A narrative review of management of wounds in palliative care setting

Introduction

Background

A chronic wound is one that is physiologically compromised as a result of the wound-healing cycle being disturbed by factors such poor angiogenesis, innervation, or cellular migration, among others (1). Various factors, such as comorbidities [for example diabetes, autoimmune illness, peripheral artery disease (PAD)], an elevated body mass index, anatomic location, and drugs, affect the precise timeframe for full epithelialization (2,3). Chronic wounds in palliative care encompass fungating malignant wounds, diabetic ulcers, venous and arterial leg ulcers, and pressure ulcers (4). Almost always, the wounds that palliative care patients frequently experience are a direct outcome of their advanced disease status. Palliation enhances a patient’s quality of life and makes them feel more comfortable, but it does not treat their illness. In palliative care, a multidisciplinary team approach to treatment tries to enhance patients’ and their families’ quality of life rather than treat the underlying cause (5,6).

Wound healing may be an unattainable aim in the palliative context due to these patients’ poor healing capability and frequently short lifespans. When this is the case, controlling wound-related symptoms and preserving or enhancing the patient’s quality of life are the key goals of wound care (7,8).

Rationale and knowledge gap

There is a paucity of clinical data regarding wound management in palliative care.

Objective

In this article, we aim to summarize the clinical assessment of chronic wounds and discuss fundamental principles and available options for treating different types of wounds in palliative care. The main question that we tried to address with this review was: what questions need to be answered and what choices need to be made for the assessment and management of chronic wounds in clinical palliative care? We present this article in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-23-138/rc).

Methods

The identification of pertinent studies published from 1965 till July 2023 was conducted by searching PubMed using various combinations of the following search terms: included “wounds”, “ulcers”, “palliative care”, “palliative management”, and “end of life”. Further research papers were discovered by examining the reference lists of pertinent publications. Publications with limited credibility and those not in English were excluded from consideration. Data extraction was performed based on the relevance of the information to the subject rather than following a systematic approach to paper selection. For more comprehensive information about the methodology, refer to Table 1.

Type of ulcers in palliative wound care

In palliative care, patients may experience various types of wounds. Pressure sores, friction wounds, and skin tears are common in hospice and palliative care patients, especially those who have limited mobility. Malignant tumors on the surface of the skin, diabetic ulcers, and vascular wounds may occur in patients with specific conditions

There are several types of wound ulcers that can occur in palliative care.

Pressure ulcers

Palliative patient populations have the highest prevalence of all wound types because of their fragility and several risk factors; among these, pressure ulcers predominate, accounting for up to 60% of wounds (9). An expert panel coined the term Skin Changes Near Life’s End (SCALE)in 2008 to refer to a series of wound occurrences caused by the complicated failure of homeostatic mechanisms at the end of life (9). At the end of life, some skin alterations, such as pressure ulcers, cannot be prevented (10). The full medical record should accurately reflect the plan of care and the patient’s response. The interprofessional team members and the patient’s circle of care should be informed of expectations regarding the patient’s end-of-life objectives and concerns (11). Suboptimal nutrition, including lack of appetite, weight loss, cachexia, wasting, low serum albumin/prealbumin levels, low hemoglobin, and dehydration, may be risk factors, symptoms, and indicators of SCALE. All areas of concern should be documented during routine total skin assessments in accordance with the patient’s requests and health. The history of the patient at the end of life must be evaluated, along with the risk of developing a skin change (Braden Scale or other valid and reliable risk assessment scale) (11). Following a comprehensive evaluation, the practitioner should promptly commission the proper pressure-relieving apparatus, providing seamless treatment for the palliative patient (6).

Venous or arterial leg ulcers

These are caused by poor circulation in the legs, which can lead to skin breakdown and open wounds. Venous leg ulcers are more common and are caused by problems with the veins, while arterial leg ulcers are caused by problems with the arteries (8-12).

Venous and arterial leg ulcers are common types of open sores found on the lower extremities, such as the legs and feet. Venous leg ulceration is due to sustained venous hypertension, which results from chronic venous insufficiency (12,13). In the normal venous system, pressure decreases as blood flows towards the heart. However, in chronic venous insufficiency, the valves in the veins are damaged, causing blood to pool in the veins and increasing the pressure in the veins. This results in damage to the vein and leakage of fluid and blood cells, causing edema or swelling. Arterial ulcers, on the other hand, develop as a result of damage to the arteries due to lack of blood flow to the tissue. Arterial ulcers are caused by atherosclerosis, thickening of the arteries, or vasculitis, among other factors. In palliative care, the management of chronic wounds, including venous and arterial leg ulcers, is important to improve the quality of life of patients. The management of chronic wounds in palliative care and end-of-life patients involves a multidisciplinary approach, including wound assessment, pain management, and addressing the underlying cause of the wound. The goal of wound management in palliative care is to promote wound healing, prevent infection, and alleviate pain and other symptoms associated with the wound (14-16).

A new intervention for venous leg ulcers has been evaluated using a self-controlled trial model and two metrics of short-term healing rate (12).

The results of the study showed that the new intervention was effective in promoting wound healing in patients with venous leg ulcers (12).

The study highlights the importance of developing new interventions for the management of chronic wounds, including venous and arterial leg ulcers, to improve the quality of life of patients in palliative care.

The management of chronic wounds in palliative care involves a multidisciplinary approach, including wound assessment, pain management, and addressing the underlying cause of the wound. A new intervention for venous leg ulcers has been evaluated, highlighting the importance of developing new interventions for the management of chronic wounds.

The literature suggests that psychosocial factors play an important role in the incidence of pressure sores. Research indicates that differences exist among groups in pressure sore history and psychosocial measures. Contrary to the expectations of a mechanical skin problem model, quadriplegics as a group (rather than paraplegics) had a history of fewer pressure sores. Therefore, it is essential to conduct a comprehensive assessment of patients with pressure ulcers, including a complete medical evaluation, to identify risk factors and develop a sound understanding of risks. Caregivers should be educated about risk assessment and prevention and should inspect patients often to prevent pressure ulcers or identify them at early stages. Additionally, structured and systematic pressure ulcer risk assessment tools can be used to reduce the incidence of pressure ulcers (8).

Diabetic ulcers

These are caused by nerve damage and poor circulation in the feet and legs, which can lead to skin breakdown and open wounds. Diabetic ulcers are more common in people with diabetes who have had the disease for a long time (17,18).

Diabetic foot ulcers are chronic wounds in the foot or feet associated with neuropathy and/or PAD of the lower extremities.

Palliative care is a philosophy and system for deciding care that can be used alone or integrated with usual chronic disease care, including diabetic foot wounds. Palliative care aims to enhance quality of life, optimize function, and manage symptoms, including early in the course of chronic diseases. A study identified palliative care needs in patients under diabetic foot surveillance with and without DFU, including a significant need for symptom management, psychological support, and end-of-life care (19-21). Palliative care can be integrated with usual foot care and is associated with improved function, a better quality of life, and greater patient and family satisfaction.

The Wound Healing Foundation recognized a need for an unbiased consensus on the best treatment of chronic wounds, including diabetic foot ulcers (17-21).

Palliative and end-of-life care competencies are essential for healthcare professionals caring for patients with stroke, including symptom management, communication, and decision-making.

Malignant wounds

About 10% to 15% of cancer patients develop malignant wounds, which are ones that are directly linked to tumor infiltration of superficial systems like the skin and lymphatics, during their disease (22-25). They are frequently regarded as “unhealable” due to their link to poorly controlled local or distant diseases, and although the body of information is sparse, it appears that healing of these wounds is exceedingly unusual (26). Given that malignant fungating wounds are the most aggressive and challenging to treat, the treatment options presented here can be used more widely for other wounds in the context of palliative care. The principal skin, breast, head, and neck, gastrointestinal (GI), and lung cancers are those that are most likely to result in malignant wounds (27). People who are developing these wounds experience severe symptoms such as pain, swelling, exudate, stench, pruritus, and bleeding. Although pain is the most common symptom (noted by up to 30% of patients), malodor frequently surpasses it in terms of its detrimental effects on a patient’s quality of life (28,29). Patients, carers, and staff all experience a visceral reaction to malodor, which can generate feelings of inadequacy in all those who come into contact with them and exacerbate isolation for patients who worry about the inevitable social stigma (30). Anaerobic bacteria of the Bacteroides spp. and Clostridium spp. break down the proteins in necrotic tissue to produce malodor in fungating wounds. These include Clostridium perfringens, Fusobacterium nucleatum, Prevotella species, Bacteroides fragilis, and Anaerobic cocci (31-35). Topical opioids are one opioid-sparing treatment option utilized in palliative and hospice care settings. Unless applied on big wounds (>60 cm² in the representative study), when bioavailability from that lesion was estimated at 20%, topical opioids have little systemic absorption. Topical metronidazole is now the antibacterial remedy that is being researched the most for malodorous wounds. Due to systemic antibiotics’ low penetration into the necrotic tissues of a malignant wound, limited available data indicate that systemic oral treatment is ineffective. Despite contradictory results, topical metronidazole is still a popular off-label treatment for wound odor, and multiple trials have demonstrated a considerable improvement with a low side-effect profile.

Clinical assessment

A thorough history and physical examination, including a review of systems, should be performed on every patient who has a wound or ulceration (1,18). In order to identify risk factors for nonhealing, the history should at the very least include the elements listed below (36).

• Determine whether the patient has any medical disorders, such as diabetes, PAD, chronic renal disease, peripheral neuropathy, impaired nutritional status, obesity, or advanced age, that are risk factors for a chronic wound (37).
• Prior wound history—inquire with the patient if they have ever had any previous wounds or ulcers. Where were they located, and what—if any—previous techniques were employed to promote healing (38)?
• Current wound history—inquire about the patient’s perception of the causes of the current wound’s onset. Has the wound’s quality changed over time (size, drainage, etc.)? What is the current procedure for wound care?
• Does the wound hurt? How bad is the discomfort? It is crucial to understand that people with neuropathy may still experience pain, which could be a sign that deeper tissue structures are involved.
• Social background: has the patient ever smoked? Is the social environment conducive to the management of wounds? Can the patient successfully maneuver around his or her environment, either with or without the aid of assistive equipment or other people? Does the patient have a job? What impact will wound care have on their daily lives (1)?
• Surgical background: has the patient ever undergone surgery before? Where did the surgical incisions occur? Was healing a problem at all? Has the patient had surgery to treat a wound that won’t heal? Has skin grafting, arterial revascularization, or vein ablation surgery been required in further detail?
  • Assessment of wounds: each wound’s features should be described in detail, along with its location and quantity. Photographic documentation and ongoing wound assessment may both benefit from using it. By using objective wound photography, one may analyze changes in the wound area over time with consistency and accuracy while reducing interobserver variability (39).
  • Documentation of the wound‘s location, length, width, depth, undermining, dried necrotic wound surface (i.e., eschar), cellulitis presence, and drainage (quantity, kind, color, and odor) is also important (40). Additionally, the maximal depth of tissue penetration should be evaluated subjectively. Has the wound reached a deep fascial layer or the dermis? Does the wound reach the bone level?
  • Each time a patient is seen, the area or volume of the wound should be calculated and recorded (1). Measure and note the largest wound’s length, width, and depth after precise debridement. Potential for wound healing may be predicted by the rate of wound healing as measured by the percent change in wound area over time (41).
  • Wound cultures—in order to aid direct antibiotic therapy, wound cultures should only be acquired in the presence of local indications of infection. Wound infection is a clinical diagnosis, and clinical judgment should always be utilized in conjunction with wound cultures. If a culture is required, the sample should be acquired after the wound has been completely cleaned and debrided; deep tissue collection is preferred over superficial wound base swabbing or drainage collection (42-46).
  • Infection symptoms—since bacteria colonize almost all wounds, a diagnosis of invasive infection is made clinically rather than microbiologically. An underlying abscess that would benefit from decompression, drainage, and/or debridement is indicated by peri-wound induration, cellulitis extending more than 2 cm beyond the wound margin, increased local warmth, discomfort on probing, and drainage from the location (44,45).
  • Vascular assessment—when a patient appears with a chronic wound of the extremities, a complete vascular examination is crucial. Loss of peripheral pulses with inadequate capillary filling, thin, atrophic skin, lack of hair on the foot and lower leg, and hypertrophic, malformed nails are all indications of arterial obstruction.
  • Patients who appear with a wound and an aberrant pulse reading, as well as those who have an ulcer or nonhealing extremities wound, should undergo noninvasive vascular testing. The ankle-brachial index, duplex ultrasound, segmental blood pressures, and plethysmography are noninvasive diagnostic alternatives for arterial evaluation (46).
  • Laboratory tests—common laboratory tests are carried out to assess the patient’s risk for nonhealing wounds and to check for active infections, anemia, nutrition status, and medical disorders (47,48).
  • Nutritional assessment—although there isn’t conclusive proof that extra nutrition may speed wound healing, it’s likely still vital to ensure appropriate nutrition to promote wound healing and reduce the risk of wound complications. For patients with chronic wounds who do not react as anticipated to adequate care, we prefer to screen for malnutrition with prealbumin and albumin and increase nutritional supplements (49,50).
• Relationships, improvement measures & expectation of outcomes.
  • Wound ulcers in palliative care can be challenging to manage, and the expectations of outcomes can vary depending on the type of wound and the patient’s overall health status.
  • Patients with advanced illness are at increased risk of pressure injuries and difficult wound healing, which can lead to prolonged healing times and increased risk of infection.
  • However, palliative care does not preclude active treatment and other supportive strategies to prevent exacerbation of existing wounds and new wounds from developing.
  • The focus of palliative care is on reducing the severity of disease symptoms rather than striving to halt, delay, or reverse the progression of the disease itself.
  • Therefore, the goal of wound care in palliative care is to provide comfort and improve the quality of life for the patient, rather than to achieve complete wound healing.
  • Discussions with the patient and their family should emphasize that nonhealing wounds are often a result of advanced age paired with declining overall health and that the focus of wound care is on symptom management and comfort rather than complete healing (42-46). A good distribution of nursing staff over the units will likely improve the quality of wound care (8). Palliative wound care management strategies should be adopted to meet the whole-person care needs of terminally ill patients, as well as older and frailer people who often present with multiple comorbidities. A systematic review aimed to quantify the prevalence and incidence of pressure ulcers in patients receiving palliative care and identify interventions that may prevent or treat pressure ulcers (47). A palliative care approach to wounds should focus on symptom management, quality of life, and the patient’s goals of care (48-50).
  • The expectation of outcomes for wound ulcers in palliative care patients should be based on the individual patient’s goals of care, overall health status, and the stage of the wound.
  • The psychosocial effects of pressure ulcers, such as odor, exudate, and pain, can be severe and lead to various negative outcomes, including embarrassment, chronic tiredness, self-imposed social isolation, depression, and anxiety. To manage these adverse social effects of pressure ulcers, frequent assessment, and intervention are necessary. The NPUAP and the AHPR recommend initial and routine psychosocial assessments that involve consultation with individual patients and their families to discuss preferences, goals, and abilities. The objective of these discussions is to promote patient adherence to the pressure ulcer treatment plan. The psychosocial assessments may evaluate mental status, learning ability, depression, polypharmacy, values, lifestyle, sexuality, and culture, among other factors. Once treatment goals are set in alignment with these domains, it is important to routinely follow-up with patients and arrange interventions, such as counseling and educational resources, as necessary (48-52).

Topical management of chronic wounds

The goal of local treatment is to lessen discomfort and itching, prevent infection and bleeding from the wound, and address the most difficult chronic wound issues that have a negative psychological and physical impact on the patient, like excessive exudate that can produce unpleasant odors. Local management for chronic wounds includes debridement and appropriate wound dressings, just like for acute wounds (53-55). Non-viable tissue or necrotic material should be removed quickly. The wound bed must be properly cared for in order to be ready to accept a skin graft, flap, or closure when necessary (Table 2) (56).

Odor: the microbial bioburden on the wound surface can be reduced with periodic mechanical debridement, topical antimicrobial medication (such as metronidazole), and/or odor-absorbing dressings, such as those that contain absorbent charcoal (e.g., Actisorb, Carboflex) (57,58). Dakin solution, hypochlorous acid, or diluted acetic acid soaks can also lessen odor. It is not advised to regularly utilize possibly locally cytotoxic substances for an extended period of time, such as Dakin solution (59).

Bleeding: to stop bleeding and lessen discomfort brought on by dressing changes, a nonadherent dressing can be applied directly to the friable wound. Bleeding can be reduced further by applying a second layer of coagulant-containing alginate dressings (60).

Chronic wounds that are prone to oozing from the ulcer bed (such as malignant wounds that cannot be excised) can be managed with topical hemostatic agents or sucralfate and gentle pressure in the form of elastic bandages (38). Focal points of bleeding can be treated with silver nitrate, handheld cautery, or local anesthetic with epinephrine.

Pruritus: chronic wounds may cause itching as a symptom. Dry or damp skin, as well as contact dermatitis, are the usual causes of itching and irritation. Itching and skin irritation can be lessened by maintaining a healthy moisture balance, protecting the skin, and, if necessary, using topical corticosteroid treatments (61).

Exudate—an absorptive dressing, which should be adapted to the precise anatomic position and wound depth, should be applied over the nonadherent dressing to control drainage, lessen peri-wound maceration, and manage the amount of exudate in the wound. If there are no contraindications, wound drainage can also be removed using a collecting device (such as an ostomy appliance or a negative pressure wound therapy device). Exudate-absorbing topicals, such as cadexomer iodine and medicinal honey formulations, may be useful in clearing the wound surface of light to moderate exudate (62-68).

Pain—it’s important to pay attention to any pain that comes with the wound, especially when changing the dressing. Other types of chronic pain can be managed using the World Health Organization’s analgesic ladder, which was created for the treatment of cancer-related pain (44). Supplemental dosages of a short-acting drug should be taken into consideration before dressing changes for patients who take steady doses of a long-acting opioid continuously. Although they can be utilized, topical or local anesthetics may only have a modest impact.

Systemic management for wound ulcers

Systemic treatments for wound ulcers in palliative care aim to alleviate physical, psychological, and emotional suffering in patients at any stage of their illness.

Total pain management is essential in the management of malignant wounds, and early palliative care referral is crucial.

Pain is one of the most common and distressing symptoms in patients with malignant wounds, and it is often inadequately treated.

The remaining 30% of wounds encountered in palliative care are a mix of various wound types, including surgical, stasis, skin tears, and tumor.

When healing is not an expectation, outcomes might include pain reduction, exudate management, odor management, and/or other quality-of-life benefits to wound care.

There are various systemic treatments for wound ulcers in palliative care, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and adjuvant medications.

Opioids are the cornerstone of pain management in palliative care, and they are effective in treating moderate to severe pain.

NSAIDs are useful in treating mild to moderate pain and inflammation. Adjuvant medications, such as antidepressants, anticonvulsants, and corticosteroids, are used to manage neuropathic pain, anxiety, and depression (69-72).

Antiseptic and antimicrobial agents: in some patient populations, topical antimicrobials have the potential to be beneficial (73).

Iodine-based—cadexomer iodine (such as Iodosorb), an antibacterial, lowers the number of microorganisms in the wound and promotes healing by creating a moist environment (74,75). Bacteriocidal to both gram-positive and gram-negative bacteria is cadexomer iodine. There is some evidence that cadexomer iodine produces greater healing rates for topical medicines than usual care, however, this should probably only be taken into consideration for short-term use (76).

Although silver is poisonous to microorganisms, silver-based dressings have not shown any appreciable advantages over conventional topical wound dressings (Table 2) (77-79).

Honey—since ancient times, honey has been used to treat wounds. Honey’s high osmolarity and high concentration of hydrogen peroxide provide it with broad-spectrum antibacterial action (79,80). Today, adhesive, alginate, and colloid dressings can be impregnated with medical-grade honey in the form of a gel or paste.

Wound dressings

A lack of clinical evidence makes the choice between the various kinds of wound dressings more difficult. The following broad guidelines for managing chronic wounds are supported by the majority opinion.

Hydrogels for the stage of debridement. Low-adherent dressings keep the granulation stage’s moisture balance in check (81). Wounds that are occluded heal up to 40% faster than unoccluded wounds. This is believed to be caused in part by epidermal cells migrating more easily in the moist environment produced by the dressing (82).

Alginates

Alginates have various benefits, including the ability to increase hemostasis, the ability to be utilized for wound packing, the majority of which may be removed with ordinary saline to lessen discomfort during dressing changes, and the ability to remain in place for several days (8). Alginates have a number of drawbacks, including the need for a secondary dressing that must be removed in order to monitor the wound, the potential for excessive drying on a wound with little exudate, and a disagreeable odor (Table 2) (83).

Hydrogels

Hydrogels are sheets, gels, or foams made from a variety of synthetic polymers that contain >95% water and are typically sandwiched between two sheets of releasable film. The outer layer of the dressing can be taken off to make it fluid-permeable, with the inner layer being applied to the wound. A supplementary sticky dressing is occasionally required (84). Depending on how hydrated the tissue around them is, these special matrices have the ability to either donate or absorb water (85). The best uses for hydrogels are on dry wounds (86). They begin by lowering the temperature of the area around the wound they are covering, which offers some patients cooling pain relief. Hydrogels have been discovered to specifically allow gram-negative bacteria to proliferate, which is a drawback even if there haven’t been any reports of increased wound infection (87).

Hydrocolloids

Hydrocolloid dressings typically consist of a gel or foam on a polyurethane film carrier. This dressing’s colloid nature retains exudate and produces a moist environment (56). Another kind of gentle, painless mechanical debridement involves trapping debris and bacteria, which is then rinsed away with dressing changes. The ability to use hydrocolloids for wound packing is another benefit. Malodor and the potential need for daily dressing changes are drawbacks (63).

Hydroactive

The most recently created synthetic dressing, called Hydroactive, is a polyurethane matrix with characteristics of both a gel and a foam. Water that is too much is selectively absorbed by Hydroactive, leaving behind growth factors and other proteins (64).

Foams

Film dressings with the addition of absorbency are what foam dressings are (65). They are made of two layers: a hydrophilic silicone or polyurethane-based foam that adheres to the surface of the wound, and a hydrophobic, gas-permeable backing that guards against leakage and microbial contamination. A supplementary adhesive treatment is necessary for some foams. Marketing for foams goes under names like Allevyn, Adhesive, Lyofoam, and Spyrosorb (66).

Films

Transparent synthetic self-adhesive sheets called polymer films are impervious to bigger molecules like proteins and bacteria but permeable to gases like oxygen and water vapor. This characteristic permits insensible water loss to evaporate, traps enzymes in wound fluid, and shields against bacterial invasion. These dressings’ benefits include their capacity to retain moisture, promote quick reepithelialization, and possess transparent and self-adhesive qualities. Film dressings have a limited capacity for absorption and are inappropriate for moderately to severely exudative wounds (67).

Enzymatic debriding agents

Enzymatic debriding agents are chemicals that are used to clean open wounds by removing foreign material and dead tissue so that the wound heals without increased risk of infection. Enzymatic debridement is a highly selective method of wound debridement that uses naturally occurring proteolytic enzymes manufactured by the body or applied topically to the wound (Table 3).

These agents are approved by the US Food and Drug Administration (FDA) for the debridement of chronic wounds and burns and are generally pain-free to deliver (81-85).

Enzymatic debridement is a slow method of debridement, and may be combined with a variety of other methods, such as mechanical and sharp debridement.

Collagenase is a commonly used proteolytic enzyme in enzymatic debridement and is selective for collagen.

It works by digesting the collagen in the necrotic tissue, allowing it to detach. Enzymatic debridement is not recommended for advanced wounds or in patients with known sensitivity to the product’s ingredients (82).

Collagenase is a water-soluble proteinase derived from Clostridium histolyticum, which is indicated for the enzymatic debridement of necrotic tissue in the treatment of severe burns and dermal ulcers. Collagenase is unique because it specifically hydrolyzes peptide bonds and digests all triple helical collagen, but it will not degrade any other proteins lacking the triple helix.

It has been shown in in vitro and in vivo studies to liquefy necrotic tissue without damaging granulation tissue. Collagenase digests the lower portion of an eschar, working from the bottom up, so it appears to work more slowly than other debriders. Collagenase-based enzymatic agents may remove substrates necessary for bacterial proliferation or may afford antibodies, leukocytes, and antibiotics better access to the infected area (83).

Clinical advantages of collagenase-based products include selective removal of dead tissue, painless application, enhanced proliferation and migration of keratinocytes, and minimal blood loss.

Papain is a proteolytic enzyme derived from the fruit of the papaya tree, which breaks down fibrinous material in necrotic tissue.

It requires the presence of sulfhydryl groups found in such tissue to stimulate activity, and it does not digest collagen. The addition of urea helps expose the activators of papain in necrotic tissue by altering the three-dimensional structure of proteins and disrupting hydrogen bonding (86).

In human comparative studies, the combination of papain and urea has been found to be approximately twice as effective at digesting protein compared with papain alone.

However, papain use is known to produce an inflammatory response in vivo, and some patients experience considerable pain with its use.

The addition of chlorophyllin has been found to reduce pain. Hydrogen peroxide solution, as well as salts of heavy metals such as lead, silver, and mercury, may inactivate papain.

Papain-based products should be applied daily with a moisture-retentive dressing, which allows patients to maintain activity without disturbing the wound.

However, papain-urea preparations produce more exudate when digesting eschar, which may irritate the surrounding skin.

According to one practice guideline reviewing the manufacturer literature, papain-urea preparations are generally well tolerated and non-irritating.

Ayello and Cuddigan published practice guidelines reviewing collected research that suggests papain-urea affects the biologic activity of recombinant human platelet-derived growth factor-BB.

They note that papain breaks down proteins containing cysteine and reminds clinicians that growth factors contain cysteine residues. Thus, they dispute the manufacturer’s claims that papain-urea is harmless to viable tissue (87).

Pain management

Pain is a common symptom associated with fungating wounds, and effective pain management is essential to improve the patient’s quality of life (25). Pain associated with wound ulcers can be managed with analgesics and other pain management strategies (8). Pain associated with wound ulcers can be managed in palliative care through various approaches, including pharmacological and non-pharmacological interventions. Here are some ways to manage pain associated with wound ulcers in palliative care.

Pharmacological interventions:

Opioids are the cornerstone of pain management in palliative care, and they are effective in treating moderate to severe pain (26).

NSAIDs are useful in treating mild to moderate pain and inflammation.

Adjuvant medications, such as antidepressants, anticonvulsants, and corticosteroids, are used to manage neuropathic pain, anxiety, and depression.

Non-pharmacological interventions: massage therapy, music therapy, and relaxation techniques can be effective in managing pain and improving the quality of life in palliative care patients (28).

As palliative wound treatment is generally not curative, a localized, noninvasive, and pain-minimizing approach to moisture control, cleansing, and debridement is recommended.

Total pain management is essential in the management of malignant wounds, and early palliative care referral is crucial.

Odor management

Odour management is an essential aspect of wound care in palliative care. Malodour and exudate associated with malignant wounds are often the symptoms most detrimental to quality of life reported by patients (30). Strong wound odours can lead to social and physical isolation, alter patient body image and self-worth, and can challenge caregivers (31). Assessment of odour is subjective and includes patient self-assessment and reports from family, carers, and clinicians. The use of standardized tools, such as the Malodour Assessment Scale, can help to quantify odour and monitor the effectiveness of interventions. Wound cleansing is an essential aspect of odour management. The use of antimicrobial agents, such as metronidazole, can help to reduce bacterial load and odour. The use of dressings that absorb exudate and contain odour, such as activated charcoal dressings, can help to manage wound odour. However, it is important to note that some dressings may cause pain and discomfort in patients. Topical agents, such as essential oils, can be used to mask odour and improve the patient’s quality of life. However, it is important to note that some patients may be sensitive to these agents, and they should be used with caution. Total pain management is essential in the management of malignant wounds, and it can also help to manage wound odour. The use of opioids and adjuvant medications, such as antidepressants and anticonvulsants, can help to manage pain and improve the patient’s quality of life. Assessment of odour, wound cleansing, dressings, topical agents, and total pain management are some strategies that can be used to manage wound odour in palliative care. It is important to note that wound care should be individualized based on the patient’s needs and preferences.

Psychological support

Psychological support is an important aspect of wound ulcer care in palliative care. Palliative care aims to provide patient-centered care that addresses the physical, emotional, and spiritual needs of patients and to help them achieve the best quality of life possible (43).

This includes providing psychological support to patients with wound ulcers. Patients with fungating wounds may experience significant psychological distress, including anxiety, depression, and social isolation. Psychological support, such as counseling or support groups, can help alleviate these symptoms. Spiritual support: patients with fungating wounds may also experience spiritual distress, and spiritual support can help address these concerns (44).

Multidisciplinary approach

A multidisciplinary approach involving healthcare professionals such as wound care specialists, palliative care physicians, nurses, and social workers is important for the effective management of wound ulcers in palliative care.

It is important to note that wound care needs to be simplified to a point where it can be delivered mainly by the patient and his/her family.

Telemonitoring may also help reduce the frequency of in-person visits and improve patient outcomes (13).

Conclusions

As our population ages, the principles of palliative wound care are increasingly important. Clinicians encounter patients with complex wounds due to multiple comorbidities and local factors. It is crucial to maintain high-quality wound care when a patient enters a palliative care pathway. By managing both wound symptoms and psychosocial patient concerns, the negative impact of living with a chronic wound can be minimized, and the patient’s quality of life can be increased. However, access to advanced wound care is a significant barrier for patients who would benefit the most. Therefore, alternative models of care, such as home visits, telemedicine, and concierge medicine, are needed to support patients aging in place and allow them to maintain their quality of life for as long as possible. In summary, psychological support is an important aspect of wound ulcer care in palliative care. It can help patients cope with the emotional and psychological impact of wound ulcers, improve their overall quality of life, and motivate them to take steps to prevent pressure ulcers.

The amount of literature examining the use of palliative care for patients with chronic wounds is still quite little. Standardizing and improving the delivery of palliative care therapies to patients with chronic wounds still requires more work.

The remaining knowledge gap in the field relates to the best moment to apply palliative care principles to the treatment of patients with chronic wounds, as well as whether palliative care professionals or surgeons would be more qualified to provide this kind of care for a given patient.

In this narrative review, there are also some limitations. As it is a narrative review, it does not typically include a statistical analysis of the studies included. This can limit the ability to draw conclusions about the effectiveness of interventions. In conclusion, while narrative reviews can provide a comprehensive overview of wound management in palliative care, they also have limitations, including limited search strategy, lack of quality assessment, lack of statistical analysis, limited generalizability, and limited depth of analysis. To overcome these limitations, future reviews should use a systematic search strategy, including a quality assessment of the studies included, perform statistical analysis, and provide a detailed analysis of the underlying biology of the interventions. This narrative review may not be generalizable to all populations or settings. This can limit the applicability of the findings to specific patient populations or care settings.

There have been also very few contributions to the literature in the fields of communication and decision-making. The pinnacle of palliative care research, the alignment of wound management in palliative care with patient-oriented outcomes, is not discussed in any of the articles found in our review. Exploring trustworthy methods to allow goal-concordant treatment for surgical patients will require more research. Our analysis has limitations similar to any narrative review, including the possibility that articles were missed despite a thorough search across several databases and citation searching with the manual assessment of specific high-yield journals. In order to provide care that is goal-concordant, guidelines and best practices must be established as therapies to support seriously ill patients with chronic wounds continue to advance. Despite recommendations for greater research on this patient group, it is still unclear which patient populations with chronic wounds benefit from palliative care interventions and how such interventions might be used most effectively because there is a dearth of information in the body of existing literature.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Marios Papadakis) for the series “Palliative Reconstructive Surgery” published in Annals of Palliative Medicine. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-23-138/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-23-138/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-138/coif). The series “Palliative Reconstructive Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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