Practice Point

End-of-life wound care focuses on:

• pain management
  
• odor control
  
• management of exudates
  
• bleeding control
  
• self-image
  
• dignity
  
• quality of life

Patient and Wound Assessment

It is essential to perform a complete head-to-toe assessment of the end-of-life patient, including physical and psychosocial health and overall quality of life. A thorough assessment will assist the healthcare professional in realistically evaluating the need for preventive interventions as well as efficacy and cost-effectiveness of achieving closure, should there be tissue breakdown. The assessment should establish both the risk for and the presence or absence of skin breakdown, including the presence of a pressure ulcer and the risk for developing additional ulcers. The following areas should be included in the patient assessment:⁴³

• comorbid health problems
  
• medications the patient is taking
  
• risk factors present in the patient
  
• nutritional status
  
• diagnostic test results
  
• psychosocial implications
  
• environmental resources
  
• patient/family goals.

The Pressure Sore Risk Assessment Scale for Palliative Care⁶⁸ was developed for use in individuals at or near the end of life. Its seven subscales include sensation, mobility, moisture, activity in bed or chair, nutrition and weight change, skin condition, and friction and shear. Scores can range from 7 to 28, with a score of 12 or lower indicating low risk; 13 to 17, medium risk; 18 to 21, high risk; and 22 or over, very high risk. Risk assessment can be done weekly or with significant changes in condition. (See Box 23-1, Hunters Hill Marie Curie Centre pressure ulcer risk assessment.) Risk reassessments are important given the likelihood of the patient’s deteriorating condition. As the end of life approaches, assessments may be performed less frequently in order to enhance comfort.⁴³

Wounds or ulcers in end-of-life patients are often chronic in nature, as healing is significantly impaired due to physical condition and existing comorbidities. A chronic pressure ulcer has a well-defined border with surrounding nonblanchable erythema. When induration is present, it can extend outward from the wound edges. Many chronic wounds have rolled-under edges that impede wound healing and closure. Wound edges roll under when the wound bed is dry. In response, the wound attempts to preserve what little moisture is present and epithelialization is slowed, leaving the wound bed unepithelialized. Most wounds have drainage, and chronic wound drainage contains destructive enzymes as well as fibroblasts that are less effective at producing collagen to heal the wound.⁸⁴ Assess the wound initially and with each dressing change, but at a minimum weekly unless the individual is actively dying.⁴³ (See Chapter 5, Acute and Chronic Wound Healing.)

Support Surfaces

Support surfaces are “specialized devices for pressure redistribution designed for management of tissue loads, micro-climate, and/or other therapeutic functions (i.e., any mattress, integrated bed system, mattress replacement, overlay, or seat cushion, or seat cushion overlay).”⁶⁷ Some support surfaces provide the additional capability of turning or rotation assistance. It is important to match the support surface to the needs of the individual such that the surface redistributes weight over a larger area, thereby minimizing tissue pressures, particularly over bony prominences.⁶⁷ These surfaces are helpful for both the bed and the chair. Refer to the NPUAP/EPUAP/PPPIA guideline⁴³ for more specific recommendations regarding pressure redistribution in palliative care patients.

Pain Management

Both prevention and treatment of skin breakdown can be uncomfortable for individuals at the end of life. The majority of patients with a pressure ulcer experience moderate to severe pain,^85–88 especially during dressing changes and wound bed treatments, and the pain can be acute or chronic.^88,89 In fact, 21 of 23 patients (91%) in one study reported a pressure ulcer as painful.⁹⁰ Likewise, in a systematic review of 15 studies addressing the impact of pressure ulcer pain, the authors concluded that “pain was the most significant consequence of having a pressure ulcer and affected every aspect of patients’ lives.”⁷³ In fact, pain from a pressure ulcer can be the most distressing symptom an individual might report.⁷³ It is important to keep in mind that “pain is anything the patient says it is.”⁹¹

Wound pain can be caused by the tumor pressing on nerves and blood vessels or by exposure of dermis.⁹² Pain in wounds often arises from painful procedures, including cleansing and dressing removal, particularly if the dressing is dry and adherent.⁹³ Given that an individual at or near the end of life has a wound that likely will not heal, the wound and wound pain are chronic in nature. Chronic pain is pain that is persistent and can occur even when the wound is not being manipulated.⁹⁴ Concomitant acute pain can occur with dressing changes, treatments, and additional trauma to the area.

One of the most significant goals in palliative care is to alleviate, or at the very least manage, pain. It is therefore essential to perform regular pain assessments.^29,81 Pain assessment tools reported to be valid and reliable include the visual analog scale for pain (VAS pain); the visual rating scale (VRS); the numeric rating scale; the FACES rating scale (FRS); the FLACC scale (face, legs, activity, cry, consolability); and the McGill pain questionnaire (MPQ). A 2005 study⁹⁵ identified the VAS pain, the FRS, and the MPQ as valid and reliable to identify pressure ulcer pain.

A mild to moderate opioid, such as 1 mg morphine or diamorphine mixed with 1 mg of a hydrogel,^96,97 or nonopioid medication can be used to relieve wound pain, as can a topical agent that contains a local anesthetic (e.g., one with lidocaine, such as EMLA cream, Lidoderm, or Regenecare)^97–99 or a foam dressing containing ibuprofen (not available everywhere).^100,101 One hospital solely dedicated to caring for palliative patients has developed a unique mixture of Balmex and lidocaine 2.75%, which may be applied topically to painful and odorous wounds. They have reported success with this strategy.¹⁰² Wound treatment pain can also be minimized by using minimal mechanical force for cleansing (4 to 15 psi irrigation force); using warmed products, such as normal saline or gauze pads¹⁰³; and avoiding antiseptic and cytotoxic agents.^43,72 Nonpharmacological strategies such as music, relaxation, position changes, meditation, guided imagery, healing touch, distraction, etc., are also available.

Wound Dressings

When possible, select a dressing that can remain in place for several days; however, this isn’t always possible when a large amount of exudate is present. A dressing that protects periwound skin is also desirable, as is one that protects the wound from moisture and feces. As a rule, nonadherent, foam, polymeric membrane, and/or silicone dressings are best. Maintain a moist wound care environment to prevent exposure of delicate nerve endings,¹⁰⁴ as dry, desiccated wound beds and dressings are nearly always painful.¹⁰⁵ (See Wound Treatment Options, Chapter 9.)

Wound Infection, Odor, and Exudate

Tissue deprived of oxygen and nutrients becomes devitalized and nonviable,¹⁰⁶ and bacteria thrive on this moist, devitalized tissue.¹⁰⁷ As the bacteria colonize, necrotic material appears in the wound and creates an odor, which varies depending on the bacteria present. Nonviable tissue eventually serves as a culture medium to support bacterial growth and inhibit leukocyte phagocytosis of bacteria.¹⁰⁶ Odor is generally associated with anaerobic and some gram-negative (e.g., Pseudomonas) microorganisms.^83,108 Anaerobic bacteria are usually present in necrotic material, thrive in the absence of oxygen, and can become buried deeper within the wound. Anaerobic bacteria¹⁰⁵ also have a stronger, more offensive odor that can be particularly distressing to the patient. The wound appearance becomes black and leathery with exposure to air or yellow-gray when exposed to moisture, which occurs over varying lengths of time depending on the underlying disorder.¹⁰⁵

It is the odor, drainage, and pain arising from the infection that are often the most distressing to the individual and therefore should be treated. Wound odor can be embarrassing to the individual and lead to isolation, depression, and poor quality of life.^2,22,108 Treatment is aimed at removing the cause of the odor and the odor itself. Because saturated dressings can hold odor, more frequent changing may help control the odor as well as the pain from the weight of the dressing. A secondary dressing may help. Frequent irrigation also helps remove exudate and odor. Nonviable tissue can be debrided, and autolytic debridement is often the least painful for the individual. Sharp debridement is more or less a last resort, and caution must be exercised to prevent excessive bleeding and/or pain.^108,109 Topical metronidazole (gel, cream, crushed tablets, oral) has been shown to be effective for anaerobic bacteria as has silver sulfadiazine.^{4,5,43,110–118} Activated charcoal dressings have also been shown to be helpful.^{80,84,109,114,118–122}

Nonsurgical (autolytic or enzymatic) debridement is recommended due to the tendency for bleeding and “seeding” of malignant cells in fungating and radiation wounds.¹⁰⁵ Topical metronidazole has also been used successfully to control odor.^2,78 Activated charcoal dressings are effective in controlling odor quickly,^{22,109,111,115,120,123,124} as are occlusive dressings and frequent dressing changes.²² Cadexomer iodine is an effective antiseptic,¹¹⁶ as is povidone–iodine.¹¹⁷ Silver dressings are effective for treating infections and thus in controlling odor. Dakin’s solution (0.25% sodium hypochlorite) is another effective odor controller; it is saturated into gauze and placed in the wound for a limited time and may cause some discomfort.¹¹⁷ Placement of larvae is another effective method of eliminating infection and controlling odor from wounds with extensive necrotic tissue.¹¹⁸ Room deodorizers are also helpful. Sugar paste and honey are once again being used for their antibacterial and debriding properties.^121,122 The high sugar content produces a hyperosmotic wound environment to inhibit bacterial growth and assist in debridement.^9,121,122

Periwound skin protection is crucial because exudate, which is liquid and sometimes caustic, can exacerbate skin damage¹²³ by causing maceration, breakdown, and itching.⁴³ Dressings that appropriately control exudate without unnecessarily increasing wetness or dryness are recommended, such as an alginate, Hydrofiber, foam, or a nonadherent dressing (silicone, polymeric foam, foam), often with a secondary absorbent pad.^105,124,125 Be sure to change dressings when they become saturated, as heavy or overly saturated dressings can cause wound bed pain and irritate periwound skin. Alternatively, if exudate is minimal, a low-absorbency dressing, such as a hydrocolloid or semipermeable film, is recommended.¹²⁶ A barrier film around the periwound area is helpful in controlling damage from moisture. See Chapter 9, Wound Treatment Options, for further information on dressings.

The inflammatory fluid that seeps from the extracellular spaces is what is known as exudate. All bacteria produce exudate, the color and odor of which vary according to the causative organism.¹⁰⁵ For example, green exudate generally indicates gram-negative, aerobic bacteria, which respond well to silver found in many dressings now on the market.¹⁰⁵ The more persistent the inflammation or infection is, the more exudate that will be produced. Exudate frequently contains proteins; when combined with inadequate oral intake of protein commonly seen in the end-of-life individual, the degree of hypoproteinemia can increase. Managing exudates can be a major challenge.¹²⁷

Fungating Wounds

Fungating wounds occur when the skin and its supporting blood and lymph vessels are infiltrated by a local tumor or by metastatic spread from a primary tumor, resulting in oxygen starvation to the tissue and eventual necrosis.^12,120,136 It’s reported that approximately 5% to 19% of patients with metastatic cancer will develop a fungating wound.^11,137 The incidence in elderly individuals over age 70 is higher.^125,134 Although these wounds often develop during the last months of life, they can be present for years.²² The most common site for development of a fungating wound is the breast, but they can also be found on the head and neck as well as in an area of melanoma. The anatomical location and the delicacy of the surrounding tissue make it challenging to address these wounds.

The term fungating refers to a malignant process of both ulcerating and proliferative growth through direct invasion.^139–142 An ulcerating wound will produce a craterlike wound, whereas a lesion with a predominantly proliferative growth pattern often develops into a nodular “fungus”- or “cauliflower”- appearing lesion.^137,139 Mixed-appearing lesions can also develop.^137,139 Skin tumors tend to become ulcerated because the skin is a bacterially contaminated surface.¹⁴⁰ Common symptoms of fungating wounds include exudate, pain, odor, pruritus, and bleeding as well as psychosocial issues.^120,136

Fungating wounds rarely heal;¹³⁹ thus, management is centered on symptom control, promotion of comfort, and maintenance or improvement of quality of life.^137,141 Assessment and management by healthcare providers, especially the nurse and physician, are most challenging.¹³⁷ Therefore, excellent interdisciplinary care and ongoing patient–caregiver communication are essential.

Care of Fungating Wounds

Woo and Sibbald⁸⁰ proposed an acronym for treatment of fungating wounds. HOPES provides a systematized approach and includes Hemorrhage, Odor, Pain, Exudate, and Superficial infection.⁸⁰ Hemorrhage due to erosion of blood vessels is the most common emergency seen in fungating wounds and can also be related to the decreased platelet function within the tumor.¹⁴² Blood vessels can become eroded from the tumor cells themselves or secondary to necrosis or sloughing of tissues after radiotherapy.¹⁴³ Nonsurgical (autolytic or enzymatic) debridement is recommended due to the tendency for bleeding and “seeding” of malignant cells.^105,124 Fungating lesions are friable and predisposed to bleeding. To minimize bleeding, use a nonadherent or soft silicone dressing, maintain a moist wound bed, and clean by gentle irrigation rather than swabbing.¹⁴⁰ Dry dressings can cause bleeding when they adhere to the wound bed and should be avoided.¹⁰⁵ Alginate dressings have a high seaweed content and exchange sodium ions for calcium ions in the wound bed, thus encouraging the clotting cascade. Alginates must be used with caution in fragile tumors, however, because these dressings can also cause bleeding.⁹⁶ Other natural hemostats are collagen and oxidized cellulose; silver nitrate is a sclerosing agent; epinephrine is a vasoconstrictor; and sucralfate is an astringent.^105,120,134 Hemostatic surgical sponges can also be used and left in place for a time.²² Alginates, foam, silicone, and polymeric foam dressings are helpful for odor.^144,145

Radiation Wounds

Radiation therapy targets a high-energy x-ray beam to an area of treatment. The target area is usually a tumor, the area surrounding a tumor, or an area where a tumor has been surgically removed. While each treatment is designed to target tissue at a particular depth, the tissues overlying the site can be affected as well.^146,147

Radiation-related skin changes or ulcerations can occur in soft tissues during the course of therapy, immediately after therapy, or a long time following therapy.^146,147 Skin problems can also be noted in individuals who underwent treatments years ago before technological improvements in radiation machines were implemented. The skin reactions seen are generally specific to the area that was irradiated, and the inflammation can occur almost immediately.^147,148 Acute erythematous wounds result from the dilated blood vessels in the irradiated area. The ulceration may be large and may present initially as a draining sinus.¹⁴⁹

The more common skin reactions associated with radiation therapy include flaking or peeling, redness, changes in pigmentation, loss of hair, decreased or absent perspiration, superficial blood vessel changes, edema, ulceration, and scarring.^140,147 (See Box 23-2, Common radiation wound skin reactions.)

Changes at the cellular level can be reflected by poor healing at the site. Healing is impeded related to atrophy of the epidermis and epidermal accessory structures, microvascular occlusions, exuberant connective tissue, decreased fibroblast reproduction, and significant amounts of cellular damage.^140,149

Most radiation-related lesions are superficial. In 1994, the Oncology Nursing Society created a classification system for radiation ulcers. This system was refined in 2002. The five-level classification system ranges from “0” or no skin problem within a radiation field to “4” or skin necrosis or ulceration of full-thickness dermis¹⁵⁰ (Table 23-1).

Treatment of a radiation-induced skin lesion is essentially like treatment for other types of wounds. Any tissue within a radiation field must be considered at high risk for potential breakdown and should be kept clean, appropriately moistened, and protected from potential injury. Skin can also be protected by avoiding restrictive clothing, adhesives, harsh chemicals, heat or sunlight, and trauma. Should a minor skin reaction such as erythema or dry desquamation occur, the same guidelines apply, along with use of a topical hydrogel or a steroid cream.¹⁴⁰ Moist desquamation is also treated in the same manner as described above, with the addition of a nonadherent or foam dressing to manage the wound environment. It’s important to cover the wound to prevent evaporation of fluid, control pain, and reduce risk of infection.^147,148

Severe ulceration or necrosis needs to be treated as an open wound, using moist wound healing principles.^140,147 However, it’s important to first rule out a new malignancy in the area.¹⁴⁸ Skin grafting or growth factor application may be required.¹³⁶ As a consequence of the vascular changes and resultant hypoxia, irradiated tissues have a decreased ability to fight infection. Avoiding or controlling infection is important, and antibiotics are best delivered topically.¹⁴⁹ The vascular changes and hypoxia also are responsible for pain being present in these ulcerations.¹⁴⁹ These wounds are typically difficult to manage and slow to heal. In all instances, systemic support is necessary to enhance the patient’s healing potential in order to minimize further trauma to the wound site.¹⁴⁷

Summary

While cure and/or healing of a wound is not always realistic, it’s possible to provide compassionate and symptom-relieving treatment for palliative care patients who have wounds. This includes balancing the management of local wound symptoms, such as pain, odor, exudate, and bleeding, while preserving patient dignity and self-esteem and maximizing quality of life. Few randomized clinical trials or other research studies exist in the area of palliative wound care. However, there is a consensus document from the International Palliative Wound Care Initiative that looks at managing these wounds across the life continuum.¹⁵¹ Continued study is needed to more clearly understand when a palliative care goal is appropriate. A comprehensive palliative wound care program needs to be developed in clinical agencies that work with these patients. The interdisciplinary team would include the physician, nurses, wound care specialists, dietitian, chaplain services, social services, and pain and hospice consultants.⁶⁹ Palliative care units are increasing in number, particularly for patients who are chronically, but not terminally, ill.¹⁵² Wounds treated appropriately, even when the goal is not healing, can markedly improve in 50% of the cases, even on a hospice unit.^7,153,154

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