A woman used to visit her 37-year-old younger brother, John, at a long-term care facility where he had resided for the past four years. He was dying; multiple body systems were failing from malnutrition and dehydration, and poison was spreading throughout his body from an infected pressure sore.

John had suffered a spinal injury in a drug-related accident that left him paralyzed from the waist down seven years ago. He dealt with bouts of depression, prescription drug addiction, and loneliness since his girlfriend broke off with him last year. He would sign himself out of the facility, visit a nearby tavern, and return hours later very intoxicated and high from street drugs purchased while out of the facility. The last months of his life he frequently refused to cooperate with therapies, activity/recreation staff, and nursing caregivers. He would not eat, and refused to bathe, or be repositioned. John became verbally abusive to staff and would strike out at them physically if they came too close at those times. He would not even allow dressing changes to his sacral pressure sore which had degraded a Stage IV wound.

Since John was awake, alert and oriented to person, place, and time, he was self-responsible and allowed to make decisions for himself. He was unbelievably depressed with how his life had turned out, blaming himself and fate, and now at the point of wanting to end it all through his own death. John got his wish.

I share John’s story with you to show that pressure sores don’t happen accidentally and that they can be a contributing factor to end of life. A certain chain of events is required to set the stage for a pressure sore to occur and develop to the point of morbidity.

Pressure sores develop from the consistent pressure of soft tissue over a boney prominence of the body. They are categorized by the depth of the wound, the layers, and type of tissue that has been damaged. Here is a breakdown used by many clinicians:

Stage I: no opening in the skin, but a color change noted on the skin, (red or darker) especially on that covering a bony prominence (heel, ankle, elbow, hip, sacrum, back of the head, around the ear). The darkness does not fade within 30 minutes of pressure being removed (non-blanchable). Sometimes there is also a change in the texture of the skin, from firm with resilience to mushy, boggy and painful to touch.

Stage II: the skin is open to a shallow depth, may drain a small amount of blood, or sero-sanguinous fluid (liquid that is blood-tinged). Can be very painful.

Stage III: This is a wound that goes down through subcutaneous and fatty tissue but not including muscle. Is deeper than a Stage II. May display tunneling (passages from the wound bed radiating outward toward healthy tissue). Can be extremely painful.

Stage IV: There is massive tissue destruction and drainage involved, can be deep and wide, and extend down to the bone. It is deeper than a Stage III. Surgery is frequently required to repair

Is it a good case for the plaintiff?
Would the young man’s case have been a good one for a plaintiff attorney to take? Certainly there were damages – death from an infected deep pressure sore. But was there liability?

Was John permitted to refuse care?

Would a jury be able to empathize with a 37-year-old depressed guy who was dependent on alcohol and drugs – a man whose behavior led to his paralysis, which in turn increased his risk for pressure sores?

Would they blame the young man for not cooperating with the healthcare staff? Would they have expected the staff to do better problem solving and offer more aggressive alternatives to treat this depression and uncooperative behavior?

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