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Care of chronic wounds
in palliative care
and end-of-life patients
Christine A Chrisman

Chrisman CA. Care of chronic wounds in palliative care and end-of-life patients. Int Wound J 2010; 7:214–235

The aim of this paper was to provide a literature synthesis on current wound care practices for the management
of chronic wounds in palliative care and end-of-life patients, focusing on the control of wound-related symptoms
for comfort and improved quality of life. These wounds included pressure ulcers, venous and arterial leg ulcers,
diabetic ulcers and fungating malignant wounds. Wound-related symptoms included pain, exudate, malodour,
infection, bleeding, dressing comfort and negative psychological and social functioning. Best care wound practices
were formulated for each wound type to ease suffering based on the literature review. Although symptom
management strategies for comfort may work in tandem with healing interventions, it is important to recognise
when efforts towards wound closure may become unrealistic or burdensome for the patient at end of life. Thus,
unique aspects of palliative wound care feature clinical indicators for early recognition of delayed healing, quality
of life measurement tools related to chronic wounds, and comfort care strategies that align with patient wishes
and realistic expectations for wound improvement.
Key Points
Key words: Chronic wounds • Comfort • Palliative care • Quality of life • Wounds
• palliative care strategies identify
delayed wound healing with risk
tools, clinical indicators and care
acronyms INTRODUCTION active treatment of the disease and contin-
• symptoms are controlled to ease The aim of this paper is to provide a literature ued through the disease spectrum to include
suffering to improve quality of review of current wound care practices for the comfort care. Hospice care is strictly comfort
• management of chronic wounds in palliative care delivered to patients with an estimated
the approach is holistic,
multi-disciplinary and patient- care and end-of-life patients, focusing on the 6 months prognosis. Through an interdisci-
centered control of wound-related symptoms for com- plinary team approach, the patient and fam-
• for some palliative care patients fort and improved quality of life (QOL). These ily are supported to address patient-centered
with wounds, treatment of the wounds include pressure ulcers, venous or
underlying condition will result goals, needs and wishes during the illness in
arterial leg ulcers, diabetic ulcers and fungating conjunction with other life supporting thera-
in full or partial wound healing
using best practice wound care malignant wounds. Specific recommendations pies or during the dying process with comfort
• for patients with advanced life- for palliative wound management are given care (2). For some palliative care patients with
limiting disease that weakens based on this literature synthesis.
the healing process, wound wounds, treatment of the underlying condi-
Symptom control in palliative care aims to
closure may not occur, and so tion will result in full or partial wound heal-
prevent and relieve suffering through effec-
quality of life is measured by ing using best practice wound care (3). How-
the extent to which comfort is tive management of pain and other distressful
ever, many of the wounds that palliative care
achieved for the patient at the symptoms related to the chronic disease or life-
end of life and as defined by the patients tend to develop are often a result of the
threatening illness to enhance QOL (1). In the
patient and family advanced life-limiting disease that has weak-
USA, palliative care can be initiated during
• best wound care practices are ened the healing process preventing normal
palliative strategies that engage wound closure despite treatment (4–8). Focus
the patient in goal setting Author: CA Chrisman, RN, BSN, CHPN, University of Nebraska
and care planning for optimal of wound care then becomes centred on what
Medical Center College of Nursing, Omaha, NE, USA
outcome achievement in the strategies will provide the patient the most
Address for correspondence: CA Chrisman, RN, BSN,
context of life expectancy CHPN, 201 W. Sherwood Road, Norfolk, NE 68701, USA comfort in controlling symptoms, such as pain,
E-mail: exudate, odour, infection, bleeding, dressing

214 © 2010 The Author. Journal Compilation © 2010 Blackwell Publishing Ltd and Inc • International Wound Journal • Vol 7 No 4

Care of chronic wounds in palliative care

comfort and reducing the negative impact on One of the first instruments developed for
psychological and social functioning (4,8–21). measuring QOL was the QOL Index. This
Chronic wounds described in the literature index was tested randomly on 349 haemodial-
review are wounds that usually have a history ysis patients and showed internal reliability
of at least 3- to 6-months’ duration with- and validity (17,33,36). This index measures
out showing signs of improvement (60–70% satisfaction or dissatisfaction in areas that are
healthy granulation tissue) or a response to important to the individual: health and func-
treatment (5,9,22,23). Chronic wounds affect tioning, socio-economic, psychological and
an estimated 5–7 million patients and cost spiritual and family (36). The values are scored
more than 30 billion dollars annually in the together for each satisfaction and importance
USA (23–27). Significant to the burden are the response with higher scores of each showing a
indirect costs to the patient and family relating positive QOL (36).
to loss of productivity, employment, caregiver The QOL Index has been used for palliative
stress and QOL (8,17,25,28–30). care patients to identify areas that the patient
needs support or intervention to relieve
suffering and thus, improve well-being. For
SEARCH STRATEGY a palliative care patient living with a chronic
A literature review was conducted of these wound, it is important that the patient’s
studies from 1992 to 2008, using Medline, QOL experiences related specifically to the
CINAHL, PubMed and Cochrane Systematic
wound be assessed regularly to guide clinical
Review databases. The Nebraska Medical
interventions (33).
Center rating system for level and quality
An instrument that is sensitive to the con-
of evidence was used for article selection
cerns of the patient and can measure the impact
(Figure 1). There is limited evidence on the
of chronic wounds on QOL is the Cardiff
most common types of wounds and uniform
Wound Impact Schedule (CWIS) (33). This
care in palliative patients (6,10,11,31). Thus,
questionnaire was tested in a three-step process
some of the care practices are based on expert
on patients with leg ulcers and diabetic foot
opinion or case studies blended with aspects
ulcers measuring three domains of QOL: phys-
of best wound care practices that support the
ical symptoms and daily living, social life and
patient’s goal and QOL (9,15,16,32).
well-being. A few of the stress items included
disturbed sleep, pain, social restrictions and
LITERATURE SYNTHESIS dressing discomfort. Significant correlation at
Quality of life P < 0·001 was found between experience and
For some disease states such as fungating stress (33). There were no significant differ-
malignancies, a complete cure or healing may ences in scores with the two wound types
not be achieved, so that assessing the QOL with high internal consistency, reproducibil-
is an essential measure for the palliative care ity and validity (17,33). This instrument is also
patient with a wound (8,28,33). With this in notable in that it is sensitive specifically to the
mind, outcomes for care are measured in terms distress caused by the chronic wound regard-
of the extent to which this goal for best QOL is less of the etiology or state of healing (33).
achieved for the patient and family (34,35). Identifying specific stressors or concerns of the
It is difficult to measure QOL as an outcome patient forms the basis for patient involvement
when there is ‘no gold standard’ (34, p. 1190). in his/her cares to guide wound management
Complicating the definition further, QOL is for an optimal realistic outcome.
recognised as a ‘multidimensional construct’ Patients with chronic wounds suffer a variety
(36, p. 29). The World Health Organization of adverse stressors negatively impacting
defines QOL as the individuals’ perceptions their daily lives (33). These stressors include
of life shaped by their cultural belief system pain, exudate leakage, restricted mobility,
relative to their goals and interests (2). In poor hygiene, feelings of disgust or shame
palliative care, the patient defines QOL as what because of disfigurement or malodour, sleep
is most meaningful in the following domains: disturbance, loss of sexuality, dissatisfaction
physical, social, psychological, cultural and with treatments, loss of control, social isolation,
spiritual (1). dependency, residency relocation, anger and

© 2010 The Author. Journal Compilation © 2010 Blackwell Publishing Ltd and Inc 215

12. (37) found in a qualitative found that 12 women with fungating breast interview study cultural differences between cancer wounds related greater freedom and France. Well-designed experimental study Inc . These stud- the Canadians with finances (37). Well-designed non-experimental study Correlational or comparative descriptive studies Case study design Qualitative studies V. Multiple studies with evidence types II. ies show that it is important that information however. All groups. The Nebraska Medical Center.RN. Meta-analysis or comprehensive systematic review of multiple experimental research studies Cochrane Review National Guidelines Clearinghouse (AHRQ) The Joanna Briggs Institute Other groups II. or IV B. Well-designed quasi-experimental study Non. Care of chronic wounds in palliative care Rating System for Level and Quality of Evidence The Nebraska Medical Center Adapted from Joanna Briggs Institute and AHRQ (2005) Level of Type of Evidence I. 216 © 2010 The Author. Canada and the UK regarding chronic an improved sense of femininity and sexual- ity when the correct wound care product was leg ulcer pain experiences. or IV that are generally consistent C. feared infection (37).17. Limited research evidence or one type II or III study only E. Office of Nursing Research & Evidence-Based Practice 8/10/2005. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.17. CS & Judy Heerman PhD. Multiple studies with evidence types II.research-based professional standards/guidelines/group article Strength of Evidence A.randomized controlled Single group pre-post design Cohort study Time-series (one group of subjects over time) Matched case-controlled studies (two or more groups matched on certain variables) IV. III. that the French group described concern Clinical concern was not centred on wound clo- with body image. researchers Mudge et al.12. The authors assessed be used to inform decisions with the highlighted that the cultural groups focused patient with attention to the patient’s descrip- on the distress of the symptoms rather than tive experiences to guide cares that support delayed wound healing. This study found used to absorb exudates and control odour (8). Rating system for level and quality of evidence. BC. lack of confidence in the healthcare provider In a separate but similar qualitative study because of failure to heal (8. Clinical examples and expert opinion Text books Non-research journal articles Verbal report Non. RN. or IV that are inconsistent D. Type I evidence or consistent findings from multiple studies from levels II.20). Adapted from Joanna Briggs Institute www. that focused on symptom distress. and AHCPR Figure 1. Type IV or V evidence only Reproduced with permission from: © 2005 June Eilers PhD. III.19). the British group with sure but symptom management to improve the taking multiple medications for pain and women’s sense of well-being (8). well-being (8.

Bacterial loads in excess of © 2010 The Author.45).25. Several researchers have conducted studies The researchers found significant inhibition to help identify clinical indicators that may of fibroblast and keratinocyte cell growth signal delayed wound healing in the context by the bacteria. lower be re-evaluated for other treatment strategies. Normal healing is usu. The researchers found significant tions. contraction and mat. The of guidelines for the treatment of diabetic underlying cause of delayed healing is multi. Care of chronic wounds in palliative care Wound chronicity treatment plan or change the goals consistent Chronic wounds ‘fail to progress through an with the patient’s wishes (4. Rijswijk (50) found that patients with full- priate wound care management for the pallia.25). appro. Margolis et al. diabetic Inc 217 . Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. cohort study.22. prognosis and clinician In an in vitro study. sepsis. infection. et al. a reduction in size of 45% after 2 weeks or cerns and assessing for factors that contribute 77% after 4 weeks should be re-evaluated for to wound chronicity for informed decision. underlying reevaluation of treatment plan. standard interventions. an important clinical indicator for early uration of a scar for functional integrity identification of non healing wounds with (9. Notably. wound bed characteristics. In a systemic review ally complete within 2–12 weeks (9. so the outcome-size.16. that management shifts to meeting the patient’s In a multi-site.19. fungating malignancies and malnutri. this diagram includes assessing goals Both studies confirm importance of wound and patient concerns in addition to the risk measurement and regular assessment for factors. thickness pressure ulcers that did not show tive patient lies in recognising patient con. van priority for comfort (4. A chal. Steed. These epithelialisation and contribute to chronic indicators would signal the need to alter the inflammation (43). study of more than 31 000 patients that Clinicians need to be knowledgeable with ulcer size (>2 cm2 ).32. thy. study van Rijswijk and Polansky explored In the 2008 position document. 1162.32.25). remodelling.39). (43) skill and knowledge for appropriate wound isolated anaerobic microflora from the deep care management that promotes an improved tissue of 18 patients with refractory chronic QOL (9. venous leg ulcers and studied the effects of these organisms on extracellular matrix prote- Clinical risk factors of chronic wounds olysis and cellular wound healing responses. ulcers.40–43). Stephens et al. In a separate making for realistic goals (4. duration (>2 months) and early recognition of the non healing wound ulcer depth predicted healing outcomes: if and the factors contributing to the chronicity to patients had all three adverse parameters. diabetic foot ulcer healing at 4 weeks was liferation. Although size.44). physical inac. 15-month long study. et al. weeks had significant effect on healing (51). Sheehan orderly and linear sequence’ of cellular heal. patient education and decision-making (47).11.25). Therefore. lenge in palliative wound management then is Treece et al. pro. (48) found that in a cohort tion (5. compromised mobility. by 40% after 4 weeks of treatment should tivity. (2006) reported that patients factorial but may include advanced disease or who fail to show a reduction in ulcer size organ dysfunction.40). sepsis and arteriopathy (49). alternative treatment strategies. arteriopathy and denervation symptom management strategies for comfort (SAD) system in a prospective single-centre may work in tandem with healing interven. inflammation. older age. The European outcomes and variables as predictors for time Wound Management Association (EWMA) to healing of stage III and stage IV pressure published a schematic diagram of the multiple ulcers: poor nutritional status at baseline factors that interact to show the complexity and percent reduction in ulcer area after 2 of chronic wound management (25) (Figure 2). which would delay re- of the basic etiology of the ulcer. identify realistic outcomes that support QOL diabetic neuropathic foot ulcers had only as defined by the patient (4.24). p. a 22% chance of healing by 20 weeks (25).7. medical condition. it is also important to recognise when associations with ulcer healing with three of efforts towards wound closure may become these categories independently contributing to unrealistic or burdensome for the patient. (49)stratified and validated risks identifying early when a wound is slow to heal for diabetic foot ulcer healing with use of despite best wound practices (25. 38. limb arterial insufficiency. (46) found that assessing uncomplicated ing processes: homeostasis.

47. 105 organisms per gram of tissue can delay healed. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. (25). wound granulation and tissue not expected because of the overall poor necrosis’ in the context of the disease prognosis prognosis (16). Galvin’s (6) 2-year retrospective audit per gram of tissue or any tissue level of study of 542 palliative care unit admissions beta haemolytic streptococci will show delayed found that despite a pressure ulcer and skin healing (27.45). Sim- ulcers having bacterial loads of 106 or more ilarly. wound would be maintained comfortably for Brown (5) found that 51 patients out of 74 the patient and stabilised to prevent infection or 68·7% acquiring nosocomial full thickness or complications (44).52. or if the patient has osteomyeli. subcutaneous ation or chemotherapy. but rather that the disease burden resulted in diabetic and pressure ulcers. stage III and stage IV ulcers had a 180-day Other intrinsic and extrinsic factors that mortality rate and that none of the ulcers can delay healing are malnutrition or protein 218 © 2010 The Author. wound healing is tissue thickness.43. In the guidelines for venous. bacterial lipid metabolism (9. tis (9. immobility. clinicians goals with the patient for wound healing at found that patients who have a high disease the end of life (55. causing pain.6). Unless the Langemo and Brown reviewed that ‘gross underlying cancer can be palliated with radi- examination of muscle mass. care protocol. 208). Complexity of wound healing. Care of chronic wounds in palliative care Figure 2. Brown (5) ascertained from this data wound healing.53). In two separate retrospective non Inc . p. that patients did not die from the ulcers. The majority of fungating malignant wounds because of micro.38. is the current standard for setting realistic mental studies with pressure ulcers. exudate and odour from life (6). the incidence of pressure ulcer Delayed healing can also be expected with damage was not reduced. The Wound Heal. ulcers was sacral and occurred as a result of bial bioburden. Reproduced with permission from Ref.54). malnutrition and decreased tissue ing Society published recommendations that perfusion that allowed for skin atrophy. The non healing burden at end of life show skin failure (5. necrotic tissue and foreign sub- the tumour or degenerative condition at end of stances.

factors that contribute to pressure ulcer devel- encouraging activity if possible. infection.42. specificity and validity (58). Notably. assessment scales for pressure ulcer preven- More research is required to test this tool for tion. retained various risk factors of other tools sure (5.56).com Inc 219 . Regarding (graded 1–4. With the Braden scale. It identified three primary include pressure support systems. respiratory infection or social isolation for and uniform evaluation of clinical indicators the patient’ (40. friction or shearing. Measures to pre. © 2010 The Author. minal conditions and ethical considerations tive care patients (7. nutrition oped for the hospice patient in Sweden called and sensory/perception (60). positioning. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.38. these studies related that small sample sizes. muscle atro- of pressure ulcer formation is an important phy. Hill Marie Curie Center pressure sore risk non steroidal anti-inflammatories. Nevertheless. Braden scales for accuracy (7).59). risk factors include skin moisture. port intervention to reduce the risk of ulcers (7). breakdown. inter-rater reli- palliative care settings. tobacco and alcohol use. If possible. prevention as dyspnoea. the researcher used com- ulcer formation (52. ability. where 4 indicates full function and nutrition. validate the HoRT tool for general use. more testing is needed to supplementation as tolerated by the malnour. HoRT compared favourably to the Norton and However.40). extreme fatigue. There is also a lack of evidence concerning short duration of study time because of ter- the validity of existing risk tools for pallia. In a With this data. using a specialised bed to practice guideline of using a valid. immuno. mobil- Risk assessment tools ity.56. This tool inadequate tissue oxygenation and pres. evidence for the palliative care patient to sup. is part of the holistic care of the patient Specific medical conditions of the terminally ill and can help inform decision between the were enumerated with the risk factors. Pancorbo-Hidalgo relating a very high risk (40).40). prothrombotic conditions. nutrition/weight Accurate assessment of pressure ulcer risk change. the Hospice Pressure Ulcer Risk Assessment vent pressure ulcers could then be planned to Scale (HoRT) (7). Interestingly. risk factors for pressure ulcers (52. Seven risk factors were identified: sensation. cachexia. For example. 30). p. activity in bed. The risks were scored promote comfort and dignity (7. Chap- et al. skin condition and friction/shear (40). thresholds were established for systematic review of literature in 2006 of risk low. reliable risk prevent pressure sores may result in ‘immobil- assessment screening tool ensures systematic ity. (58)could not conclude that use of risk lin related the importance of recognising the assessment scales in clinical practice decrease comfort of the patient over the prevention prac- pressure ulcer incidence. poor was piloted on 291 patients in a 41-bedded glycaemic control. activity. systemic steroids. but also considered the skin condition. As with the lined by AHCPR encourage dietary intake and Hunter Hill tool. high and very high risks (40). Chaplin developed the Hunters suppressive medications. reduced subcutaneous tissue component of holistic care in palliative care to and dehydration (40). the best tice. In an effort to address limited effective analysis in palliative care pop- the vulnerability of the terminally ill for skin ulations (7. specialist palliative care unit (40). stress. the clinical practice guidelines out. anaemia. wound experts note a lack of research 1 indicates very deteriorated or no function). such clinician and the patient.6. Because weekly or with significant changes from a min- of the lack of research evidence found imum score of 7 to a maximum score of 28 in the systematic review. to measure to guide intervention and if possible prevent the validity of the tool. mobility and age (below 75 years or older) (7).57). skin hygiene opment at the end of life: physical activity and nutritional interventions (7). Care of chronic wounds in palliative care deficiencies. medium. Another pressure sore risk tool was devel- mobility. hypother. frailty.40).56. moisture. the authors found the Braden scale to be inter-rater reliability and validity by others in the best risk tool for sensitivity. parative analysis of professional judgement of The Braden and Norton scales are supported palliative care nurses for patients at risk for by the [Agency for Healthcare Policy and pressure ulcer development and the numeri- Research (AHCPR)] and the National Pressure cal scores over an 18-month period: validity Ulcer Advisory Panel (NPUAP) for identifying of the tool depended upon its application (40). Both of ished patient with wounds (52). assessment tool (the Hunters Hill tool) which mia.

The TIME framework scale was developed for easier clinical applica- includes the following parameters: Tissue (non tion. Exudate and tis- Expanding on the TIME tool. wound assessment (wound treatment effectiveness) and Edge data must be used in conjunction with clin- (condition of edge and surrounding skin) (45). to why a wound is not healing based on the In fact. Appearance (wound bed). depth and area). moisture and bacterial item that showed significant change was the balance and adequate oxygenation (47). In a prospective study of nurs- Moisture (balance or imbalance). These tools offer an understanding as objective measurement of wound progression. Although there is no official and alternative end points if wound heal. but benefi- Goals can then be addressed with appropriate cial for research purposes (15.66). Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.45. (TELER) method and the Wound Symptoms lines were developed as conceptual tools to Self-Assessment Chart (WoSSAC) (15.45). Exudate (quantity with full-thickness wounds and disease burden and quality-odor). and Edge ing home residents with predominantly stage II of wound (non advancing or undermined) pressure ulcers. two assessment tools for measur- noteworthy also because it incorporates a ing risks and patient perceptions have been patient-centered approach with inclusion of created but not yet validated for generalised pain assessment to identify suffering. the wound care experts in 2002 introduced the Bates-Jensen Wound Assessment Tool (BWAT) TIME acronym which was further developed formerly known as the Pressure Sore Sta- by the EWMA in a position document (57. inform the medical community on the bene. debridement. Further studies on patients width.62). Undermining. a key applicability for the palliative care experi- concern of palliative care (1.65. of symptoms (63). Re-evaluate As with all tools used. preventing infection and ate appropriate outcomes in wound man- relieving pain offers goals for improving QOL agement (64). Care of chronic wounds in palliative care Assessment of chronic wounds a challenge on how effectively these two tools for targeting interventions are applied reliably by clinicians (39. the only PUSH cause.63). This outline is wounds. The BWAT is in addition to the risk factors that can help time consuming and detailed. wound healing. Infection or inflammation. types of treatment interventions for the control for assessing chronic wounds: Measure (length. impractical for most clinical uses. control expressed by the individual rather than ciples. system for assessing malignant fungating ing is not achievable (22. It remains objectively measuring fungating wounds with 220 © 2010 The Inc . ical judgement of patient risk factors and Assessing these parameters for clinical out- comes for controlling exudate. In an effort to standardise the assessment of There are several tools or scales that are chronic wounds by clinicians and increase considered reliable and valid for assessing knowledge to guide discussions with patients. reliability (63). these fits of wound bed preparation for a systematic two tools emphasise the importance of spe- approach for proper chronic wound manage. the PUSH scores significantly (57. making this tool identify patients with non healing wounds. Suffering (pain). appropriate scale used for confirmation (63). MEASURE. For example.63) (Figure 3).3). ence: the Treatment Evaluation by LE Roux’s Both the TIME and MEASURE guide. would be beneficial. cific QOL measures for optimal symptom ment and for developing best practice prin. This clinical tool provides guidance decreased over time among the healed ulcers in monitoring the wound and targeting and compared favourably with the then PSST the interventions. For pressure ulcer healing. Although this wound bed preparation for a diabetic ulcer study was well controlled for the small sample could entail patient assessment for underlying size (32 ulcers) and for variance.57). Unlike previous measurement tools. minimising or the overall goals of the patient to evalu- eliminating odour.61). The PUSH tailored interventions. sensitivity to wound changes and inter- viable or deficient). Grocott (65) related in her longitu- underlying wound abnormality and whether a dinal case study the various limitations in certain treatment is effective (39. wound size (length × width). tus Tool (PSST) and the NPUAP Pressure This TIME model offers a comprehensive Ulcer Scale for Healing (PUSH) provide valid approach to monitor certain wound parameters measurement (10.61). a group of sue type did not show change possibly because wound healing experts outlined guidelines of predominately stage II ulcers and multiple with another original mnemonic.

Persoon et al. definitions of the TELER indicator codes to founding the control of variables. as the researcher records (66). gain consensus with the patients. recognise the expertise of the patient who lives tistical method of measurement (TELER) and with the chronic wound and the need to include a self-report questionnaire (WoSSAC) allow symptom distress in assessing wound manage- the patient to relate changes in the wound ment for optimal care.19. (17) found that pain was of codes (TELER) or a 5-point Likert scale the first and most dominant distressful experi- (WoSSAC). Furthermore. Reproduced with permission from Ref.68).67)indicated that they had to modify dressing products required multiple fits con. socialisation. Browne ings to determine exudate volume as these et al. using an ordinal scale patients. National pressure ulcer advisor panel pressure ulcer scale for healing (PUSH). Care of chronic wounds in palliative care Figure 3. necrotic tissue researchers did the same for future study. (66. TELER is recorded by the clinician based on mood.17. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. (63). Both tools provide indica. There is cal staff (10. The primary difference is that the ence. Nevertheless. which could because of infiltration of the tumour into the challenge ensuring a robust system if other skin and adjacent structures. Wound pain tors on tracking progress towards or away In a systematic review of 37 studies describing from the patient-centered treatment goals for the negative impact of leg ulcers on daily life of symptom management. disturbing Inc 221 . these two palliative care tools surement (65). mobility. grooming and relationships. In addition. Clinical note-taking with a sta. a qualitative consensus agreement with the descriptive studies suggested under-treatment patient through dialogue and the WoSSAC and reporting of pain by nursing or medi- is completed by the patient (66.67). These patients with potential for bias with the TELER method chronic wound pain verbalised feeling ‘out of © 2010 The Author. subjectively and document the distress with daily life (65–67). caused malodour requiring subjective mea. ultrasound. photographs and weight of dress.12. Also.

p. Using a permeable non adher- Rating Scale (FRS). prepa. to promote one dressing product over another ence and is able to associate pain with affective for wound care management (79). VAS and FRS were valid Healing Societies (WUWHS) to handle leakage and reliable to diagnose pressure ulcer pain. the patient timing of the wound pain to identify the stim. To prevent pain removal (71). Hydrocolloids should be used with caution ment scales are available for assessing the as this type of dressing has strong adhesion patient’s perspective of pain: Visual Analogue and can tear fragile peri-wound skin upon Scale (VAS). the following self-report pain intensity. hydrogels.68. de Laat hydrofibres. there is a prolonged international survey of 11 countries. a moist fort). validated pain measure. Clearly.18). foam dressings or soft silicones. With pain measure- rance about the leg ulcer (12. Prolonged damage can cause been substantiated by various researchers and neuropathic pain. to bacteria. tected by applying a barrier. wound inflammatory response stimulating the local practitioners rated dressing removal to be afferent skin receptors (nociceptive) or periph. On-going assessment and team from peri-wound maceration. Several Inc . is valid and reliable (72).69. wounds to avoid pain. With this dressings. For palliative management of to assess and manage chronic wound pain. and caregiver are active participants in man- ulus for pain intervention: off loading the agement decisions and product choices (77).54). Numeric Box Scale. Therefore. friction and pressure.72). a thorough pain assessment confirming the To reduce pain. clinicians should use proper compres.41. long wear time. et al. impermeability the context of wound bed assessment. (10) found that The McGill pain ques. 9). is recommended by World Union of Wound tionnaire (MPQ). Care of chronic wounds in palliative care control’.15. diabetic ulcer or decreasing oedema in the Appropriate dressing prevents strike- venous ulcer for improved oxygen transport through and exudate leakage which can to healing tissues with compression bandages increase bioburden and thus. in mind. non cyclic (single incident) and chronic wound healing environment. Factors that contribute that any stimuli can be painful to the patient. pessimism about healing and igno. skin can be pro- communication are essential for effective man. absorbency of ration and aetiology so that the wound and excess exudate to prevent skin excoriation pain are treated at the same time for opti. It is hoped distress. Krasner as three types: cyclic (periodic discom.20. gentle adherence.76). to pain with dressing changes are dried out making pain difficult to control (69). such as calcium alginates. The Faces removal (15. Importantly. Kras. minimisation of (persistent discomfort). dressing. packed gauze. In an In chronic wound pain. it is important also to assess the patient to alleviate suffering it is important to have for socio-cultural issues related to pain (74).78). adhesive dressings and cleansing (74). infection which. products that adhere. should be covered with a moist dressing dur- ner (70)developed an original holistic approach ing changes (32). the FLACC pain tool dressing products described are only a few 222 © 2010 The Author. paste or a liquid film-forming acrylate (38. In a systematic review of literature. The clinician also assessed the giver (11.73). can be painful for the terminally ill and To assist clinicians in managing pain. such as zinc oxide agement (71).27. This model is placed in shear. and ease of dressing use by patient or care- mal QOL (71). Allodynia can develop with experts with case studies to highlight the prob- repeated noxious stimulation of the nerves so lem (32. and reduce pain (77). Pain with dressing removal has hyperalgesia (69). For patients who cannot appropriate dressing. Expos- sion bandaging technique to reduce allodynia ing wounds to air with the dressing removal pain in patients with venous leg ulcers (9). cost-effectiveness. it is lengthy and difficult to complete that with more research conclusions can for acutely ill or terminally ill patients in the be drawn to help the clinician choose the clinical setting (10. assessing for the underlying cause. Although the McGill questionnaire measures There is limited research evidence available sensitivity to the overall wound pain experi. and the Face Legs Activity ent contact layer with a secondary absorbent Cry and Consolability (FLACC) scale (71. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. local wound care involves patient’s subjective experience. an ideal dressing would These pain processes are further described by offer non bulky comfort sized to the wound. or choosing the appropriate dressing for gentle in turn. the time of greatest pain for the wound eral nerve endings with increased sensitivity or patient (74). ment. increases pain (77).18.

However.38. Alvarez et al. cleansing is debatable. during and after the leakage. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. a source of wound pain (74). allowing for fewer dressing changes.57. wound care experts sup- of times the compression therapy needed to port limited use of antiseptic agents to reduce be reapplied. pacing limited study is the Versiva by ConvaTec the procedure according to the patient’s pref- (Skillman. Best prac. Pain was also reduced. Dakin’s solu- study that assessed performance of five tion. More research support for this lipidocolloid soft polymer is needed on larger sample sizes. mechanical or biologi- tice guidelines recommend warm potable cal (larval therapy) (9. Microbeads silicone dressing for the management of release iodine into the wound bed at levels not traumatic wounds. Also. advantage of also preventing wound infec- Wound cleansing has been identified as tion.57). non randomised as povidone iodine. Mepitel (Mölnycke Health Care.85). skin tears and chronic toxic to the cells to reduce bacteria ( Inc 223 . USA). Care of chronic wounds in palliative care examples – with limited critique – that have dressing changes (82).84). delayed amputations in five and case studies. into one product: hydrocolloid. (9) and been beneficial for wound care management. Antiseptic agents such film (80). Williams (84) promise but without sufficient research is found that topical cadexomer iodine in the the product. With a secondary dressing. ulcer healing (81). NJ. mild wound cleansing agent or saline review of new and experimental treatments for simple cleansing of wounds (52). hydrofibre and The use of antiseptic agents for wound a top layer of polyurethane (gelling) foam. avoiding cold fluids and antiseptics osteomyelitis cases to prevent amputation (24). It combines three layers of action dressing change to minimise trauma. povidone iodine has in 82% of leg ulcers within 5 weeks of using proved useful in palliative wound care as a top- Versiva under the compression bandage. autolytic. non randomisation multi-disciplinary and addresses the underly- and non comparison and a small sample ing cause of the infection so that the patient size (n = 11) (80).57. offering ‘time-out’ to the patient and to reduce wound pain and handle exudate assessing the pain before. and not to wipe across the wound during Patient consent to maggot treatment would be © 2010 The Author. the authors found that NPUAP also recommends avoiding hot water maggot debridement significantly decreased and excessive rubbing (56). there has been no can fight the infection (83). Fur- gel or the compression therapy (80). In a systematic water. Clinicians removal. White and Morris (21) found limb salvage therapy in four. In a systematic review form of microbeads prevented wet gangrene in of randomised control trials (RCTs) and all patients. The ical antiseptic for wet gangrene to decrease bac- product also offered a long wear time of 5 days terial burden (9. It has been promoted erence. iodophor. Goteborg. researchers found that cleansing because of toxicity studies in the healing or marked improvement was observed laboratory (52).38. Sweden). The of diabetic foot ulcers. reducing the number consensus document. although it is should use these agents with caution and know not known if this was because of the soothing the indications and risks for safe practice. debridement may be surgical or sharp. in an international which was cost effective. enzymatic. This dressing used Topical wound pain control can involve as a first layer allows wound exudates to pass debridement to reduce necrotic tissue and bac- through its netting to a secondary absorbent terial burden (9. In a multi-centre. acetic acid and hydrogen peroxide are different ConvaTec products on healing of not recommended by the AHCPR for wound venous leg ulcers. In a retrospective study of 11 patients with Another dressing product that has shown chronic critical limb ischaemia. Hollinworth (82) stress the importance of talk- One composite dressing product that has ing with the patient to identify anxiety. There thermore. To date. Exudate was absorbed well and high bacterial loads in wounds to aid healing peri-wound skin was protected with easy or to prevent wound infection (83).85). Agents that show conclusive evidence that supports one dressing limited research efficacy in reducing biobur- type under compression bandaging that affects den are silver and cadexomer iodine (83). painful draining wounds. Palliative care offensive odour and pain and has been rec- experts recommend gentle cleansing of the ommended as a last resort for gangrene and wound. antiseptic agents need to be used were other limitations to the study because in context with a management plan that is of possible company bias.

88). promise in controlling pain in ulcers are lido- ment (9). Wilmington. topical morphine and ibuprofen ommended for fungating malignant wounds in non adhesive foam dressings. Radiation can cause described by the World Health Organiza- radiotherapy skin reactions and chronic dam. Vernassiere et al. Zeppetella et al. phine 10 mg/1 ml in 8 g of Intrasite gel applied toe pressure greater than 50 mm Hg. (88)studied topical mor- be an ankle–brachial index of greater than 0·5. In a systematic literature. seda- pain (11. capsaicin or clonidine (69). Adjuvant therapies for fungating wounds then this would reduce the need for systemic are surgery.76). Evan’s and Grey’s review (2005) can penetrate damaged skin. If topical analgesia of ulcers could be achieved. are important to determine whether the Systemic medications for pain control may benefits of treatment outweigh the burden in be ordered following the three-step model view of the prognosis. recommended (87). a systematic review of the literature has EMLA cream to relieve pressure ulcer pain. patients versus placebo of water mixed with In a systematic review restricted to six Intrasite gel. tect against infection in diabetic ulcer wounds Other topical anaesthetic agents that show of palliative care patients following debride. Regular analgesia is determined age to connective tissue and vascular sup. the Palliative Care Institute and The assessed for side effects to prevent and control Center of Curative and Palliative Wound Care suffering (89). Evans and Gray (69) found lidocaine review of Inc . which consists of lidocaine and in pain (P < 0·01) with no adverse effects (88). zinc oxide cream (9). caine patches. (10) found a wound healing dressings containing ibupro- need for further research on the effects of fen.79). However. tion (89). Further RCT stud- debridement and covered with plastic film ies are needed with larger patient samples to produced a mean reduction of 20·65 mm in draw conclusion on the efficacy of topical mor- pain score with a 95% confidence interval phine. daily use of reported a lack of research for conclusive bene- this anaesthetic cream to control pain is not fit in using aspirin. Systematically reviewed in the potential to granulate (38. New York. This cream controls pain cal application of silver sulfadiazine 1% is used quickly and lasts up to 4 hours for relief of by the Calvary Hospital in New York to pro.75. Topi. by regular assessment of the pain inten- ply (16). significantly reduced the pain In a similar randomised control study on 18 intensity during and after sharp debridement patients with leg ulcers. Briggs and Nelson (75) found that debridement (88). Patients are wounds. Although isolated controlled studies and no adverse effects on ulcer size of have reported effective relief of pain with moist healing (69. A thick layer of EMLA 5% cream trol with topical use of morphine 10 mg mixed applied to the ulcer 30–45 minutes prior to with 15 g of Intrasite gel. cream (EMLA 5% Astrazeneca. Bronx. USA). Surgery can cause enterocutaneous sity described by the patient for choosing fistulas producing corrosive drainage (16). Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. tion and nausea (87). This pilot study found significant reduction DE. de Laat et al.86). hormone therapy opioid management. how. to painful sacral ulcers once daily and cov- scutaneous oxygen saturation greater than 30% ered with Tegaderm dressing in five hospice for best outcome. failed to substantiate effectiveness with RCT Because EMLA cream has a pH of 9·4 and evidence (69). (87) of leg ulcers as determined by VAS versus did not find statistical significant pain con- placebo. ever. have administration should be timed accordingly formulated topical lidocaine 2·75% in Balmex to route at rest and prior to dressing cares 224 © 2010 The Author. which exposes patients to or chemotherapy to reduce the tumour and opioid side effects such as constipation. but more because of bleeding risk or ischaemic arterial clinical trials are needed for conclusive evi- wounds because of desiccation and the poor dence (69. tumour pain per case study reports. Pain intensity scores were use of eutectic mixture of local anaesthetic rated and compared twice daily using VAS. Goals of care discussions. Intrasite gel is a hydrogel used for RCTs. and tran. McDonald and Lesage (15) patches applied to cover painful areas worn found that for ischaemic arterial wounds the for a maximum of 12 hours daily controlled distal perfusion prior to debridement should pain. Care of chronic wounds in palliative care a priority in the goals of care discussion. debridement is not rec. prilocaine. drugs with different modes of action and as For topical local pain control of fungating needed for breakthrough pain (89). radiotherapy. Appropriate pain medication at Calvary Hospital.16.

UK) were found onto peri-wound skin (38). times daily. Other means to fit the wound and absorb the fluid (11. small tion. stripped.32.79. Actisorb Silver (Johnson & Johnson Medicine Heavy exudate is common with fungat- Ltd. For palliative Inc 225 . relaxation therapy. Gross deformity can result. social isolation and withdrawal. mak- did not find research on the odour-absorbing ing it difficult to choose a correct dressing capacity of charcoal dressings. scant (moist and not measureable). Because accuracy with the tool is have shown metronidazole 0·75–0·8% gel or dependent upon the clinician’s skill.57): Film dressings are best for dry or faction (9. adequate 1% cream applied directly to the wound once training is important (63).56. New Brunswick. reposition. of controlling odour based on case studies According to a systematic literature review. If not also be used for haemostatic control of bleed- sealed.79). care must be taken to cut the dressings CarboFLEX (ConvaTec) and Clin.76). phyll tablets one tablet after meals and at tant in controlling pain by educating the bedtime and then advancing two tablets four patient and family to encourage participa. spread into the lymphatics denuding the skin ing microorganisms (38). 50–75%) and heavy (covers 75–100%) (93).76.91). Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. social and spiritual management of wound exudate.90). Institute for Clinical Systems Improvement rec.71. USA) are also an ing malignant wounds that can ulcerate and option for controlling odour and also inactivat. Care of chronic wounds in palliative care to reduce suffering (15. the choice of support. The Draper (79) in a systematic review catalogued BWAT uses a metric measure guide divided malodour distress as causing involuntary gag. dressings (3. dressing should control exudate without dry- ing. appropriate dressing ing out the ulcer bed (52).9. ing (9. Therefore. NJ.3.. ately absorbent and are non adhesive for ease bial dressings with activated charcoal such as of dressing removal. moderate (covers triggering anxiety with poor QOL (8. Hydrocolloids to wound for 7 days (3). (dry).65–67. weight sure amount of exudate on the dressing: none loss.15. or twice daily or together with calcium alginate. transcutaneous electrical nerve stim.. there are choice. kitty litter under the bed. rated tissues with >25% to <75% of dressing) Systemic or topical metronidazole has been and large (tissues bathed in fluid with >75% of effective for reducing odour. (10) in a or by tumour necrotic outgrowths or fistu- systematic literature review on pressure ulcers las (11. com- tion. or foam dressings are significantly trol based on the amount are the follow- effective in controlling odour with patient satis. sloughy wounds with ommends either topical metronidazole 0·75% small amounts of exudates and can provide a gel or cream or crushed 500 mg tablets directly cooling relief for painful ulcers. behavioural contracts. © 2010 The Author. into four 25% pie-shaped quadrants to mea- ging. London.76. Alginates are highly absorbent for trolled odour if the dressing fit as a sealed unit moderate-to-heavy levels of exudates and may and if the wound was maintained dry. caution must of literature that activated charcoal dressings be used with removal so friable skin is not applied to fungating wounds significantly con. dis. than 25% wound surface). light (covers less toms that are most distressing to patients. acupuncture.68.9. minimal exudates as these are not absorbent. alginate to size the wound to prevent wicking isorb (CliniMed Ltd. Foams are moder- to meet these requirements (79).15. de Laat et al. visual imagery. Some dressing categories for exudate con- hydrofibre. biofeedback. Small studies dressing) (94). gauge choice of dressing for effective absorp- tion. (drainage <25% of dressing).16).16.92). cold and warmth therapy. ing any topical agents as none. Hydrogels are for dry.38. vomiting. In addi. Some interventions are coping skills mercial deodorisers and peppermint oils on training. The charcoal ing wounds. the odour would escape.16). AHCPR guidelines state that for effective traction. are for mild-to-moderate exudating wounds Draper (79) found in a systematic review that offer autolytic debridement. Antimicro. The PUSH tool defines exudate drainage Wound odour and exudate after removal of the dressing and before apply- Odour and heavy exudates are two symp. moderate (satu- ation for healing (57). music.18. exudate measurement tools for the clinician ulation (TENS unit) and physical therapy to assess the amount of wound exudate to exercise (1.62. chronic wound fluid inhibits cell prolifer. decreased appetite. pressure support. Non by experts are oral administration of chloro- pharmacological interventions are also impor.

Case studies for palliative management of Draper (79) cited that the dressing choice wounds have found that bleeding may be for fungating wounds should not only be controlled by careful removal of dressings based on the wound characteristics but also moistened first with warmed normal saline.85). This dressing was cosmetically haemorrhage (16).15. management of a wound is necessary.15).9. If haemorrhage can be acceptable and comfortable under clothing and anticipated. with moist dressings and fewer amputations Current care has been suggested by wound (4·1% versus 10·2% ) (97). VAC In a Cochrane intervention review of RCTs. espe- devices have been used to handle heavy exu. for chronic wound healing (98). vapor-permeable absorbent dressings and denied’. NPWT is also contraindicated for the ostomy appliances (3. a Cochrane care experts in this field for palliative man.79. applying alcohol-free saline gauze or hydrocolloid gel dressings skin barrier films. cially if febrile or cellulitic to determine the dating or infected wounds: pressure ulcers. appropriate systemic antibiotic (15. A multi. If antimicrobial wounds by reducing the bioburden (9.57).38. Wound bleeding In a systematic review of literature. dark towels for should work with the patient in finding the absorption may lessen the anxiety of the patient appropriate comfortable dressing with maxi- and the family (15). a Topical negative pressure wound therapy wound culture or tissue biopsy is rec- (NPWT) or vacuum-assisted closure (VAC) ommended to isolate the Inc .79). the clinician and the patient is terminal. conclusive evidence supporting NPWT over tle wound cleansing. the wound does not get smaller payment is sive. there is the risk of spontaneous wound (112). should have minimum bulk. Optimal dressing choices include that demonstrate wound closure. systemic review of seven RCTs found no agement (11. For bleeding that is spontaneous self-adhesive border. high-quality RCTs studies are required for con- ing bacteria and controlling pain and bleed. Care of chronic wounds in palliative care Adderley and Smith(95) could not find suf. 1183) states Draper (79) found a lack of evidence to that ‘NPWT does not get used in the pal- support the use of one type or brand liative care setting as CMS reimbursement of dressing for the care of fungating policy mandates routine wound measurements wounds. iodine in venous and diabetic ulcers for pain and odour to help stabilise a non the palliative treatment of heavily draining healing wound (11. Treatments include gen. p. (9. prevent leakage. so that if foam and alginates as these are non adhe. manag. gentle pressure be comfortable and cosmetically acceptable to for 10–15 minutes at site.9. However. Naylor (2001) applying gauze saturated with 1:1000 solution found that a hydropolymer foam dressing- of epinephrine. reducing the port the routine use of systemic antibiotics exudate burden as the ulcer heals. topical low-dose (100 units/ml) Tielle Plus-managed heavy exudate and mal- thromboplastin or 0·5–1% silver nitrate (3. venous ulcers and diabetic ulcers (38). as should have long wear time but should these lesions could granulate (9). The authors stated 226 © 2010 The Author. Dressings treatment of malignant cutaneous wounds.96). ing (3. devices for wound fluid management decrease O’Meara et al. ulcers found significant ulcer closure with neg- ficient evidence to guide practice for care of ative pressure (P = 0·007) 43·2% versus 28·9% fungating wounds because of lack of research. Furthermore.16.15.57. odour effectively for a patient who had a large If the fungating wound erodes major blood malignant fungating breast and chest wall vessels. referral to vascular surgeon may be provided proper seal on contours with its planned (15).16.15. choosing appropriate dress.16. clusive evidence for healing chronic wounds.79. mum benefit for palliative management of the wound (11. use of non adherent dressings. (96)found no evidence to sup- the number of dressing changes.16).96).57. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.38. In a case study. cauterisation or by the patient. be changed when exudate strike-through is present (15). Alvarez et al.38. Ultimately. There has been a limited amount of research Wound infection showing some effectiveness with cadexomer Controlling bacteria can decrease exudate. to promote healing by reducing bioburden center RCT of 342 patients with diabetic foot in venous leg ulcers.79). Additional ings to control exudate and odour.

autologous For palliative care patients. that honey treated with gamma irradiation is Amato et al. quality research. of RCT studies of diabetic foot ulcers. for granulation and cell Inc 227 .57. Bridgewater.101). cost.102. Care of chronic wounds in palliative care that the lack of research should not pre. This treatment is the usual treatments for diabetic ulcers – off © 2010 The Author. the benefits are not conclusive NJ. authors found that HBOT platelet-derived growth factor (rhPDGF). iodine could not be recommended for venous Jull et al. especially sinuses. 23 (85·2%) used for palliative management of wounds: patients were re-occluded within 1 year.100). Other topical prepara. chances of healing venous ulcers in conjunction In Cochrane reviews of RCTs assessing the with compression bandages by improving cir- effectiveness of topical silver in the treatment culation to the tissues. healing action is not understood (104). Aventis Pharma- evidence (96). all limb salvage was 74%. with Becaplermin in wounds less than 5 cm. lungs and in less time with rhPDGF treatment. risk and likelihood of healing in the context of peroxide-based preparations and povidone patient’s wishes for comfort. In a Cochrane nous wound healing is recombinant human review of four trials. (24) reported significant wound healing and lungs and barotraumas to ears. USA) has been used to treat claudication for silver as an effective treatment of chronic pain as well as endovascular intervention for wounds (99. ogy advocates confirming peri-wound hypoxia This review recommended this alternative by transcutaneous oxygen measurement first therapy to trial to avoid amputation when before trialing HBOT (38). ischaemia. Although the vessels Advances in adjunctive therapies for chronic re-occluded in 85·2% of the patients. For the adjunctive therapies to vent the use of antibiotics when there be considered for the palliative care patient. one trial (99). Eldor gen which may include toxicity to the brain et al. In another systematic review Because of side effects of breathing pure oxy. but honey releases hydrogen peroxide at low complete or partial wound healing occurred in concentrations which inhibits bacterial growth 80% and rest pain improvement in 57%. This used to treat diabetic foot ulcers significantly growth factor has been used for treatment of reduced the risk of amputation and may the diabetic foot ulcer to stimulate cell pro- improve the chance of healing at 1 year (103). also costly (38). USA) Silver impregnated dressings have been 400 mg tablet taken three times daily increases used for antimicrobial action in wounds. Pletal (cilostazol. the American Academy of Dermatol. cutaneous transluminal angioplasty (PTA) on control of exudate and odour and aids wound healing and reduction in pain with a healing (79. would be important to consider prognosis. ceutical Company. because of a lack of Otsuka Pharmaceutical Company. plaque excision (9). overall health of the patient and ifylline for venous leg ulcers (38. Princeton. These patients were poor surgical candidates Adjunctive therapies for wound healing and aged 80–89 years old. patient wishes. In a retrospective study of More research is also needed for evidence 37 elderly patients with critical leg ischaemia.47). liferation (39. However. avoiding amputation. ambulation or medication may be increases healing in venous leg ulcers and the effective treatments (9). treatment or care surgical skin grafts. There was also evidence of contaminated or infected wounds. the major- wound healing include electrical stimulation ity enjoyed improved QOL during this year which activates fibroblasts and growth factors following this minimally invasive procedure. honey is being procedural success rate of 84·2% . NJ.103). For palliative care patients secondary benefit in patients with leg ulcers who have ischaemic arterial ulcers and who or chronic wounds with a silver dressing in do not have heart failure. ethacridine lactate. hyperbaric oxygen therapy options can be guided by the severity of the (HBOT) for diabetic ulcers and oral pentox. the that healing improved without the compres- authors found significant less leakage as a sion bandages (102). tions such as mupirocin. (105) evaluated the effects of per- effective for treatment of wound infections. over- and debrides the wound (15). (102)concluded from 11 trials that leg ulcer treatment because of insufficient oral pentoxifylline (Trental. If the ischaemia is mild to There is weak evidence that ultrasound moderate. it is an infection (96). However. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. New An additional adjunctive therapy with lim- therapies are expensive and have had limited ited research evidence to encourage endoge- trials for evidence of efficacy (24).

symptoms and are cost effective (108). p. At a Chicago hospital with a palliative care realistic expectations can be communicated unit. showed partial healing or more. The authors are in the are taking place to institute research for process of ‘identifying a predictive profile’ formulating clinical protocols or standards of of patients that will not heal to provide practice (44. compliance. system wide approaches expectations (44).com Inc . were selected from wound care clinics that Wounds healed or improved in 68·4%. strategies consistent with the patient’s wishes life expectancy and patient perspective. absorbent wound dressings. 104). avoid being labelled ‘too difficult or costly to heal’ (44. Care of chronic wounds in palliative care loading. Once symptoms are identified. Although were determined to be non healing. control and practice (44. that have posed clinical. E = eliminate odour. P = domains: physical. care delivery provided by a multi-disciplinary for the end-of-life patient. approach for total healing and for significant Given that lower extremity amputations reduction in wound size defined by greater have a profound effect on QOL. It is also important to identify the impact components of an original mnemonic for on the family or caregiver and coping ability. and there were limitations to the study because of these patients were enrolled in the palliative inability to control certain variables such as care program for non healing end points wound characteristics. glycaemic a subacute wound unit for wounds with control and revascularisation-fail.107). the clinician should interventions aimed at comfort which have identify the patient’s understanding of disease included original medication compounds that and the effect of the chronic wound on his/her are cost effective (9). cultural and preventing new wounds. spiritual. non healing wound isons within each quintile estimated significant after confirmation with healing rate data to positive results (95% CI) (106). Margolis than 50% volume reduction (44). the C = control pain. debridement. stabilising the wound. If the patient et al. Ennis and Meneses (44) have published for prevention and treatment strategies based data conveying the growth in numbers of on best practice guidelines for correcting chronic wound cases from 1999 to 2004 underlying causes. this patient mated effectiveness of rhPDGF for wound would transition across the continuum for a healing and prevention of amputation. performed over 6 months duration on 108 strates in the wound bed to mobilise before patients with 133 wounds with intent to heal considering rhPDGF treatment. grade. Using and the prognosis for wound improvement. It was also important System approach to chronic wound to confer with the patient and family to management decide whether palliative care goals and In an effort to improve the practice of palliative objectives were appropriate to support QOL medicine for recalcitrant wounds and improve as defined by the patient and for realistic QOL in patients. However. it is important to team. The goal for these cialty care and unknown covariates. Symptom distress involves assessing QOL E-C-I-A-L (S = stabilising the wound. palliative chronic wound management: S-P. clinical indicators and validated risk tools. I = infection prophylaxis. compar. These interventions target life. economical and closing the wound. A multi-disciplinary team assessed by a multi-disciplinary team of approach is optimal for care planning and cost- experts guided by this tool in determining care effectiveness in the context of disease aetiology. Best practice guidelines should be for debilitated patients. 16·1% had diabetic neuropathic foot ulcers. spe. antibiotics. p. clinician involves the patient in the wound A = advanced. (106)designed a cohort study that esti. psycho-social. Wound experts at the palliative care unit at Calvary Hospital in New York have carried out CONCLUSION studies on recalcitrant wounds and effective For all wound types. Patients are that improve QOL. 103). for symptom control (44). patients was a stable. Clinicians would be guided guidelines for evidence-based decision-making by standards that contribute to healing. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. or controlling distressful ethical challenges when healing was unlikely symptoms. This hospital has viewed through the lens of the patient and 228 © 2010 The Author. Patients different level of care such as home health. A prospective management study was assess the likelihood of having the basic sub. management that will achieve realistic goals L = lessen dressing changes) (9).

Provide psycho-social and case study examples. Min- healing wounds to guide patient-centred imise and control pain during dressing discussions for goals of care in context removal and wound cleansing as defined of life expectancy.9. Inc 229 . Offer hope and support 3. practice that support the patient goals 15. Consider non pharmacologi- patient wishes. 14. 12. the following rec. assess wound healing. accordance with the patient’s wishes. deteriorated. Finally. 8. Engage the patient and family in partic- chronic wounds are suggested for care prac. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. The clinician is encouraged to rate the team through education. Encourage adequate nutrition or nutri- bacterial burden reduction and moisture tional supplements as tolerated by the balance. Refer to wound care experts for consult 7. Use the CWIS to measure QOL with a wound. ommendations for palliative management of 9. Assess practice guidelines for the type of wound for psycho-social and cultural issues that for care planning. that patient’s comfort and care remain 4. bleeding. Consider the aspects of best wound care on recalcitrant wounds (44). Refer to best medicate prior to dressing change. especially at the end of life. patient (5. bed preparation: tissue debridement. disease aetiology and 4-week trial of ‘intent to RECOMMENDATIONS heal’ and then discuss with the patient FOR PALLIATIVE MANAGEMENT and family whether or not to pursue OF CHRONIC WOUNDS treatment or switch to S-P-E-C-I-A-L Based upon the information reviewed from wound care if healing is unlikely and if in this literature synthesis. odour for intent to heal. care options and choices. Identify patients at risk for skin break.7. Pre- wishes to promote QOL. Use the PUSH tool to cal pain interventions. wound patient’s wishes. exudate. Assess for clinical indicators for non impact pain measurement accuracy. appearance and wound tive care research is sparse.42. on-going assess- articles for level and quality of evidence ment and dressing choices for comfort. Care of chronic wounds in palliative care family for optimal comfort and not necessarily pain. Recognise that comfort of the patient. chronic wound care for optimal patient out- 10. stabilisation.27. Assess pain with VAS or FRS or FLACC mine risks and benefits of various treat- (cognitively impaired) pain rating tools ments in light of the overall goals and and provide adequate pain control.51–53). Assess and wound care that supports QOL and which address the emotional aspects of living encourages a partnership with the patient and with a wound to help the patient and family. 5. cost. take precedence over ulcer prevention down using the Braden risk scale and and should be discussed by the multi- institute the hospital prevention skin care disciplinary team for goal reassess- protocol. Engage and educate the patient ment and documented as supporting and family in wound prevention. wear time. Ensure adequate tissue perfusion. often based on characteristics. (Figure 1) and to keep in mind that pallia. Confer with patient and family to deter- 13. Consider a 2. infection. ipation with the multi-disciplinary care tice. the clinician is spiritual support and promote indepen- encouraged to adopt a holistic approach to dence. Correct the underlying cause of the tissue patient that his/her health status has damage if possible. Skin breakdown is a visible sign to the 2. may 1. Use the MEASURE mnemonic for wound priority. family cope. 6. 11. © 2010 The Author. Consider a wound care clinic for uni- and focus the interventions on achieving form practice and system wide approach outcomes in accordance with the patient’s for palliative management of chronic wishes to control distressful symptoms: wounds (44). Further quality designed and dressing wear time and comfort research is needed for evidence-based chronic that supports improved QOL.

Prevent moisture evaporated from the second amputation if possible. acti. wound bed preparation.47. smoking cessa- time and proper fit.38. cosmetic appearance. Case studies promote the use of wound normalised ratio and basic metabolic care products. Anticipate bleed. Assess pain with a valid pain tool retention layer of foam. dressing wear caemic control. albumin. Instruct on nutritional supple- distressful symptoms. Wound cares are directed to control- ling the symptoms distressful to the 1. Diabetic foot ulcers occur in 15% of diabetic patients and are a leading cause of amputa. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. Assess for risks and clinical indicators of to reduce pain and handle leakage. Consider assessing QOL with use of contact layer (soft silicone perforated the CWIS to minimise suffering and sheet) for exudates to be absorbed and address distressful symptoms. patient education for Inc . glucose. 2. Include the and manage pain for comfort. ing for care strategies listed previously. anxi. a non healing wound: failure to show vated charcoal dressings for malodour. weeks and use of the SAD classification vated charcoal for infected. Consider patient in choosing the product that is gabapentin for neuropathic pain. Consider using the tion. ments if malnourished (24. surgery Fungating wounds and adjunctive treatments such as platelet- Because there is a lack of standardised derived growth factors (PDGFs). Consider topical goals of care with the patient (49). Below are listed ture or tissue biopsy to identify infection for common principles for palliative care of the local or systemic antibiotic treatment. glycaemic control. tissue. prothrombin time/international 3. underlying malignancy.53). Re-occurrence rates are 8–59% (47). Venous ulcers tions (24). For haemoglobin A1c .109). Re-assess treatment strategy and wounds for comfort.109). and non adhesive gelling foam dressings 3. reduction in ulcer size of 40% after 4 and antimicrobial dressings with acti. elec- protocols based on research and evidence. infection control. Treat fungating wound. ones that have a non adherent wound 5. exercise. hepatic function profile. complete blood count. discuss with the erythrocyte sedimentation rate. malodourous system. The primary treatment for uncomplicated Best practices primarily include aetiology venous leg ulcers (ankle–brachial oressure 230 © 2010 The Author. Check laboratory values as appro- Efforts are geared to stabilising the wound priate such as prealbumin. 4. Other dressing brands to consider are approach for care (109). if wound has bacterial load of 105 or more 1. Care of chronic wounds in palliative care 16. NPWT. adequate nutrition. off end of life for standardised care practices loading. other palliative measures to treat the lipid profile. urinary micro- end of life. Cleanse wound gently with warm normal per gram of tissue or any tissue level of beta saline and keep wound moist. such as polyurethane foam panel (47. optimal tissue perfusion. thyroid- patient/family benefit versus burden at stimulating hormone level. evaluation of arterial CARE WOUND MANAGEMENT and venous status of the affected limb. lower extremity and foot inspection. debridement of callous and necrotic that support QOL. Educate patient on proper foot wear. 2. capsaicin cream (0·25–0·075%) applied thinly three to four times daily to affected Diabetic wounds areas (110).52. haemolytic streptococci (9. metronidazole gel for odour control. Perform wound cul- case studies or expert opinion. gly- ety. Support research in palliative care and treatment. layer or alginates with a secondary 6. HBOT and revascularisation treatment of fungating wounds is based on for ischaemic ulcers (47). weight management and adequate WoSSAC for patient self-assessment of nutrition. appropriate dressings BEST PRACTICES AND PALLIATIVE for moist environment. patient with attention to comfort. and preventing further deterioration. Suggest most comfortable with long wear time. Use a multi-disciplinary specialist team 4. trical stimulation.

mechanical ventila- reduction in size after 4 weeks or use tor pneumonia prevention. Avoid use 400 mg three times daily to influence of adult diapers while in bed or leave microcirculatory blood flow and tissue open to air if possible. perineal cares cleansing.9. Reduce friction and shear by using lift a high bioburden consider using silver or sheet. pressure that damages underlying tissue (9. 1. Compression should be position comfort or use of air mattress and applied correctly by a trained practioner (53). pads promptly when soiled (3. improves venous return definition of comfort such as customising and blood flow (111). Discuss with the patient Pressure ulcers as an interdisciplinary team realistic The most common ulcer for palliative care goals such as control of troublesome patients is the pressure ulcer that results from symptoms. Care of chronic wounds in palliative care index of >0·8) is compression bandaging (53). protocols but always consider the patient’s reduces oedema. or aspiration the Rule of 6: ulcer >6cm2 in size. therapy for immobility issues. duration >6 months. Assess aetiology.40). and wrinkle free (3. ance to determine level of compres.9. No specific dressing is recommended term with indwelling urine catheter if to use under compression bandaging. discuss the in the USA exceeds $1·33 billion (52).9.56). 10. Use MEASURE for wound bed prepara. Recognise and prepare the patient and QOL and areas of patient distress for family that the skin fails also at end of goals of care discussions. prevent new ulcers.56). Provide good skin care. Instruct to elevate legs if tolerated by Hunters Hill tool for hospice patients patient (53). nence and/or control conditions short- 5. protocol (at least every 2 hours) to Re-assess treatment plan and goals with stay off existing pressure ulcers and to patient. Consult physical 1.111). 6. Change under- oxygenation to ischaemic tissues.40. Assess pain with a valid pain tool and turning and re-evaluate support surface manage pain for comfort as described to maximise comfort. not comfortable. ing pain with dressing removal and 4.15. Instruct on adequate nutrition and may opt against scheduled turning if exercise if tolerated (53. For venous ulcers with 2. ity with care strategies. sider also risk factors identified in the 4-week treatment trial. Treat and manage infection after de. are medical contraindications such as 6. Reduce risk by 4. wound Inc 231 . Assess for non healing ulcer if no difficulty breathing. For palliative care patients that have Total national cost of pressure ulcer treatment pre-existing pressure ulcers.31. trapeze and head of bed (HOB) cadeoxomer iodine dressings to control no more than 30 degrees unless there bacterial levels. Follow hospital pressure ulcer prevention Bandaging reduces hypertension in veins. Consider prescribing oral pentoxifylline nence episode or cleansing. comfortable for the patient or stoma but dressing should be comfortable. Use barrier ical modalities for pain control. life and wound closure may not be a realistic goal. Offer analgesic prior to 8. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. identifying reversible causes of inconti- bridement. precautions (9.59).52.7. dition to appreciate the need for flexibil- tion. there is no progress towards healing © 2010 The Author. relative to the underlying medical con- 3. cream and re-apply after each inconti- 9. If the AHCPR (52.52). Use the Braden risk factors but con- sion (53. The best benefits versus the burdens of an ‘intent practice guidelines are from the NPUAP and to heal’ 2. and unlikely to 3. comfort and toler.27. Consider using the CWIS to measure 5. and regular skin inspection. stay pouches for drainage to protect skin in place and effective in managing the integrity (3. Patient and family 7. Keep linens dry previously with attention to minimis.54). other off loading devices.54. Provide frequent turning per hospital heal with compression in 6 months (111).56). Consider non pharmacolog.52.

52). Scholte OP. 2nd edn. dez L.icsi. Sibbald RG. Health Qual Life choice of dressing for comfort. J Palliat Med 2007.19(3):148–54. 57–66. ventions aimed at wound-related complaints: 10. URL http://www. Müller K. Adamsen L. impact on daily life. ily that the swallowing reflex will Chrzanowski G. Int J Palliat Nurs 8. Nurs Stand 2007.11(11): ity palliative care. 5 Brown G. Pressure ulcers in pallia- treat to acceptable level of intensity tive care: development of a hospice pressure identified by the patient. Patient/family wishes will Ferris FD.14(4):464–72. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.22(45):53. re-evaluated.who. Use the MEASURE or SPECIAL mne. The ideal dressing is malignant wounds. For end-of-life patients or the frail 9 Alvarez OM. Encourage the patient in review on the impact of leg ulceration on patients’ quality of life. Skin Wound Care 2006. Baker JJ.21(24): comfortable.14(8 Suppl): to the patient that his condition is 4S–27S. 1 National Consensus Project for Quality Palliative 16 Naylor. the URL http://www. Meehan M. 232 © 2010 The Author. Kalinski C. goals and 14 Langemo DK. Organization quality of life (WHOQOL)-BREF. A guide to wound management in Care. J Palliat Med REFERENCES 2006. Gustafsson M. Nusbaum J.49(10):42–50. Ennis W.8(5):214–21. Comfort CP. A systematic vides moisture. tion (symptom management) in patients with chronic wounds.49(4):2. which can result in poor nutri. Pressure ulcers: diagnostics and inter- patient (9. inine and sexual perspectives. prepare the patient and fam. be respected for goals of care.52). outlined previously.nationalconsensusproject. van der Vleuten CJM. pressure ulcers: healing and mortality. 1–5. the patient. van Achter- tional supplements for the malnourished berg T.asp-8k-cached [accessed 29 Achterberg T. and the treatment plan should be 2009]. debridement as an exudate and odour from chronic venous leg option needs to be considered in the ulceration. When the goal is palliative care. Incorporating weaken. Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. An audit of pressure ulcer incidence and family. [corrected] [published erratum appears in 3 Institute for Clinical Systems Improvement.27. 18 Reddy M. feelings and provide support to patient 6 Galvin J. Adv benefits (9. a review of the literature. van idelines download. Impact of For other sites. Robinson J.10(5): ences to discuss benefit versus burden 1161–89. 12 Herber OR. Int J Palliat Nurs 2005. Bradley M. J Clin Nurs 2005. Consensus Project. Fernandez-Obregon A.9(2):285–95. this may signal the frail population. controls wound characteristics and pro. 15 McDonald A. Rogers R. Rieger MA. Pittsburgh. Wounds 2002. Reduce pressure over ulcer site. 4 Alvarez OM. van de Kerkhof PCM. Rodeheaver G. of enteral nutrition. As the skin fails. 2004. November 2007. Consider non phar. requires minimal changing.9(11):474–84. Clinical practice guidelines for qual. Int J Palliat Nurs tle dressing removal and cleansing as 2003.14(1):56–64. Long-term outcomes of full-thickness worsening and facing his/her mortality. The World Health 341–54. PA. context of patient’s wishes.13(3): 2 The World Health Organization. 8 Lund-Nielsen B. Carlisle C. Offer care confer. Outcomes 2007. Assess pain with a valid pain tool and 2002. Lesage P. ulcer risk assessment scale. Health OSTOMY WOUND MANAGE 2003 May. Kennedy KL.5(4):44–56. URL 17 Persoon A. Barr W. Nurs Stand 2008. J Clin Nurs 2004. Practice gen. 11. wounds in women with breast cancer: fem- ment. 10 de Laat E. Care of chronic wounds in palliative care during this time period. Parker R. W. Keast D. Practical treatment of wound pain and trauma: abuse/research/tools/whoqolbref/en [access a patient-centered approach. Thomas DR. Heinen MM. May leave heel eschars alone if intact (3). care order set: palliative care.51. Ostomy Be attentive and listen to validate Wound Manage 2003. Assess for fears and address coping Chronic wounds: palliative management for ability. Care of patients with fungating get care strategies. J Clin Nurs de Rooij MJ.15. 9. wound healing strategies to improve pallia- tion or aspiration. Hernan- elderly. 7. 2009 National 572– Inc .org [accessed 20 May ulcer. Leg ulcers: a review of their June 2009]. Ostomy Wound Manage 2003. Reimer WJ. Pappous E. Schnepp W. palliative care. 49(5):8]. in a palliative care setting. an overview ed 29 June 2009]. Provide oral nutri. monic tools to assess the wound and tar- 11 Grocott P. Kyriannis C. USA. 13 Jones JE. Malignant macological modalities for pain manage. Queen D. Kohr R. 7 Henoch I.

Nurs 1995. Stotts N. Harkless L. Nettleton R. quality of complete healing in a 12-week prospective of life. Rodeheaver G. Chronic wounds: TIME. J Wound 26 Moffatt CJ. a new diabetic foot ulcers: a comprehensive review pain reducing wound dressing.html [accessed 7 March 2009]. New of life for patients with venous leg ulcers: proof and experimental approaches to treatment of of concept of the efficacy of biatain-ibu. Plast Reconstr Surg 2003. 2007. 2008. URL nonhealing wounds and wound care dressings. Halfens 49 Treece KA.57(5):494–504. Wound bed preparation and a brief history of 23 Jones KR. Vázquez M.12(1): practice recommendations for wound assess- 48–59. Mason S. Thomas DW. 42 Soriano LF. Wouters-Wesseling W.19(1):39–42. Giurini JM. DC. Hill CM.21(11):1161–73.10(1):27–3. Wounds 2005. and life in patients with chronic wounds of the lower wound grade on healing. WHO definition Nixon J. and legal benefits.22(6):1092–100. Gould L. Dermatol Nur trial. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.21(9):987–91. Wall IB. Aslam Inc 233 . Doherty Care 2004. Davies Randomized trial of four-layer and two. Johnson A. Widdershoven G. Price 21 White R. Mamelak A. 2008. 456–66. responses in vitro. Iglesias C. 36 Ferrans CE. Dassen T. The WOC nurse: economic.58:185–206. Raz I. The tion document: hard-to-heal wounds: a holistic effectiveness of oral nutritional supplementa- approach. D’Souza L. Pain and quality 24 Eldor R. R. Care of chronic wounds in palliative care 19 Spilsbury K. Boulton AJM. Int Wound J 2004.9(1):5–10. http://www.18(1):58–64. ulcers over a 4-week period is a robust predictor 30 Kaufman MW. Crossland M. Mozingo DW. Palliative care and wound Thomas D.14(3):233–9.117(7):239S–44S. J.12(3):S1–17S.1(1):19–32. Treating the chronic chronic recalcitrant wounds? WORLD WIDE wound: a practical approach to the care of WOUNDS 2004 [WWW document]. Praburaj DV. J Adv Nurs 2009]. Colaizzi T. Wound chronic. Diabet Med 2006. Posi. Cardiff wound impact sched. URL http://www. Br J Nurs pain: an international perspective.2(4):364–8. Nelson A. Harding K.worldwidewounds. Lenihan A.17(4):99–104. Quality of life in palliative care cancer Jeffcoate WJ. Allen-Taylor L. Harding KG. 34 Jocham HR. ule: the development of a condition-specific Diabetic neuropathic foot ulcers:tThe associ- questionaire to assess health-related quality of ation of wound size. Pound N. J Adv 1992. 31 Chaplin J. Pressure sore risk assessment in pallia- nonhealing after 5-6 months of care. Got. 2004. 44 Ennis W. Anaer- layer bandage systems in the management obic cocci populating the deep tissues of of chronic venous ulceration. Nurs Stand 2004. Wound Repair Regen J Community Nurs 2004. Pressure ulcers and their of palliative care. tober/Enoch-Part2/Alternative-Enpoints-To. 2006. ment. Hill KE. Wilson MJ. Psychometric assessment 20 Walshe C.14(6):680–92. Guidelines for the treat.who. ity and fibroblast senescence–implications for Percent change in wound area of diabetic foot treatment. Graupera 25 European Wound Management Association. 2007. © 2010 The Author. 37 Mudge EJ. Phillips L. Bowering CK. Br J Dermatol 2003. factors influencing healing within 3 months and 40 Chaplin J. Moosa H. Jones P. Living with a venous leg ulcer: a of the quality of life index. Validation of a system of foot ulcer patients: a literature review.8(2):19. Aronson-Cook B. Wound Repair Regen outcome data. Phillips TJ. Game FL. Woo K. Serena T. 48 Margolis DJ. Chin GA.14(6):663–79. Guidelines for the treat- practice of wound care in the community.15(9):1188–95. 39 Schultz GS. Dean C. 2006. 2004. O’Connor T. Moore K. be considered to evaluate outcomes in Kohli A. 2002. Berlin JA. Wound Repair Regen 2004. 43 Stephens P. Patients’ experience of wound-related dressing with safetac technology.11(3):166–71. Int Wound J 2004. Br ment of diabetic ulcers. Wagenaar L. Mole T. trup F. treatment and effects on quality of life: int/cancer/palliative/en [accessed 13 May hospital inpatient perspectives. Morris C. 35 The World Health Organization. Hourican J Am Acad Dermatol 2008. Mepitel: a non-adherent wound PE. Hoffstad O.1(1):10–17. Powers MJ. tion in the healing of pressure ulcers. Meaume S. Diabet Med Regen 2006. 28 Anand SC. MEASURE: a proposed Health-related quality of life tools for venous. Healing. Price P. Caselli A.19(3):51–63. Wounds tive care. Cowan D. Wound management in palliative care. Meneses P. Stevens J. McCullagh L. MacKean GL. 45 Keast DH. Int Wound J 2005. Robson M.13(8):319–22. Barbul A. Lazarus G. Franz M. Friis GJ. London: MEP Ltd. Should alternative endpoints 38 Fonder M.148(3): 27 Whitney J. Gottrup F. wound duration. Robson MC. Evans AW. 2001. Macfarlane RM. Res Nurs Health descriptive study of patients’ experiences. Maristany CP. Veves A. Veves A. 29 Harding KG. Br J Nurs 2003. EWMA J 2009. 22 Enoch S. assessment framework for developing best ulcerated patients. Fennie K. Wound Repair chronic wounds impair cellular wound healing Regen 2003. CE. Diabetes Care limb.15(1):29–38. care: 2 emerging fields with similar needs for ment of pressure ulcers. Burrows C.13(3):215–9. Ben Yehuda A. J Tissue Viability 2000.25(10):1835–9. 41 Jørgensen B. Cullum N. J Clin Nurs classification in diabetes mellitus. Sharing the burden: the complex Wiersma-Bryant L. Barillo DJ. 32 Hollinworth H. Sheehan P. 2009a. 33 Price P. Sibbald RG. Attinger C. Franks PJ. Wound Repair of emerging treatment strategies. 47 Steed DL. 46 Sheehan P.

Aslam R. Schulz VN. 2002. Oster- National Pressure Ulcer Advisory Panel. brink J. Principles of best practice: wound OM. Ruby E. D. A liquid film- 63 Gardner SE.41(3):20–5. Pressure 1995. London: MEP Ltd. Am Fam Physician 1996. 2005.14(11):S4– Decubitus 1993. Bergquist S. Report No. Cameron J. ulcer prevention points.asp?/pageId method involving users. Woo K. wounds: the wound pain management model. 1994. Sibbald RG. URL http://www. 67 Browne N. Wound bed prepa. Lovatt A.49(10):16–8.epuap. Nelson EA.2(3):230–8. Developing a tool for researching management of chronic leg ulcer wounds. Chronic tion document: wound bed preparation in prac. Bourguignon C. Teot L. 72 Malviya S.html [accessed 80 Daniels S. Posi. Keogh A. Wiersma. 61 European Wound Management Association.worldwidewounds. 2004. A consensus containing metronidazole for wound odor and document. Fogh K. Frantz RA. Gray M. 0653.1-4[EPUAP document] URL http:// 2005. Ennis W. Cowley S. Grocott P. Skin fails too: acute. Wounds 2005. http://www. uation of a new composite dressing for the 65 Grocott P. tool: improved reliability and validity for pain ration: a systematic approach to wound assessment in children with cognitive impair- management. Laboy D. Part 2: symptom self-assessment in Manage 1994.40(8):40–51. D. products (WRAP): validation of the TELER URL http://www. Do topical analgesics reduce venous ulcers. Wide Wounds Document] 2002(July):1–13. Managing painful chronic Report No.6(1):16–21. to healing deep pressure ulcers. a conceptual model. 76 Queen D.17(4):84–90. Harding K.41(5):559–71. Full-thickness pressure ulcers: 2001(July):1–17 [WWW document]. EPUAP. and end-stage skin failure. Alvarez-Nieto C. Garcia-Fernandez FP. Ostomy Wound Manage 56 National Pressure Ulcer Advisory Panel. Nurs Res for clinician. Database Syst Rev 2003. Voepel-Lewis T. Wound Manage 2003. Woundcare research for appropriate management of venous leg ulcers. Description of pressure Harding KG. London: MEP Ltd. Risk assessment depressive symptoms. The management of malodour and ulcer prevention guidelines. The chronic wound pain experience: Wound Care 2006. URL patient and wound healing characteristics. exudate in fungating wounds. Sibbald RG. & Polansky.worldwidewounds. The revised FLACC observational pain MC. Ochs DE. Guidelines for the treatment of 69 Evans E. Bryant L. Krasner DL. Champagne M. Int J Nurs Stud = 924& [accessed 19 April 2009]. Hernandez L. Vowden K. Printing Office. or debridement of chronic wounds? J Wound 55 Langemo DK. Medina IM.19(4):206–11. Kemp M. fungating wounds.rnao.(4 Suppl)1:4–15. and pain catastrophizing scales for pressure ulcer prevention: a system. 2004:1– 2007. 57 Schultz GS. Hamill JB. Ostomy Continence Nurs 2005. Gary Sibbald R. tion document: pain at wound dressing 60 Bergstrom N. Dowsett C. Wound Repair Regen [accessed 19 April 2009]. Practical management of pressure 74 European Wound Management Association. 2007:1–10. A forming acrylate for peri-wound protection: prospective study of the pressure ulcer scale for a systematic review and meta-analysis (3M healing (PUSH). npuap. Dealey 53 Registered Nurses’Association of Ontario. Predictors of time 14 March 2009]. J Snyder RJ. Care of chronic wounds in palliative care 50 van Rijswijk L. Steed DL. Lowery JC. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines. L. Topical agents or dressings multisite study of the predictive validity of the for pain in venous leg ulcers (Review). Margolis DJ. Stacey Tait AR. Alvarez (WUWHS). Lopez. Effectiveness of a topical formulation exudate and the role of dressings.54(1):94–110. Vanscheidt W. Sibbald RG. Comfort C. Ostomy tice.: Government ly/Naylor-Part2/Wound-Assessment-Tool.: AHCPR95. 62 Kalinski C. London: MEP Ltd. Becker A. 234 © 2010 The Author. Wound Repair Regen 2003. Falanga V.83(11):827–34. McGrinder B. chronic. html [accessed 14 March 2009]. 54 Robson MC.html [accessed 51 van Rijswijk. Eval- 7 March 2009]. ly/Grocott/Fungating-Wounds. 73 Roth RS. Brown G. exudate control. changes. Cooper DM.(1):1– Inc . Cochrane braden scale. www. 1–15. Sibbald RG. Predicting pressure ulcer risk: a 75 Briggs M. Thomas DR. Int Wound J 2005.60A(1):93–7. 78 Schuren J. Merkel S.16(3):258–65. Schnepf M. Washington. Assessing persis- 58 Pancorbo-Hidalgo P. the management of fungating wounds. Posi- ulcers.11(1 ment.: 71 Price P. Ostomy Wound 66 Naylor W. tent pain and its relation to affective distress. Braden B. Am J Phys Med Rehabil 2004. Romanelli M. Br J Nurs UK 1998. Adv Skin 70 Krasner D. wound pain and palliative cancer care. M. Washington.C. in patients with chronic wounds: a pilot study.26(3):115–20. Nurs. Serena TE. Ayello EA.11(8):290–4. 68 Szor JK. C. 64 European Pressure Ulcer Advisory Panel.32(5):287–90. J Adv Nurs 2006. Eager CA.14(6): pain associated with wound dressing changes 649–62. atic review. 2002:1–8. Vow- ing best practice guidelines: assessment and den P. Glynn C. 59 Findlay D. Int Wound J 2007. ulcer pain at rest and at dressing change. Gould LJ. Suppl):S1–28S. World Wide Wounds J Wound Care 2002.C. WOCN 1999. Paediatr Anaesth 2006.[World 52 Agency for Healthcare Policy and Research. Shin CD.: Revised 2007.URL Pressure ulcer treatment quick reference guide http://www. J Gerontol A Biol Sci Med Sci cavilon no-sting barrier film). 77 World Unionof Wound Healing Societies Nusbaum J. Pressure 79 Draper C.54(5):1519–28.47(5):261–9. Burke C.

Piscione F. 1–6. Wound infec. Ayala J. 110 Wound. Cornet C. therapy using vacuum-assisted closure with (supplement) 10(6):524–530.html [accessed 29 June 2009]. Honey as a topical 86 Heinen MM. Ostomy. http://www. Compagna R.5(6):20–8. Therapeutic 2005. Flemming K. Ireland. Vol. Cochrane Database Syst de Kerkhof PCM. Vol. Effect of sharp debridement using 100 Bergin S. 65–6. Bennett [accessed 19 117(7):193S. Iuliano GP. Effectiveness of recombinant human 90 Langemo D. 93 National Pressure Ulcer Advisory Panel. Michaels JA. Br J Nurs 2001. © 2010 The Author. Sheehan P. de Laat E. BMJ 2007. 2006. Roeckl- Truchetet F. J Clin Nurs for treating venous leg ulcers. infected wounds. Rosenberg HJ. 1998. Cochrane Database Syst Rev tive cohort study. Harris K. Hanson D. O’Mara A.1(76 health organization pain ladder 2009b.17(3):196–202.1:1–26. Rodgers A. 91 Bale S. Ovington L. Wounds 2009. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.13:131–7. Cochrane Database Syst Rev 85 Williams D. Diabetes Care 82 Hollinworth H. Walters J. Evidence-based protocol for dia- sure Ulcer Advisory Panel. Waters J.who. Schneider JS. Schmutz JL. Study to deter. Ver- 83 Medical Education Partnership Ltd.13(3):355–66. Paul J. Debus SE. Hoffstad O. 97 Blume PA. D. Topical negative pressure for tion in clinical practice: an international consen. 103 Kranke P.20(7):65. Guideline for management of wounds in ity and reliability of the pressure sore status patients with lower-extremity neuropathic dis- tool. The world of elderly patients. Pentoxifylline and pain-related interventions. van Hattem JM. Br Palliat Nurs [accessed 08 March 2009]. Anderson J. www. PUSH tool. Smith R. Boulton AJ.guideline. Hyperbaric oxy- card F. painful ulcers. www. URL http:// betic foot ulcers. Nurs Stand 2005. JA. Database Syst Rev 2007(3):1–49.. Using a new foam dressing in the tis J. Granel Bro. 84 Williams RL.. Nelson EA. Wound and skin care: understand. 335(244):1–77. URL http://www. Barbaud A. Syer S-B. 101 Jull AB. A topical metronidazole Palliative wound care at the end of life. Cochrane sus. Miller D. 2003. meulen H. Dressings advanced moist wound therapy in the treat- for venous leg ulcers: systematic review and ment of diabetic foot ulcers: a multicenter meta-analysis.13(6):531–6. Decubitus 1992. Care of chronic wounds in palliative care 81 Palfreyman S. Arroll B. and Continence Nurses Soci- 94 Bates-Jensen BM.13(11):S4. ultrasound for venous leg ulcers (Review). ety.25(6):555–8. Ubbink DT. Evans D. gel used to treat malodorous wounds. 95 Adderley UJ.31(4):631–6.2(1):28–30. Reimer W.21(1):15– 106 Margolis DJ. Comparison of negative pressure wound care of fungating wounds. URL Suppl):11–5. 96 O’Meara S. Payne W. prospec. Valid. Antibiotics (Eds). J Nurs 2004. A tool to aid nurses’ decision of malignant malodorous wounds.guideline. Storm-Versloot palliative dressing in chronic critical limb MN. Berlin adder/en/index. URL http:// Database Syst Rev abstract 2008(1):1–3. 111 Smith & Nephew Ltd. WOCN: 2004. Piscitelli V. Cadexomer iodine: an effective 99 Vermeulen H. Price P. Analgesic Cochrane Database Syst Rev 2008. 1–13. gen therapy for chronic wounds. Malay S. Venous leg ulcer Rev 2008(4):1–47. 98 Ubbink DT. Grace P.npuap.37(1): Repair Regen 2005. 107 Hughes RG. painful chronic skin ulcers.: National Pres. Br J Nurs Home Health Care Management & Practice 2004. platelet-derived growth factor for the treatment Hunter S. Wound Repair Regen 2006(1):1–17. Kovner CT. Bartus C. Ribeiro MDC. Cochrane for practice. 88 Zeppetella G. Topical agents and dress.13(15):S6. Cochrane gov [accessed 08 March 2009]. Wraight. Cochrane 2004.2:1–15. 2005. in wound care. Topical silver for treating ischemia. Harding KG. van Achterberg T. randomized controlled trial. Dublin. Database Syst Rev 2008(3):1–32. Wiedmann I. efficacy of morphine applied topically to 105 Amato B. James J. Markabauoi AK. 39. Cochrane mine the efficacy of topical morphine on Database Syst Rev 2004(1):1–37. 2005. Westerbos SJ. patients: a review of the literature on lifestyle 102 Jull AB. Walker N. The management of patients’ pain 2008. Plast Reconstr Surg 2006. Lan. J Pain Symptom Manage Masone S. Vredevoe DL. Bakos AD. Tebble N. Commun N.5(3):1–1. Esposito G. Schnabel A. April 2009]. Al-Kurdi D. Price P. Parag V. Wound ing palliative wound care. Brecht ML. Acta Biomed 2005. ease. ulcers (Review). 2007(1):1–43. NPUAP 109 Brem H. Endovascular procedures in critical leg ischemia 89 The World Health Organization. of diabetic neuropathic foot ulcers. Leg ulcer guidelines: a pocket guide and antiiseptics for venous leg ulcers. treating chronic wounds (Review). van treatment for wounds. Cuny JF. ings for fungating wounds (review). Land L. 92 Vollstedt C. Int Wound J 2008. Silver based wound dress- curette on recalcitrant nonhealing venous leg ings and topical agents for treating diabetic foot ulcers: a concurrently controlled. 87 Vernassiere C. Enoch S.C. Thompson P. 3 (WOCN clinical practice guideline). 112 Naylor W. Trechot P. Nurs 2007. Washington. Symptom management: management 108 Keen D. Database Syst Rev 2007. J Wound Care 104 Al-Kurdi D. Alla F. J Hosp making in relation to dressing selection.14(6):289– Inc 235 . P.