Wound Series Part 5: Terminal Wounds: When Complete Healing is not an Option

• Minimize wound enlargement if possible:
  • While minimizing wound enlargement is a typical goal for non-cancerous wounds, this may be an unrealistic expectation with some cancerous skin lesions. However, minimizing skin erosion due to exudate-related skin breakdown to the surrounding skin IS a reasonable management goal, as well as addressing pain, bleeding and odor (Emmons & Dale, 2016).
• Protect periwound skin (prevent or reduce periwound skin breakdown if possible):
  • Protecting the periwound skin may be accomplished by a variety of options, including the selection of wound dressings appropriate to absorb the anticipated amount of wound exudate, applying a liquid moisture protective barrier (skin barrier wipe or spray) or moisture barrier cream or ointment (such as a petrolatum-based ointment, silicone polymer, dimethicone, or zinc oxide cream). Applying a hydrocolloid may be an option to "window the wound" (apply to all of the peri-wound skin up to the skin edges), forming a protective barrier on which to secure other dressings (Woo et al., 2015).
  • If hydrocolloid is used to window the wound, applying a protective skin barrier (wipe or spray) and allowing it to dry first before applying the hydrocolloid can help protect the skin from damage when removing the hydrocolloid. With regards to fistulas within the wound, hydrocolloids may also help protect the periwound skin and provide a base on which to apply fistula management systems or ostomy pouching appliances - depending on the location of the wound and fistula, and if the moisture could be contained in some way - such as isolating the fistula with ostomy management supplies, and applying ostomy seals (waxy strips, paste, or rings to seal edges of appliances and prevent leaking) to the edge of the hydrocolloid near the source of drainage. Controlling exudate from these cancerous lesions is often challenging, especially if it drains from a diffuse area (the whole lesion) (Emmons & Dale, 2016).
• Manage wound-related moisture/exudates:
  • Managing wound moisture for Mr. Smith could include using a liquid skin barrier to the surrounding skin (or other moisture barrier cream or ointment as mentioned above) if the liquid skin barrier is unavailable. Following that, applying a super absorbent layered primary dressing held in place with a non-traumatic securing device such as a silicone (gentle adherent) border dressing as a secondary dressing (making sure the skin liquid protectant is applied to the skin which the dressing's adhesive border will be applied to).
  • In this case, the primary dressing could be changed as needed as often as every 2 hours during the day, while re-using the secondary silicone securing dressing as warranted- changing at least daily. This could allow the patient more mobility. During the evening (or if the patient's drainage amount warrants it during the day), the wound drainage, especially fistula exudate, could be contained in an ostomy or fistula pouch (using an opaque pouch instead of a clear pouch to address the patient's aesthetic concerns). This drainage may be emptied by the patient or caregiver during the night if needed and could help prevent soiling of bed sheets and prevent maceration of periwound skin, as well as help prevent a secondary fungal infection from excessive moisture in the area (Woo et al., 2015).
  • If bleeding is a problem, calcium alginate should be considered a component of the primary dressing with direct contact with the wound, as this may help reduce any blood oozing from the wound. However, care should be taken to prevent dressings from adhering to the wound, potentially increasing the bleeding of these friable tumors when removed (Cornish, 2019). If frank bleeding occurs, a clinician could consider applying a silver nitrate stick or topical coagulant agents, which rapidly coagulate blood like gelling hemostatic foams or a topical application of liquid epinephrine (by a qualified clinician) on gauze or a cotton swab (Emmons & Dale, 2016).
• Minimize secondary infection (bacterial and fungal):
  • Minimizing secondary infection and reducing exudate odor could both be addressed by several approaches. First, ensure potential bacterial sources are minimized or eradicated (external contaminants, poor hygiene, poor technique with wound care, inadequate clean storage of dressing supplies, expired materials, etc.). Treating infection is often not considered an option for patients in palliative care. Still, if the infection causes pain, further skin/wound breakdown, or decreased quality of life, it is appropriate to address it (Cornish, 2019).
  • Bacteria often cause unpleasant odors, so removing bacteria and necrotic tissue (that bacteria may attach to) as much as possible is useful. When appropriate, these approaches could be considered: enzymatic ointments such as collagenase, surfactant gels, larval debridement therapy, and careful surgical removal by a qualified clinician. Also, cleansing the bacteria away regularly by washing/irrigating the wound with clean water, wound cleansers, saline, or an antimicrobial solution (such as <10% povidone-iodine solution or weak <0.025% sodium hypochlorite solution), and changing soiled linens, clothing, and wound dressings promptly should be considered (Cornish, 2019).

• Decrease unpleasant odors associated with the wound:
  • Using dressings that contain activated charcoal can reduce odor, as can applying topical metronidazole ointment directly to the fungating wound. Some studies report limited success with topical silver and manuka honey-coated wound products (Emmons & Dale, 2016). Additional ways to minimize odor in the room is to place a pan of odor absorbing or neutralizing kitty litter on the floor or shelf near the bed and change the litter regularly. Baking soda on a window sill or odor-absorbing/neutralizing electronic air fresheners are additional options. Note: Many patients with cancer or odor sensitivities may not appreciate air fresheners that cover up the unpleasant odor with a stronger odor (so take care to look for odor neutralizing ones, not just fragranced air fresheners).
• Address wound pain:
  • Wound pain is a concern for this patient because he reports his pain to be an "8 to 10" on a scale of 1 to 10. He reports only taking acetaminophen and reports, "it does not do much, but I do not want to get hooked on pain meds." When asking about pain medication, do not forget to ask the patient if there is anything else he does or takes (eats, drinks, smokes, or alternative medicine) that helps relieve his pain. His understanding of his medical condition, prognosis, expectations of care, and pain treatment goals are important to explore with the patient (and family if appropriate) and discuss with his team (Cornish, 2019). 
  • Self-medicating with alcohol, marijuana, or other street drugs is something people may be more apt to try if individuals are terminal or have previously tried it. You would need to know for several reasons.
    • Does it work?
    • How much, and how often?
    • Does he drive or operate machinery while under the influence?
    • Could it pose a risk of greater harm to himself or others?
    • Would it potentially interact with any other pain treatments/medications?
    • Is a referral to a Pain Management specialist warranted, desired by the patient, or feasible in this situation?
  • The healthcare provider may also ask if the patient has or would like to consider adding alternative treatments such as massage therapy, art in medicine, acupuncture, or acupressure. Some evidence suggests they may help reduce self-reported pain and an increasing sense of well-being in cancer patients (Vickers et al., 2018).
• Psychosocial concerns (including aesthetic considerations to minimize feelings of social isolation):
  • Special considerations for managing the care of this individual: When addressing the most common issues with these types of wounds, it is critical to consider the patient's (and family member's, if appropriate) preferences, physical abilities, and emotional needs. It is also important to consider their functional abilities and care environment, ask the patient about their perceptions of the wound/wound care, allow discussion of their feelings, and offer choices based on this input during management planning (Cornish, 2019). A multidisciplinary approach is recommended (Cornish, 2019). Furthermore, this patient portrayed in the case scenario is at high risk of depression and possible suicide, which his multidisciplinary health care team should address (Alexopoulos et al., 2009).
  • The patient's Veteran status, presence of guns in the house, recent social isolation, possible feelings of helplessness/hopelessness, and terminal diagnosis make this case a particularly dangerous situation for the patient. At the first possible opportunity, the patient should be asked by a qualified individual (suicide prevention trained social worker, mental health professional, nurse, physician, therapist, etc.) about any suicide ideations and be encouraged to let a trusted friend take possession of any guns or weapons in the house, speak to a mental health professional to formulate a plan to help strengthen his coping skills and post the Veteran Crisis line on or near his phone. (Ganz & Sher, 2013). The National Suicide Prevention Lifeline is 1-800-273-8255 (Veterans should press 1 for the Veterans Health Administration hotline) (Tsai et al., 2019).
  • He should also be encouraged to participate in regular phone follow-up calls with a health care provider team at his local VA and perhaps consider getting involved in a support group for terminal cancer patients near him (Steeg et al., 2013). His local church or some Veteran's groups may be a potential support source if the patient allows them. If his clinical wound treatment plan included measures to help him feel less uncomfortable about his wound/tumor with visitors, this might help increase social support for this Veteran. If the patient does express any suicide ideations (for instance, has a suicide plan), it should be considered a medical emergency, with prompt intervention as warranted (e.g., call 911, do not leave the patient alone, and remove any means of self-harm such as guns or pills if at all possible) (Ganz & Sher, 2013). 

• Minimize wound enlargement if possible:
  • Taking aggressive steps to prevent further amputation of Mr. Simpson's right lower leg is imperative to decrease his mortality risk and improve his quality of life (WOCN, 2019).  The right lower leg is likely the one he uses for most transfers if his mobility is limited to a chair/wheelchair. With arterial ulcers, some of the main ways the wound could enlarge are through infection, increasing ischemia, repetitive trauma, or deterioration of the patient's overall health or nutritional status. While enlargement of the wound due to some of these factors may be prevented, and others may not, each of these factors should be considered (Sussman and Bates-Jensen, 2012).
  • Mr. Simpson's recent great toe amputation of the right foot for osteomyelitis is of concern if that surgical wound does not heal or if there is any exposed bone in that toe or the proximal portion of the gangrenous toe. Exposed bone or the ability to probe to the bone through a wound opening is predictive of osteomyelitis even in the absence of acute signs of deep infection (WOCN, 2019). Who is following up on Mr. Simpson's surgical site wound? Whether vascular surgery, orthopedic surgery, or podiatry performed the amputation, it is recommended to keep them appraised of the current condition and see if they will make an outpatient appointment for regular follow-up until the gangrenous toe and the right great toe amputation site are resolved.
  • Mr. Simpson's smoking is one factor impacting his tissue perfusion and ischemia that could be modified (WOCN, 2019).  Notably, he can only smoke one cigarette daily due to his residency in a long-term care facility. Exploring barriers to help Mr. Simpson stop smoking altogether is important. The 2014 WOCN Guidelines for the Management of Wounds in Patients with Lower-extremity Arterial Disease (LEAD) recommends, "Smoking cessation should be encouraged for patients with lower extremity arterial disease/arterial ulcers." Smoking cession "slows the progression of atherosclerosis and decreases the risk of cardiovascular events/death" (Level of evidence = B).
    • Does the facility have any programs on-site to help Mr.Simpson quit completely?
    • What are the reasons he still smokes?
    • Does he feel it is useless to stop?
    • Has he given up so much already that he feels he must retain this one last act of independence?
    • Exploring these questions can help you address the barriers and facilitators to quitting smoking.

• Minimize wound enlargement if possible (continued):
  • Mr. Simpson's left lower leg amputation is of concern because it increases his immobility, and he may be using his other leg for all transfers; therefore, he may be unable to stay off the leg/foot with the wounds. Is there a way for him to transfer that does not create repetitive injuries to any areas of the existing wounds or the rest of the foot? Assessing the arterial perfusion and sensation in the rest of the foot and taking measures to protect the foot from further trauma are vital for this patient (Schaper et al., 2019). Also important for wound healing and minimizing the progression of the existing wounds is to monitor his laboratory values, nutritional intake, and medications (WOCN, 2014). It is good that his labs and medications have remained stable and unremarkable for the last six months, but any change (addition of steroids or non-steroid anti-inflammatory medications, for instance, could have a negative impact on his wound healing) (Schaper et al., 2019).
  • His medications include daily oral Warfarin, with bi-weekly to monthly PT/INR blood tests being drawn, which remained in a therapeutic range for the past four months. Monitoring this is also important, especially if there is any consideration of surgically removing the gangrenous toe. He would have to be placed on another anti-coagulant for the surgery and possibly after surgery. His bleeding risk increases with any dressing or securing device that adheres to the wound or surrounding skin.
  • One of the biggest concerns with dry gangrene is to prevent it from evolving into a wet or "gas" gangrene (Al Wahbi, 2018). One non-surgical way clinicians may attempt to do this is to paint the gangrenous tissue with a drying/antimicrobial agent such as 10% povidone-iodine (if the patient is not allergic to iodine), spray products with balsam of Peru and trypsin, or skin protective barrier wipes/spray (typically containing alcohol, butenedioic acid, monobutyl ester, or polymer(s)). Any one of these products may be applied daily and let it air dry / keep it uncovered / open to the air or covered only with a light cotton dry gauze (non-occlusive) (WOCN, 2014).
• Protect periwound skin (prevent or reduce periwound skin breakdown if possible):
  • Mr. Simpson's skin is very dry, with only fair skin turgor. Working with a multidisciplinary team to approach the issue of adequate hydration for Mr. Simpson is important. With his history of CHF, he may be on fluid restrictions. Assessing the patient's knowledge and understanding of these factors is important to managing his care. His right great toe amputation site has some slight maceration at the inferior border up to 0.5cm away from wound edges. Only scant yellow/serous exudate is noted on the dry gauze dressing over this area.
  • Applying a skin protection barrier wipe to his periwound skin with each dressing change and using a gentle, non-abrasive dressing securing device (surgical netting, silicone tape, etc.) would be recommended to avoid any damage to the periwound skin due to maceration or with dressing changes. Caution is warranted with any wrap gauze or netting/sleeve securing device so that care is taken to not further impair circulation to the area. Making sure you are using an evidence-based wound dressing that meets the needs of his current surgical wound is important, as well as evaluating the tissue perfusion to these other wounds besides the dry gangrenous toe (WOCN, 2019).  Is there adequate tissue perfusion for healing these other wounds?
• Manage wound-related moisture/exudates:
  • Mr. Simpson's wounds are not draining a large amount, so managing wound-related moisture can be addressed, keeping these three things in mind:
    • Care of an open wound includes maintaining a moist wound bed.
    • Area(s) affected by gangrene should be kept as dry as possible.
    • Closed surgical wounds (closed incision sites with no openings in the surgical incision site) should also have a dry protective dressing if one is warranted (WOCN, 2019). Mr. Simpson's open granulating wound is at the incision site, but it has been 12 weeks since surgery, so this is no longer a fresh post-op closed the surgical incision. Rather, it is a chronic open wound (0.5 cm wide) that has some scant exudate. The parts of this open wound should be kept moist without harming the surrounding skin. A silicone interfaced wound dressing, petrolatum-based wound ointment or impregnated dressing may be options to meet that need (Woo et al., 2015).
• Minimize secondary infection (bacterial and fungal):
  • What is the temperature of the extremity? Literature suggests that colder temperatures that keep the affected extremity below normal body temperature may impair wound healing and promote bacterial growth in diabetic foot ulcers. Mr. Simpson's interdigit spaces (space between toes) appear dry and intact, which is good news. You will want to keep an eye on these areas to ensure they remain moisture-free (which promotes fungal growth). Look at the patient's toenails – is there evidence of onychomycosis (toenail fungal infection)? If so, this is common in diabetics and has been associated with an increased risk of fungal infection in the wound, and between the toes, so good skincare of the foot and especially between the toes is important (Schaper et al., 2019).
• Decrease unpleasant odors associated with the wound:
  • Mr. Simpson has no odor associated with his wound or exudate (drainage).
• Address wound pain:
  • Mr. Simpson denies any wound pain. Does he have pain elsewhere? Is he currently taking any medications (prescribed, over-the-counter, or other drugs) for pain elsewhere in his body? Assessing this is important. Evaluating the sensation in the foot and taking measures to protect the foot from further trauma is also vital for this patient (Schaper et al., 2019).
• Psychosocial concerns (including aesthetic considerations to minimize feelings of social isolation):
  • Mr. Simpson has been living in a long-term care facility for eight months, with no plans to return to independent living. How is he coping with this? He has no living family (a widower of 20 years and no children) and has had no visitors in the past eight months. This indicates a serious risk of social isolation (Cornish, 2019). When you talk with him, his affect is rather flat, although he brightens up when he talks about his wife and some of their trips abroad. Asking the patient what his goals are can be important at this point.
    • What are his goals for wound healing?
    • Are they realistic?
    • Is it feasible to attempt to reach any of these goals?
    • What are his goals for his care where he is at now?
    • Does he have any short-term goals (3 to 6 months) or one-year or five-year goals?
  • A multidisciplinary team approach to Mr. Simpson may include some steps to address his goals, come up with a treatment plan that is acceptable to him/considers his preferences and values, and decrease his social isolation (examples: arrange for volunteer visitors to come and talk to him about his travels, display some of his photos or personal effects related to happy memories around his room, encouraging a recreational therapist to meet with him regularly, explore ways to get him more involved in activities/hobbies, perhaps a short field trip to a location that interests him for a few hours).

• Minimize wound enlargement if possible:
  • Management goals for this occurrence at the end of life commonly focus on comfort and pain control (and rightly so). However, for any pressure-related skin/tissue damage, offloading or minimizing pressure and reducing friction and shearing forces should always be considered. Addressing both pains and pressure/shear reduction is a challenge, yet just because a patient is terminal does not mean clinicians should stop providing good skincare and attempt to minimize friction/shearing/pressure and moisture insults to the skin (Cornish, 2019).
  • In this case scenario, Mrs. Jones's skin is presently intact, and measures can be taken within the patient's advanced directives to minimize the risk of breakdown. For example, reducing friction/shear and moisture insults the skin (such as with incontinence). In addition, taking measures to minimize the risk of secondary skin infection (bacterial and fungal) by good skin assessments and skincare as tolerated by the patient is important. Applying a good skin moisturizing cream may help dry skin to be more supple and allows the skin to retain some suppleness, which can help skin resilience to external forces.
  • Furthermore, her nutritional status and indicators of poor hydration put her skin at a higher risk of breakdown for this patient. The bottom line is that her organs are failing (CHF and ESRD), and now it appears her skin is starting to fail. The skin is the largest organ in the body, and at the end of life, when other systems or organs fail, the skin is likely to fail as well (Doughty D, McNichol, 2016).  It may or may not be possible to prevent the enlargement/progression of this wound.
• Protect periwound skin (prevent or reduce periwound skin breakdown if possible):
  • To try and minimize wound enlargement/pressure ulcer evolution and protect the periwound skin: If the patient can tolerate it, a low air loss, alternating, or even foam/memory foam mattress may help redistribute some of the pressure in bed. Avoiding extended lengths of time sitting up in a chair or bed with the head of the bed elevated over 30 degrees would be an important consideration to reduce friction and shearing forces as well as concentrated pressure on the sacral/coccyx areas (Doughty D, McNichol, 2016).
• Manage wound-related moisture/exudates:
  • Mrs. Jones does not currently have any wound drainage.
• Minimize secondary infection (bacterial and fungal):
  • Consideration for managing any incontinence or excess skin moisture may help minimize the risk of skin irritation, further skin deterioration, or fungal infection. Avoiding powders in skin folds (which trap moisture) may also help reduce the risk of fungal infection (Doughty D, McNichol, 2016).
• Decrease unpleasant odors associated with the wound:
  • There are no unpleasant odors related to Mrs. Jones's skin discoloration/Kennedy ulcer.
• Address wound pain:
  • Some of the newer mattresses or mattress overlays have turn assist features that accomplish slight position changes in very small increments so as not to cause pain but be enough of a change in position to relieve some pressure. While the patient's comfort is paramount in palliative care, repositioning and offloading can be an important pain relief measure since a body that remains immobile for a long period tends to get still/sore. Timing all repositioning for 30 minutes AFTER pain medication is administered (to allow the medication to work) – instead of immediately before or within only a few minutes after administering the medication would be an important pain relief measure. In non-verbal patients, assessing grimacing and moaning during movement may indicate discomfort.
• Psychosocial and other concerns:
  • Documentation is an important part of the palliative care for these terminal individuals. Skin and wound care are important but are only one part of a total care plan for the whole patient. Improving the hydration status in a slightly dehydrated individual may improve their overall well-being. However in a "no-code" individual or someone with an advanced directive indicating they do not wish to have any life-extending measures, offering more fluid and nourishment is limited to what the patient wants (Woo et al., 2015).
  • This is very challenging for family members and health caregivers in a person with altered mental status. Therefore, the palliative care plan must be patient-centered (it is extremely valuable to have detailed advance directives drawn up while the patient is completely lucid before such documentation may be needed). At the same time, documentation must meet the facility, state, and organizational requirements. Ideally, when a patient enters into palliative care, a meeting with the patient, the patient's caregiver (CG) and family members are documented with the education provided to the patient and family about what palliative care is and what the care goals are for the patient under palliative care and what can be expected at the end of life (including skincare and potential skin changes at the end of life) (Woo et al., 2015).
  • The medical record should document the patient's clinical condition, comorbid conditions, pressure ulcer risk factors, skin assessment(s), and interventions (consistent with the patient's/family/CG wishes as appropriate per state laws and evidence-based guidelines). The documentation should also report the patient's response to interventions (Krasner, 2014).
  • Controlling wound-related pain is a high priority, and using foam wedges and positioning pillows that can minimize pressure to boney prominences, including at the heels and knees, hips, elbows, shoulders, scapula, spinal vertebra, and occiput as well as sacrum and coccyx helps to reposition as well as provide comfort. Using silicone sheeting or silicone border wound dressings over sacral areas to prevent Kennedy Terminal Ulcers or SCALE (intact skin lesions) is somewhat controversial. They may be used more frequently in intensive and long-term care to prevent pressure or friction/shear-related injuries (Grigson et al., 2016). Still, some more research is warranted related to any potential they have in preventing SCALE lesions (especially if most SCALE lesions are unavoidable due to skin failure). As there is currently no strong evidence to support or refute that they may be helpful, clinicians are urged to review the literature and make decisions based on their clinical judgment.
  • These silicone border dressings tend to be large, butterfly-shaped, self-adherent dresses with a silicone interface and some foam padding. Some experts feel they may help provide an extra measure of protection and reduce shearing forces over sacral areas and may be left in place for several days (5-7 days) if unsoiled, but the silicone interface allows for the clinician to lift and daily assess the skin underneath the dressing and replace it in place easily (Hess, 2013). Once it is moist or soiled, it should be removed/replaced (see below for one example of this type of dressing).

Example of silicone dressing
Photo source: molnlycke.co.uk