Participants will identify key considerations when managing terminal wounds or wounds not expected to heal.
After completing this continuing education course, the participant will be able to meet the following objectives:
When an individual exhibits a wound (injury, surgical incision, etc.), the treatment goals typically include complete wound closure and wound healing. Furthermore, the healing trajectory is anticipated to follow established pathways or phases: Hemostasis, Inflammation, Proliferation, and (in full-thickness wounds) Scar Maturation or Remodeling. However, in complex and chronic wounds such as many diabetic foot ulcers, venous leg ulcers, pressure ulcers, where healing is delayed, this expected pathway is interrupted and wounds may get "stuck" in a chronic inflammatory state (please see more complete descriptions of these phases in Leaper et al., 2014 or other parts of the CEUFAST, Inc. Wound Series).1 Nevertheless, even in these chronic wounds, the treatment goal is typically complete closure and healing or resolution of the wound.
What about wounds we do not expect to heal, or where complete closure or resolution is not an option? Wounds such as non-operable malignant tumors protruding from the body of individuals with a terminal illness, non-healing wounds due to arterial insufficiency where surgical revascularization is not an option because of severe comorbid conditions, or pressure ulcers at the end of life due to skin failure (often called Kennedy Terminal Ulcers)? What should the treatment outcome goals be in these wounds?
Using fictitious case scenarios built from the author’s clinical experiences with real patients, this course will focus on palliative wound care measures and wound treatment options where the desired wound management goal is something other than complete resolution or closure of the wound. Specifically, this course will provide treatment considerations and potential options to prevent or minimize wound enlargement and/or periwound skin breakdown, decrease unpleasant odors associated with the wound, manage wound-related moisture, address wound pain, consider how to help the patient aesthetically (to minimize their feelings of social isolation and improve quality of life), and suggest other useful management tips regarding some of these challenging wounds. The photos in this course were taken from the internet because of the similarity in appearance to what could be seen with the case scenarios (no photos or actual clinical information were taken from the author's clinical case files, to protect patient privacy).
Mr. Smith is a 62-year-old male with a protruding 6cm irregularly -shaped tumor on his left cheek, which is inoperable. His comorbid medical conditions include diabetes mellitus type II (DMII), hypertension, obesity, and malignant melanoma of the right cheek (with systemic metastasis to other organs). Although this case scenario is a fictitious patient, the photo below represents what his tumor may have looked like before opening up as fistula at the inferior border (at 4 o’clock) on the photo - involving the mucous membrane of the mouth.
Image of tumor
Photo source: intranet.tdmu.edu.ua
Other relevant medical information about Mr. Smith includes:
Laboratory values: Hemoglobin (Hgb) 11.1 / Hematocrit (Hct) 42.0; White blood cells (WBC) 9.8; Electrolytes were all within normal ranges. Hemoglobin A1c (HgbA1c) 6.9; Fasting blood sugar 135.
Mr. Smith’s medications include: Metformin 500 mg (milligrams) orally twice a day, a baby aspirin (81 mg) orally once a day, atenolol 50 mg orally once a day, and a multivitamin once a day. He reports taking acetaminophen 500 mg orally every 4 to 6 hours as needed.
Pertinent social information: Mr. Smith had a girlfriend he lived with for more than ten years, but she left him after his cancer diagnosis, saying she "couldn't stay around to watch him die." He lives at home alone and is a Veteran with a history of having served two tours of combat duty. He also reports having several guns at home. Nothing is known about any history of post-traumatic stress disorder (PTSD), and the patient states he has not received care at his local VA, stating only that he "has closed that chapter of his life." He has home care nurses who visit him daily for wound care; otherwise, he cares for his wound himself.
Mr. Smith has had only one social visitor from his local church, but the patient asked them not to come back. When asked, “Why?” he said he was embarrassed by the wound odor, appearance, and amount of drainage that he kept having to deal with during the visit. He has not left his house except for doctor's office visits and grocery shopping at a 24-hour grocery after midnight to minimize how many people see him.
Other clinical information and wound description: Mr. Smith’s weight is 175 lbs.; his height is 5’ 10”; his vital signs (blood pressure or BP, pulse, respiration, and temperature) are all unremarkable. The patient complains of pain at the tumor site and inside of mouth near the tumor site at "8" on a scale of 1 to 10, which is constant and "achy" most of the time, but occasionally he experiences a sharp jabbing sensation.
The physical exam also demonstrated Mr. Smith would not often make eye contact and was holding a folded towel against his right cheek near the tumor for exudate control. The tumor is protruding from his right cheek, approximately 3.0cm at the apex of the tumor. The size of overall tumor/lesion is 6.0cm at longest axis x 4.0cm at widest axis and is irregularly shaped with periwound redness and irritation and erosion at inferior border around the 4 o’clock position (using the body as a clock, think of the head always at 12 o’clock and the feet always at 6 o’clock). This area now has an open wound, which has been defined as a fistula tracking to and involving the mucous membrane of the mouth, currently draining copious amounts of clear to brownish liquid (slight sour odor from exudate). Mr. Smith also complains it feels “raw” (very painful to touch) at the inferior border. Chewing on that side increases pain sharply (“up to a 10” on a pain scale of 1 to 10), cold compresses seem to provide minimal and temporary relief (pain level is “3 or 4” on a scale of 1 to 10 when he has the most relief).
Pathophysiology of malignant fungating tumors: In some patients with advanced cancer, a tumor may protrude through the skin, which may or may not be operable. Some studies suggest that 5 to 19% of all patients with a diagnosis of malignant neoplasm will develop a metastatic cancerous skin lesion.2 A great percentage of metastatic breast cancers may result in cutaneous wounds on the breast/chest. Metastatic cutaneous lesions may be ulcerous lesions (tend to look like craters) or fungating.
Fungating lesions result from the infiltration of malignant cells into the skin, surrounding lymph vessels, and supporting blood vessels. They tend to have a nodular or cauliflower-like appearance that sits above the surrounding skin level. Approximately 62% of all fungating wounds will be found on the breast, and 24% of all fungating wounds will be related to head and neck cancers.3 Pain, bleeding, persistent exudates, and odor are the most common complaints reported with malignant cutaneous lesions.4 Still, these wounds also produce a great deal of emotional stress for patients and their caregivers due to the appearance of the wound.3 These cancerous lesions may bleed easily (friable) because of the vascular involvement in the tumor, which often results in a poorly organized growth of new blood vessels within the tumor cells, which tend to leak.5
Mr. Simpson is a 74-year-old man with a history of Type II Diabetes Mellitus and arterial insufficiency to the right lower extremity. He also has an active diagnosis of congestive heart failure (the last hospitalization for CHF was over eight months ago) and peripheral vascular disease, as well as a history of a stroke two years ago with some slight residual left-sided weakness. He had previously experienced a left lower leg (below the knee) amputation for arterial insufficiency two years ago and a right great toe amputation for recurrent diabetic foot ulcer to the first metatarsal head and osteomyelitis 12 weeks ago. He now presents with non-healing wounds to his right foot and dry gangrene to his right 4th toe - due to arterial insufficiency. Surgical revascularization is not an option because of his severe comorbid conditions.
Other relevant social and medical information includes: Mr. Simpson lives in a long term care facility (for eight months, with no plans to return to independent living) and has no living family (being a widower of 20 years and no children). He is a smoker (1.5 packs per day for over 30 years), though currently he is limited to smoking only outside at the long term care facility when he can be taken out to the porch by a staff member (approximately once a day). He has had no visitors in the past eight months, and his affect is rather flat, although he brightens up when he talks about his wife and some of their trips abroad. Laboratory values and medications have remained stable and unremarkable for the last six months. His medications include daily oral Warfarin, with bi-weekly to monthly Prothrombin Time and International Normalized Ratio (PT/INR) blood tests being drawn, which remain in a therapeutic range for the past four months.
Other clinical assessments and wound description:
Image of dry gangrene
Photo Source: wikimedia.org
Mr. Simpson's left lower leg amputation stump is well-healed with no skin breakdown noted. Overall, Mr. Simpson's skin is very dry, with only fair skin turgor. His right great toe amputation site still has a linear 3cm long x 0.5cm wide wound at the old incision site with pink, slightly hypergranulating tissue noted and some slight maceration to 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. There is a small 0.7cm round dry, a scabbed area noted to the inside aspect of his 2nd toe proximal to the foot. The interdigit spaces appear dry and intact, but the tip of the 4th toe is black and shriveled with dry gangrene. No exudate is noted from the 2nd toe nor the 4th toe. He denies any wound pain.
Pathophysiology of non-healing arterial ulcers and dry gangrene: As could be surmised from the term "arterial insufficiency" or "arterial ulcer," These skin lesions are the result of a lack of adequate blood flow to intact or injured skin. Small blood clots in the microvasculature (small blood vessels), narrowing of these vessels due to plaque or factors which constrict blood vessels, and lack of power behind the "pumping" action of the heart (as in CHF or with very low cardiac ejection fractions) impairs blood flow and oxygenation to distal extremities such as feet and toes. This not only impairs the ability of these areas to heal but also may cause skin injury (the skin and tissue die due to lack of oxygen and lack of adequate nutrient and waste transport to/from cells). In many cases, the initial damage may be reversible with revascularization surgery or procedures aimed at restoring adequate blood flow. However, in time, if not corrected, skin and tissue damage may become irreversible.8, 23, 24
Gangrene is the term given to the tissue necrosis (irreversible death) which occurs due to significantly reduced blood supply. Gangrene may occur due to injury, complications of diabetes, arterial insufficiency, infection, or other health conditions. Gangrene is classified as dry, wet, and gas gangrene. In dry gangrene, it is desirable to keep it dry (not to ever apply moist dressings over this), as it may progress to wet and then gas gangrene (so noted due to gases typically produced by Clostridium bacteria in the tissue), which indicates a serious infection and is a surgical emergency. Diabetic patients are very susceptible to wet gangrene because of peripheral neuropathy, vascular insufficiency, and hyperglycemia.25
In wet and gas gangrene, surgical amputation is usually performed to prevent the progression and spread of infection to other tissues or sepsis. Sometimes in dry gangrene (as in a distal toe), if there is a clear demarcation of the dry, necrotic tissues, autoamputation may occur (the dry, dead part of the toe may fall off). In certain parts of the globe, autoamputation is desirable, while some evidence suggests surgical amputation of dry gangrene may improve patient outcomes as well.25,26
Level-of-Evidence Rating for WOCN Guidelines24:
Mrs. Jones is a 86 year old frail female resident of a long term facility who has been steadily declining in health for more than a year. Her comorbid conditions include dementia, osteoarthritis of the hips and knees, congestive heart failure (CHF), hypothyroidism, end-stage renal disease (ESRD), and hypertension (HTN). She is no longer eating very much (weighs 88 lbs.), except for small amounts of water and liquid food being offered to her by the long term care (LTC) staff every 2 hours through a needleless syringe to the mouth. She is still able to swallow relatively well but seems to have lost interest in food. Although she could not remember any staff member's names, until recently, she used to arouse easily and smile at staff when they would sing to her. Recently, however, she has been more difficult to arouse and no longer smiles at staff even when they sing to her. Mrs. Jones moans whenever she is turned. Her family visits about once a week and have been informed of her declining status. She has been declared a “no-code,” meaning no resuscitative efforts will be made to revive her if she has a cardiac or respiratory arrest. Mrs. Jones has lost 10 lbs. in the past three weeks.
Other relevant medical information includes:
Mrs. Jones does not like to be turned (as evidenced by her groaning whenever she is repositioned), and her family members do not want to see her pain increased by turning her. Her organs are failing (CHF and ESRD)8,12, and her skin is now also failing. The skin is the largest organ in the body, and at the end of life, when other systems or organs are failing, the skin is likely to fail as well.29-31
Laboratory values: Her hemoglobin and hematocrit are 8.5 g/dl and 32% respectively; albumin is 2.0 g/dl; pre-albumin was not drawn in the past six months. Her BUN and creatinine and serum glucose are all slightly elevated as well as her sodium, indicating her serum osmolality is higher than normal. This indicates some poor nutritional values as well as potential dehydration.
Medications: Levothyroxine 50 micrograms orally per day in am; Atenolol 25 mg orally per day in am; Furosemide 20mg orally per day in am.
Other clinical assessments and wound description: Mrs. Jones has a large (6cm Long x 8cm Wide) butterfly-shaped area of deep purple discoloration to the intact skin over the sacral region (documented by the nurses as a suspected deep tissue injury, likely related to pressure). Her skin turgor is poor, and her mucous membranes in her mouth are somewhat dry.
Pathophysiology of Kennedy terminal ulcers: This type of skin discoloration has been described in the scientific literature as a Kennedy Terminal Ulcer32 or, more recently, as Skin Changes at Life's End (SCALE).30 Kennedy Terminal Ulcers are typically located in the sacral region and initially may present as deep purple to maroon, deep tissue injury discoloration in a butterfly shape (see figure below). According to the National Pressure Ulcer Advisory Panel (NPUAP)33, an area of intact skin with deep purple or maroon skin discoloration over a bony prominence (related to pressure and/or shearing forces) is also known as a Deep Tissue Injury (DTI). In the case of Kennedy Terminal Ulcer, it was first described by Karen Lou Kennedy in 198932 and has also been described as Skin Changes at Life’s End (SCALE).30 These deep tissue injuries over the sacral area in terminal patients represent organ failure of the skin at the end of life when tissue perfusion is decreased, and other organs such as the heart, kidneys, and lungs are failing.30,32
The skin is the largest organ in the body, and even with optimal care, individuals at the end of life with multiple organ/system failure may experience this type of 'skin organ failure.32 The deep purple discoloration may evolve slowly or quickly develop into a full-thickness pressure ulcer (stage 3 or 4) even with optimal care.29-34 Caregivers often feel guilt when Kennedy Terminal Ulcers occur, yet many experts believe these types of ulcers at the end of life are unavoidable.
Image of Kennedy Terminal Ulcer
Example of silicone dressing
Photo source: molnlycke.co.uk
In summary, we have briefly discussed three fictitious cases involving “terminal wounds” or those not expected to heal completely. We have highlighted the need to consider a holistic approach to clinical care and possible ways some of these factors could be addressed: minimizing wound enlargement if possible, protecting the periwound skin (prevent or reduce periwound skin breakdown if possible), manage wound-related moisture/exudates, minimize secondary infection (bacterial and fungal), decrease unpleasant odors associated with the wound, address wound pain and psychosocial concerns (including aesthetic considerations to minimize feelings of social isolation) when approaching a clinical management plan for these patients. Every patient is unique, and you have the potential to contribute your unique gifts to a multidisciplinary team and make a positive impact on a person who is experiencing a challenging situation.37