to adverse drug reactions (Preventing and Treating Pressure Ulcers, 2009).

Pressure ulcers are best addressed through preventive care: turning the patient regularly so blood flow is not compromised, using catheters or impermeable dressings to keep bed sheets dry, and shifting paralyzed patients on a regular schedule or using pressure-distributing mattresses. Additionally, higher levels of Vitamin C appear to have a beneficial effect on both the prevention and healing of bedsores (Preventing Pressure, 2011; Meschino, 2011).

Ironically, even though Medicare and Medicaid do not reimburse — or do not reimburse fully — for the treatment of pressure ulcers, more than 2.5 million people in the United States develop them each year. Within acute care, the incidence is as high as 38%, and in long-term care it is 24%. The rate is considerably higher within intensive care units, likely due to immunocompromised patients, with 8–40% of patients developing sores (Pressure Ulcers in America, 2001).

The Centers for Medicare and Medicaid Services announced as far back as 2008 that it would no longer reimburse hospitals for treating pressure ulcers because, in the agency's view, they are preventable. Several academic papers and professional medical societies have refuted this position, arguing that there are clinical circumstances in which pressure ulcers are unavoidable even with excellent multidisciplinary care. Because the skin is the body's largest organ, many diseases overwhelm it, and even best practices cannot prevent pressure ulcers 100 percent of the time (WOCN Society, 2009).

The situation involves a patient admitted to a hospital from a skilled nursing facility because of severe dehydration. Both facilities frequently cross-refer patients and maintain a close working relationship. Within a few days of admission, hospital staff noticed a pressure ulcer and claimed it was caused by the nursing facility. The nursing facility countered that there was no documentation of any skin issues prior to the patient's discharge and that the hospital was to blame. Beyond the clear moral and ethical dimensions, there is also the matter of payment from Medicare, which classifies bedsores as "never events." Several arguments therefore surround this type of case.

The core of the argument extends beyond healthcare management into medical ethics and the bureaucracy of healthcare financing. Medicare Part A is hospital insurance that helps cover care in hospitals and skilled nursing facilities, generally covering inpatient care and inpatient rehabilitation costs. Medicare Part B covers medically necessary services: physicians, medical equipment, home health care, and services or supplies that treat a medical condition. Medicare Part D is specifically for prescription drug coverage and, once enrolled, covers costs based on co-payments, a yearly deductible, medication costs, and the pharmacy used; in any case, pharmaceuticals are less expensive than they would be without coverage (Medicare.gov).

Scenario: A Disputed Pressure Ulcer Case

There is not a great deal of research available on the timing of pressure ulcer development. A number of factors affect this, including predisposition, actual health status, nutrition, severity of injury or surgery, pharmacological profile, and the patient's weight, size, and body dimensions. Based on available research, findings indicate that pressure ulcers are likely to develop between the first hour and 4–6 hours after sustained loading onto the tissues (Gefen, 2008). In this case, it is therefore more probable that the pressure ulcers developed after the patient was transferred to the hospital — though it is possible that the final day of care at the nursing facility contributed to the event. Based on the charting showing that the skin sores were not noticeable for 24–48 hours, there is a higher probability that the patient did not receive sufficient preventive care at the hospital.

The ethical conundrum in this case is considerable. The patient is likely elderly and on a fixed income. Within the framework of the ethical care model, several medical ethics principles are relevant:

1) Beneficence. At the core of medical ethics is the value of beneficence, which provides the primary goal and rationale of medicine and healthcare — the core of the Hippocratic Oath — expressed as: "As to disease, make a habit of two things: help, or at least do no harm."

Practical Issues: Medicare Coverage and Ulcer Timing

2) Veracity. In medical ethics, veracity is a fundamental component of the trust relationship between the healthcare professional and the patient. Honesty and truthfulness in what the healthcare professional communicates are now expected, and this relationship is reciprocal — the healthcare professional also expects the patient to be honest about concerns, attitudes, and information regarding physical or mental symptoms. The patient did not cause the infection, so the question becomes: why should the patient suffer the consequences?

3) Non-maleficence. The principle of non-maleficence not only asserts an obligation not to harm intentionally, but also an additional obligation to use any and all appropriate treatments available to cure the illness (Benjamin & Curtis, 2010).

Medicare will typically not pay for any preventable condition or mistake resulting from a hospital stay. In this patient's case, it would not cover the drugs, treatment, or extra days in care that were strictly attributable to the pressure sores. This policy was designed to make hospitals and healthcare facilities more accountable, but it creates a financial burden for the patient (Medicare Will Not, 2007). Medicare and Medicaid specifically note that pressure sores will not be covered because they result in higher payments to the hospital even when the hospital caused the condition (Medicare Nonpayment, 2012).

Based on the research, it does not appear that there were strong predispositions toward pressure ulcers at the skilled nursing facility in this particular case. Dehydration, however, could have contributed to the problem because tissue with insufficient fluid is more susceptible to abrasion. Upon admission to the hospital, it can be assumed that the patient was given fluids, though there is no mention of the actual location of the sores or of any protocol for repositioning the patient.

In this case, it appears the hospital will have to absorb the costs of the pressure ulcer care. The administrator should immediately convene a committee to develop a standardized, best-practices care protocol for patients at risk of pressure ulcers. This protocol would naturally focus on elderly patients and would establish procedures to prevent sores from forming, alleviate contributing factors (such as moisture from bed linens), and, if sores are identified, treat them aggressively before they become serious.