Adapting the Braden Scale for End-of-Life Care

Providing care for someone at the end of life is an incredibly personal and sensitive experience. During this phase, the focus often shifts from curative treatments to ensuring comfort, dignity, and quality of life. This is when tools like the Braden Scale—originally designed to assess the risk of pressure injuries in more active patients—can be adapted to support the comfort of individuals who are nearing the end of life. While pressure injuries remain a concern, the way we assess and address them changes as the patient's needs evolve.

In end-of-life care, especially in the home, the approach to managing skin integrity and pressure injuries becomes less about prevention and more about minimizing discomfort and promoting comfort. This article will explore how to adapt the Braden Scale for end-of-life care, how it fits within a home care setting, and the best practices for ensuring a patient’s comfort during their final days.

Understanding the Braden Scale in End-of-Life Care

The Braden Scale has long been used to assess a patient's risk of developing pressure injuries, particularly in those who are immobile or have other factors that increase the likelihood of skin breakdown. It evaluates six key areas: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Each factor is scored from 1 to 4, with lower scores indicating higher risk.

However, when working with patients in the final stages of life, the traditional use of the Braden Scale may need to be adjusted. Rather than focusing on prevention, the goal shifts toward minimizing the development of painful pressure ulcers and supporting the patient’s comfort. This adjustment does not diminish the importance of monitoring skin health; rather, it reflects the shifting priorities in end-of-life care, where comfort becomes the ultimate focus.

When to Use the Braden Scale in End-of-Life Care

In end-of-life care, decisions around using the Braden Scale are typically made after considering the patient’s overall prognosis. If the person is still able to interact with their environment and move occasionally, the Braden Scale can still be useful. However, in cases where the patient is entirely bedbound or unable to communicate, some subscales—such as sensory perception and mobility—may be of less concern.

Ultimately, the goal is to use the Braden Scale not just as a clinical tool, but as a way to foster communication between caregivers, the family, and other healthcare providers. It provides a systematic way to evaluate the risk of pressure injuries while also offering insight into where interventions may be needed to ensure the patient’s comfort.

Adapting Each Subscale for End-of-Life Care

In the context of end-of-life care, each of the six subscales of the Braden Scale should be viewed through the lens of comfort and symptom management rather than strict prevention. Let’s explore how each subscale can be adapted:

1. Sensory Perception

In end-of-life care, the ability to feel discomfort or pain from pressure can be impaired for various reasons, including neurological decline or sedation due to medications. While this may lower the score in the traditional Braden Scale, in the context of end-of-life care, the goal is to focus on minimizing potential pain or discomfort regardless of sensory perception.

For patients who may not be able to communicate their discomfort, caregivers must rely on visual signs of skin distress, such as redness or changes in skin tone. Also, due to the focus on comfort, more frequent repositioning may be required, even if the patient cannot actively signal discomfort.

2. Moisture

Moisture in end-of-life care is a critical factor, particularly as the patient may experience incontinence or profuse sweating. Excess moisture, especially in areas of friction or under pressure points, can increase the likelihood of skin breakdown, causing pain and discomfort. However, at the end of life, comfort and dignity should be the primary focus.

Caregivers should assess how often the patient is exposed to moisture, including sweat and incontinence. If necessary, absorbent pads or moisture-wicking bedding may help keep the patient dry. Barrier creams or ointments should be applied to protect sensitive skin areas, especially when incontinence is present.

Because the patient may no longer be moving frequently, special attention to moisture management becomes a key part of maintaining skin health and comfort.

3. Activity

The activity subscale assesses the level of physical movement, with higher scores indicating more movement and lower scores indicating immobility. In end-of-life care, many patients are often immobile or bedridden, which significantly impacts their ability to shift pressure away from certain body parts.

In these cases, the Braden Scale helps guide caregivers in implementing interventions to reduce the risks associated with immobility. Since the priority is comfort, the goal is not necessarily to encourage mobility, but to ensure that the patient is frequently repositioned to alleviate pressure from vulnerable areas, such as the sacrum, heels, and elbows.

This may involve creating a repositioning schedule for caregivers to follow. Frequent repositioning, combined with pressure-relieving devices such as air mattresses or cushions, can help manage the risk of skin breakdown.

4. Mobility

Much like activity, mobility refers to a patient’s ability to change positions independently. In end-of-life care, mobility is often significantly reduced, and some patients may rely entirely on caregivers for repositioning.

For those patients who are unable to reposition themselves, the Braden Scale can guide caregivers to adjust the patient’s position regularly to relieve pressure. It’s also important to use the proper equipment, such as slide sheets, to assist with repositioning, minimizing discomfort and preventing additional skin damage.

However, as mobility may no longer be a concern for comfort in these cases, the focus shifts entirely to regular repositioning and careful monitoring of areas at high risk for pressure injury.

5. Nutrition

Good nutrition remains important, but in end-of-life care, it may be difficult for the patient to eat or drink sufficiently. The Braden Scale usually highlights the need for increased calorie and protein intake to maintain skin integrity. However, in the case of terminally ill patients, the priority should shift to what the patient can tolerate and enjoy, rather than stressing over meeting nutritional goals.

Caregivers should assess the patient's ability to eat and drink and consider offering small, frequent meals or liquid supplements if necessary. When the patient is unable or unwilling to eat, maintaining hydration and ensuring comfort is more important than strictly adhering to nutritional guidelines.

Nutritional support, such as supplements, may be considered if appropriate, but the focus should always remain on comfort, providing the patient with what they enjoy and can tolerate.

6. Friction and Shear

Friction and shear refer to the mechanical forces that can cause skin damage when moving or repositioning a patient. At the end of life, friction and shear often become significant concerns, as patients may require frequent repositioning, but their skin may be more fragile and prone to damage.

The Braden Scale’s assessment of friction and shear should still guide caregivers in using the right equipment, such as pressure-relieving mattresses, repositioning aids, and appropriate lifting techniques, to minimize friction and shear. Caregivers should be trained in proper lifting and handling techniques to avoid causing pain or injury.

Additionally, protecting areas of the skin that are under constant pressure—like the heels, sacrum, and shoulders—becomes more critical in end-of-life care to avoid further discomfort.

Using the Braden Scale in End-of-Life Care at Home

In the home care setting, the Braden Scale can be particularly helpful for ensuring that caregivers are mindful of the patient’s needs even when the patient is nearing the end of life. Caregivers can use the Braden Scale to document the patient’s condition regularly, identifying any changes that might indicate the need for increased attention.

Many caregivers use home care software to track patient conditions and record Braden assessments. These systems allow for seamless communication between caregivers and healthcare providers, ensuring that the care plan remains responsive to the patient’s evolving needs. If there is a noticeable decline in a subscale score, adjustments can be made in real time—such as changing the positioning schedule or introducing additional comfort measures.

Family Caregiver Support in End-of-Life Care

Family caregivers often play a key role in providing end-of-life care, and supporting them is critical. Ensuring that caregivers feel comfortable using the Braden Scale can help them better manage skin health and promote the patient’s comfort. Regular training sessions, clear instructions on how to assess each subscale, and emotional support can help caregivers feel confident in their role.

In addition to using software for home care to track and update the patient’s condition, caregivers should also be encouraged to keep communication open with healthcare professionals. This collaboration ensures that all aspects of the patient’s comfort are being addressed and that any issues related to skin integrity are promptly managed.

Conclusion

Adapting the Braden Scale for end-of-life care is an important step in ensuring that a patient’s comfort and dignity are maintained during their final days. Whether through repositioning, moisture management, or careful attention to nutrition, the Braden Scale can continue to play an important role in guiding care, even in a terminal context.

The shift from prevention to comfort-focused care may be subtle, but it requires thoughtful adaptations to existing care protocols. For caregivers, whether they are family members or professional providers, using the Braden Scale as a tool for proactive intervention can ensure that skin integrity remains intact and that the patient’s overall well-being is prioritized during this sensitive time. As always, communication, compassion, and the use of supportive tools like home care software can help ensure a holistic and comfortable approach to end-of-life care.