Palliative management of pressure ulcers and malignant wounds in patients with advanced illness

Defining palliative wound care: A scoping review by European Association for Palliative Care wound care taskforce

BACKGROUND

Deciding whether to transition to wound palliation is challenging for health care professionals because there is no agreed definition or understanding of palliative wound care, including the goals, core elements and differences from general wound management.

OBJECTIVES

To conduct a scoping review with qualitative synthesis to define palliative wound care in terms of its conceptual framework, goals, principles, components, and differences from general wound management, and provide a new definition of palliative wound care based on this scoping review.

ELIGIBILITY CRITERIA

Published literature that refers to the definitions, concept, goals and core elements of palliative wound care using any methodological approach, without any time limits, published in English.

SOURCES OF EVIDENCE

The searches were conducted in CINAHL Complete via Ebsco, Medline via Ovid, Cochrane Library, Scopus, and Google Scholar.

CHARTING METHODS

A data extraction form was developed by the review team and used independently for data charting purposes. Braun and Clarke's six phases of thematic analysis guided the qualitative synthesis.

RESULTS

A total of 133 publications met the inclusion criteria. Three main themes were developed to define palliative wound care and understand its differences from general wound management: 1- Healing potential of wounds and patient vulnerability, 2- Understanding the impact on individuals and family to address needs, 3- Towards new goals and perspectives in approach to care.

CONCLUSIONS

Palliative wound care focuses on symptom management, comfort, and dignity, but does not always target the healing of the wound, which is the goal of general wound care. The needs of the individual and their family must be addressed by clinicians through the provision of care and support that takes into account the true meaning of living and dying with a palliative wound.

PROTOCOL REGISTRATION

A review protocol was developed but not registered.

Effect of Percutaneous Endovascular Angioplasty Combined with Negative Pressure Drainage on the "One-Stop" Treatment of Ischemic Diabetic Foot Ulcer

BACKGROUND

To explore the therapeutic effect, safety, and economic benefit of a "one-stop" diagnosis and treatment mode of vascular surgery for ischemic diabetic foot (DF) ulcer and to analyze the associated and independent factors that affect ulcer healing.

METHODS

In a prospective, single-center study, patients with ischemic DF ulcers from January 2017 to July 2021 were treated with either percutaneous endovascular angioplasty combined with negative pressure closed drainage (PTA-VSD) or percutaneous endovascular angioplasty combined with depuration (PTA-UD). The effectiveness and economic benefits of the 2 measures were compared, and independent factors affecting ulcer healing were explored via univariate and logistic regression analyses.

RESULTS

Fifty patients with ischemic DF ulcer (25 patients in the PTA-VSD group and 25 patients in the PTA-UD group; 40 males and 10 females) were included, with an average age of 67.74 ± 10.71 years. No difference was observed in the demographic data. The findings showed that the ulcer healing time in the PTA-VSD group was significantly shorter than that in the PTA-UD group (154.79 vs. 238.31 days), and the ulcer healing rate at 180 days post surgery was significantly greater in the PTA-VSD group (52% vs. 12%) (P = 0.002, < 0.05). The ulcer score in the PTA-VSD group decreased significantly at 3, 6, and 12 months post surgery. The duration of hospitalization in the PTA-VSD group was greater (P = 0.002, <0.05), but no significant difference in hospitalization frequency and cost was observed between the 2 groups. During follow-up, there was 1 death and 1 amputation in the PTA-UD group, but no death or amputation in the PTA-VSD group. Arterial occlusion was primarily located in the femoral-popliteal artery and the inferior knee artery in the 2 groups, and PTA intervention effectively opened the outflow tract of the affected limb. Two to three outflow tracts were opened in 41 patients. The ankle-brachial index (ABI) after surgery was significantly higher in both groups than before. Univariate and multivariate logistic regression analyses revealed that the Wagner grade and number of outflow channels and therapies (PTA-VSD) could be independent factors affecting ulcer healing.

CONCLUSIONS

The severity of DF ulcers is an important factor affecting the quality of life of patients. A multidisciplinary "one-stop" treatment strategy based on percutaneous endovascular angioplasty combined with negative pressure-sealing drainage can rapidly and effectively restore the blood flow to the affected limb and promote ulcer healing without increasing medical costs.

Management of Wound Myiasis in the Hospice and Palliative Medicine Setting

Complex wounds are common complications in hospice and palliative medicine (HPM), especially in patients with aggressive malignancies. Myiasis, or an infestation of maggots, is a rare but significant complication of such wounds. While uncommon in the United States, many HPM patients have multiple risk factors and comorbidities that increase their vulnerability to this condition. Currently, there are no standard diagnostic or treatment guidelines for wound myiasis. In addition, common management strategies may not be easily accessible in HPM settings. We present this case of a patient with malignant squamous cell carcinoma of the neck complicated by myiasis while in hospice, and our experience diagnosing and managing her infestation. We also reflect on special considerations for HPM patients when addressing the physical and psychological symptoms of wound myiasis.

Revisión de las prácticas de enfermería en cuidado paliativo de pacientes con heridas oncológicas

Introducción: Los pacientes con heridas oncológicas o tumorales tienen unas necesidades específicas de cuidado, por dolor, exudado y mal olor; por lo tanto, los profesionales de enfermería deben brindar un cuidado integral y proporcionar confort y alivio de síntomas, a fin de mejorar la calidad de vida del paciente y su familia. Objetivo: Consolidar hallazgos de la literatura sobre prácticas de enfermería en cuidado paliativo de pacientes con heridas oncológicas en el manejo del exudado, dolor y olor. Método: Revisión integrativa mediante la búsqueda electrónica de artículos bajo la pregunta orientadora: ¿cuáles son las prácticas de enfermería en cuidado paliativo de pacientes con heridas oncológicas en cuanto al manejo del exudado, dolor y olor?, en el periodo 2000-2017, idioma inglés, español o portugués, en las bases de datos IdeA, Pubmed, ScienceDirect, SciELO, ProQuest y Dialnet. Resultados: Se identificaron 52 artículos, de los cuales 22 se ajustaban a la pregunta y presentaban información relevante. Esta revisión logró consolidar aspectos importantes sobre las prácticas de enfermería en cuidado paliativo, siendo de utilidad para profesionales de enfermería como un referente de intervenciones dirigidas a esta población con necesidades especiales de cuidado. Conclusión: Se requieren más estudios sobre el manejo de estos síntomas; no obstante, las prácticas documentadas hasta el momento se basan en una adecuada técnica, limpieza de la herida y control de carga bacteriana, elección de apósito atraumático de alta capacidad de absorción y múltiples intervenciones no farmacológicas.

Intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral

Objetivo: identificar intervenciones de enfermería para el diagnóstico de olor fétido en herida tumoral. Métodos: revisión integradora de la literatura a partir de las bases de datos MEDLINE, CINAHL, LILACS e Cochrane, que resultó en la selección de 48 artículos científicos acerca de la temática investigada. Resultados: con base en las evidencias empíricas identificadas en los artículos incluidos en el estudio, se elaboraron 24 intervenciones de enfermería para el control y la reducción del olor fétido en heridas tumorales. Conclusiones: las intervenciones de enfermería presentadas en el estudio posibilitan la promoción de la calidad de vida al paciente con herida tumoral en cuidado paliativo. Como sugerencia posterior al Consejo Internacional de Enfermeros, se deben validar clínicamente para que su inserción se realice en el subconjunto terminológico cuidados paliativos para una muerte digna, de la Clasificación Internacional para la Práctica de Enfermería (CIPE®).

Systemic antibiotics for treating malignant wounds

BACKGROUND

Malignant wounds are a devastating complication of cancer. They usually develop in the last six months of life, in the breast, chest wall or head and neck regions. They are very difficult to treat successfully, and the commonly associated symptoms of pain, exudate, malodour, and the risk of haemorrhage are extremely distressing for those with advanced cancer. Treatment and care of malignant wounds is primarily palliative, and focuses on alleviating pain, controlling infection and odour from the wound, managing exudate and protecting the surrounding skin from further deterioration. In malignant wounds, with tissue degradation and death, there is proliferation of both anaerobic and aerobic bacteria. The aim of antibiotic therapy is to successfully eliminate these bacteria, reduce associated symptoms, such as odour, and promote wound healing.

OBJECTIVES

To assess the effects of systemic antibiotics for treating malignant wounds.

SEARCH METHODS

We searched the following electronic databases on 8 March 2017: the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, 2017, Issue 3), Ovid MEDLINE, Ovid Embase and EBSCO CINAHL Plus. We also searched the clinical trial registries of the World Health Organization (WHO) International Clinical Trials Registry Platform (apps.who.int/trialsearch) and ClinicalTrials.gov on 20 March 2017; and OpenSIGLE (to identify grey literature) and ProQuest Dissertations & Theses Global (to retrieve dissertation theses related to our topic of interest) on 13 March 2017.

SELECTION CRITERIA

Randomised controlled trials that assessed the effects of any systemic antibiotics on malignant wounds were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and selected trials for inclusion, assessed risk of bias and extracted study data. A third reviewer checked extracted data for accuracy prior to analysis.

MAIN RESULTS

We identified only one study for inclusion in this review. This study was a prospective, double-blind cross-over trial that compared the effect of systemic metronidazole with a placebo on odour in malignant wounds. Nine participants with a fungating wound and for whom the smell was troublesome were recruited and six of these completed both the intervention and control (placebo) stages of the trial. Each stage lasted fourteen days, with a fourteen day gap (washout period) between administration of the metronidazole and the placebo.The study, in comparing metronidazole and placebo, reported on two of this review's pre-specified primary outcomes (malodour and adverse effects of the treatment) and on none of the review's pre-specified secondary outcomes.MalodourThe mean malodour (smell) scores for the metronidazole group was 1.17 (standard deviation (SD) 1.60) and the mean for the placebo group was 3.33 (SD 0.82). It is unclear if systemic antibiotics were associated with a difference in malodour (1 study with 6 participants; MD -2.16, 95% CI -3.6 to -0.72) as the quality of the evidence (GRADE) was very low for this outcome. The study was downgraded due to high risk of attrition bias (33% loss to follow-up) and very serious imprecision due to the small sample size.Adverse effectsNo adverse effects of the treatment were reported in either the intervention or control group by the trial authors.

AUTHORS' CONCLUSIONS

It is uncertain whether systemic metronidazole leads to a reduction in malodour in patients with malignant wounds. This is because we were only able to include a single study at high risk of bias with a very small sample size, which focused only on patients with breast cancer. More research is needed to substantiate these findings and to investigate the effects of systemic metronidazole and other antibiotics on quality of life, pain relief, exudate and tumour containment in patients with malignant wounds.

Diabetic foot disease: From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities

The burden of diabetic foot disease (DFD) is expected to increase in the future. The incidence of DFD is still rising due to the high prevalence of DFD predisposing factors. DFD is multifactorial in nature; however most of the diabetic foot amputations are preceded by foot ulceration. Diabetic peripheral neuropathy (DPN) is a major risk factor for foot ulceration. DPN leads to loss of protective sensation resulting in continuous unconscious traumas. Patient education and detection of high risk foot are essential for the prevention of foot ulceration and amputation. Proper assessment of the diabetic foot ulceration and appropriate management ensure better prognosis. Management is based on revascularization procedures, wound debridement, treatment of infection and ulcer offloading. Management and type of dressing applied are tailored according to the type of wound and the foot condition. The scope of this review paper is to describe the diabetic foot syndrome starting from the evaluation of the foot at risk for ulceration, up to the new treatment modalities.

Is the use of negative pressure wound therapy for a malignant wound legitimate in a palliative context? "The concept of NPWT ad vitam": A case series

BACKGROUND

The management of malignant wounds remains particularly difficult. They are often malodorous, highly exuding, and painful. In this context, the use of negative pressure wound therapy is usually not recommended. It is, however, an effective procedure for maintaining a good quality of life in certain palliative situations.

CASE PRESENTATION

Five patients underwent negative pressure wound therapy for a malignant wound in our unit. Three had sarcomas, one patient had a parietal recurrence of breast carcinoma, and one patient had melanoma. They were in a metastatic palliative situation and were no longer receiving specific treatment.

CASE MANAGEMENT AND OUTCOMES

The patients reported a decrease in odor and exudates with negative pressure wound therapy, compared with conventional dressings. No patients complained of pain associated with the suction system itself. Fewer dressing changes reduced the pain and encouraged the resumption of social interactions. The average duration of negative pressure wound therapy before the death of the patients was 49 days. No complications or bleeding were observed. The duration of the patients' stay was shortened by implementing negative pressure wound therapy at home.

CONCLUSION

We report on our experiences with five patients for whom manufacturers and health authorities contraindicated the use of negative pressure wound therapy because of its potential to encourage tumor growth, although it was considered to be beneficial for all of these patients. This procedure may offer an alternative to conventional wound dressings at the end of life and improve the quality of life of patients by controlling the three most disabling elements: the odor, exudate, and pain associated with changing the dressings. Miniaturization and lower costs could promote the systematic use of negative pressure wound therapy.

Choice of wound care in diabetic foot ulcer: A practical approach

Diabetic foot ulcers are the consequence of multiple factors including peripheral neuropathy, decreased blood supply, high plantar pressures, etc., and pose a significant risk for morbidity, limb loss and mortality. The critical aspects of the wound healing mechanism and host physiological status in patients with diabetes necessitate the selection of an appropriate treatment strategy based on the complexity and type of wound. In addition to systemic antibiotics and surgical intervention, wound care is considered to be an important component of diabetic foot ulcer management. This article will focus on the use of different wound care materials in diabetic foot. From a clinical perspective, it is important to decide on the wound care material depending on the type and grade of the ulcer. This article will also provide clinicians with a simple approach to the choice of wound care materials in diabetic foot ulcer.

Clinical parameters associated with pressure ulcer healing in patients with advanced illness

CONTEXT

Pressure ulcers are the most prevalent wounds affecting patients with advanced illness. Although complete wound healing is the most desired outcome, it remains unlikely in the setting of patients with limited life expectancy. Realistic goal setting may be enabled using objective clinical parameters.

OBJECTIVES

To identify clinical parameters associated with complete healing of Stage II pressure ulcers.

METHODS

Univariable and multivariable competing risk analyses were used to assess the association of complete healing with the following six clinical parameters, namely gender, age, total number of pressure ulcers, total number of other wounds, number of failing organ systems, and Palliative Performance Scale (PPS) scores.

RESULTS

A total of 147 patients with 245 Stage II pressure ulcers were followed until death; 9.4% of Stage II pressure ulcers achieved complete healing. Univariable analyses showed hazard ratios (HRs) for complete healing in favor of higher levels of PPS scores (HR 1.82-5.99, P<0.001) and age younger than 80 years (HR 3.28, P=0.031). Multivariable analyses showed HRs for complete healing in favor of higher levels of PPS scores (HR 1.49-3.34, P=0.003).

CONCLUSION

Higher levels of PPS scores are associated with complete healing of Stage II pressure ulcers in patients with advanced illness.

Locally advanced breast cancer made amenable to radical surgery after a combination of systemic therapy and Mohs paste: two case reports

INTRODUCTION

Chemotherapy and other systemic therapies are the primary treatments for patients with unresectable, locally advanced breast cancer. The clinical application of supportive care using Mohs paste has become widespread for the purpose of improving patients' quality of life. Here, we report two cases of locally advanced breast cancer, for which the patients underwent radical surgery after a combination of systemic therapy and Mohs chemosurgery.

CASE PRESENTATIONS

Patient 1 was a 90-year-old Japanese woman with right breast cancer diagnosed as stage IIIB (T4bN1M0). The treatment included Mohs paste application and hormonal therapies. Patient 2 was a 60-year-old Japanese woman with right breast cancer diagnosed as stage IIIB (T4cN2aM0). Her treatment included Mohs paste application, together with chemotherapy (four cycles of 5-fluorouracil, epirubicin, and cyclophosphamide, and four cycles of docetaxel). In both cases, a reduction in the primary tumor volume was observed, and radical mastectomy and axillary lymph node dissection were possible without relaxation incision or skin flap.

CONCLUSION

We report patients with no distant metastases who were able to undergo radical resection after a combination of systemic therapy and Mohs chemosurgery. For locally advanced breast cancer, Mohs chemosurgery, in addition to multidisciplinary treatment, is useful.

Management of bleeding associated with malignant wounds

Bleeding malignant wounds in palliative care patients can be anxiety-provoking for patients, their caregivers, and healthcare providers, and can be difficult to manage. We present the case of a 60-year-old man with a bleeding neck wound due to squamous cell carcinoma of the hypopharynx admitted to our inpatient palliative care unit. Management of bleeding included local wound care measures and psychosocial support for the patient and his wife. We review therapeutic approaches to managing bleeding malignant wounds with the aim of providing clinically useful information.

Wound outcomes in patients with advanced illness

A prospective case series was studied to assess the potential for complete healing of wounds among patients with advanced illness referred to a regional palliative care program in Toronto, Canada. Two hundred and eighty-two patients, of which 148 were primarily diagnosed with cancer and 134 with non cancer advanced illness, were assessed and followed until their deaths. On the baseline initial referral date, 823 wounds were documented. The wound classes assessed included pressure ulcers, malignant wounds, skin tears, venous leg ulcers, diabetic foot ulcers and arterial leg/foot ulcers. Proportions of patients showing complete healing of at least one wound were calculated, stratified by patient's survival time post-baseline (1 week, 1 month, 3 months and 6 months). Proportions of patients showing complete healing of at least one wound increased the longer patients lived and ranged between 12·9% and 43·5% for stage I pressure ulcers, 0% and 60% for stage II pressure ulcers, 2·4% and 100% for skin tears, 10% and 100% for venous leg ulcers and 0% and 50% for diabetic foot ulcers. Only one person showed complete healing of a stage III pressure ulcer and no complete healing was observed with stage IV pressure ulcers, unstageable pressure ulcers, malignant wounds and arterial leg/foot ulcers.

Pressure ulcers in cancer palliative care patients

Terminally ill cancer patients are considered at high risk for pressure ulcers because of their clinical condition. However, in Italy, data about pressure ulcers and their prevalence are insufficient. This paper reports a study on pressure ulcers incidence and prevalence in a population of oncology patients cared for in an Italian palliative care service. A retrospective analysis of 414 clinical records of patients admitted over 6 months showed a prevalence of pressure ulcers of 22.9% and an incidence of 6.7%. Karnofsky Performance Scale Index scores, age and length of the stay were significantly related to the pressure sore development. These results support the need to focus attention on pressure ulcers prevention and treatment in terminally ill cancer patients, and to further define specific guidelines aimed at warranting patients' comfort and quality of life.

Providing palliative care to seriously ill patients with nonhealing wounds

Patients may experience wounds at or near the end of life that are difficult to treat and may not be amenable to healing. In these cases, hospice and palliative care may be considered. Palliative care approaches include stabilization of existing wounds, prevention of new wounds, and symptom management with a focus on quality of life. Treatment goals for nonhealing wounds at the end of life include managing exudate, controlling odor, maximizing mobility and function, preventing infection, and controlling pain and other symptoms. Complementary components of palliative care are also instituted including communication and psychosocial support for patients and families.

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

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.

Symptoms associated with malignant wounds: a prospective case series

A significant proportion of cancer patients develop malignant wounds. Malignant wounds are generally nonhealable and are managed with palliative methods. Palliative wound care encompasses the pain and symptom management of such wounds. Sixty-seven of 472 cancer patients from a prospective sequential case series of palliative medicine consultations demonstrated malignant wounds at the time of referral and were studied to determine the most common symptoms and anatomic sites associated with malignant wounds. Data were collected from patients' own reports of up to three wound-related symptoms. Overall, 67.7% of malignant wounds were associated with at least one of the following eight symptoms: pain, mass effect, esthetic distress, exudation, odor, pruritus, bleeding, and crusting; 21.9% of wounds were associated with two or more symptoms; and 11.5% of wounds were associated with three symptoms. The symptom point prevalence was 31.3% for pain, 23.9% for mass effect, 19.4% for esthetic distress, 17.9% for exudation, 11.9% for odor, 6% for pruritus, 6% for bleeding, and 1.5% for crusting. Breast cancer patients had the highest prevalence of malignant wounds (47.1%). The anterior chest wall and breast was the site of 31.2% of wounds. The perineum and genitalia presented with the highest ratio of symptoms per wound (2.2). The results of this study reflect that malignant wounds are associated with a significant symptomatic burden, and reinforces the need for thorough clinical assessment and evaluation of symptoms. Further research is required to define the optimal methods of pain and symptom management for malignant wounds.

Wounds in advanced illness: a prevalence and incidence study based on a prospective case series

A prospective observational sequential case series was studied in order to ascertain an accurate inventory of the various wound types, their point prevalence and incidence rates and their anatomic locations in patients with advanced illness. Five hundred and ninety-three patients were serially assessed until their deaths. Forty-three individual wound types were identified and grouped into nine distinct classes. Data were stratified between patients suffering from malignant and non malignant disorders. One thousand and thirty-six individual wounds (average 1.8 wounds per patient) were identified at baseline. Eight hundred and ninety-one individual wounds (average 1.5 wounds per patient) were identified between baseline and their date of death. Pressure ulcers constituted the most commonly occurring wound class affecting more than 50% of all patients. Malignant wounds were observed only in cancer patients. Baseline point prevalence for pressure ulcers, traumatic wounds, venous ulcers and arterial ulcers in non cancer patients exceeded that in cancer patients. At baseline, iatrogenic wounds were more prevalent in cancer patients than in non cancer patients. Incidence rates for pressure ulcers, traumatic wounds, diabetic ulcers, arterial ulcers and ostomies in non cancer patients exceeded those in cancer patients. The broad range of wounds along with high rates of prevalence and incidence, identified in this study, reflects that wounds represent a significant management issue for patients with advanced illness. Therefore, there exists a need for advancement in modalities and measures aimed at risk assessment, prevention and appropriate goal-oriented management.

Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds

BACKGROUND

Palliative wound care should be centered on symptom management and is a viable option for patients whose chronic wounds do not respond to standard interventions, or when the demands of treatment are beyond the patient's tolerance or stamina. Palliative wound care is the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing (total closure). Palliative wound care strategies must also work in conjunction with curative treatment objectives as wounds often heal completely in spite of serious illness and advanced disease. Palliative wound care is much more than pain, exudate and odor management. Common curative treatment goals such as physical correction of the underlying pathology, addressing nutrition and other supportive aspects of care, and sensible (nonharmful) local wound treatments should never be ignored.

OBJECTIVE

(1) To provide a fresh and effective approach to palliative wound care by integrating individual clinical expertise with clinical and laboratory evidence from the (curative) wound healing literature and (2) to share our (Calvary Hospital) experience and approach to palliative wound care in an inpatient, home, and outpatient setting. This approach can be summarized with the mnemonic S-P-E-C-I-A-L (S = stabilizing the wound, P = preventing new wounds, E = eliminate odor, C = control pain, I = infection prophylaxis, A = advanced, absorbent wound dressings, L = lessen dressing changes). Throughout this paper we will offer rationale, principles and recipes, for each of the steps of the "SPECIAL" approach in an effort to facilitate the caring for chronic wounds in palliative medicine.

CONCLUSIONS

A practical marriage of wound palliation (symptom management) with current wound healing concepts to provide options for the palliative care provider and improve the practice of palliative medicine.