General Principles and Approaches to Wound Prevention and Care at End of Life: An Overview
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The NPUAP-EPUAP Guidelines5 note that, while it is important to address nutrition and hydration needs compatible with the individual’s condition and wishes, adequate nutritional support often is not attainable. Providing several small meals per day, a liberal diet, and nutritional protein supplements when ulcer healing is the goal are some suggestions.
The term fungating is used to reflect a wound originating from a malignant (ulcerating, proliferative94 or mixed95) growth process. In the ulcerating growth process, a crater-like wound develops; when the growth is primarily proliferative, a nodular “fungus-” or “cauliflower-” appearing lesion develops.95,96 The fungating tumor wound bed is ulcerated and has a bacterially contaminated surface.85 Patients with a fungating tumor often experience exudate, odor, pruritis, pain, bleeding, and related psychosocial issues.87,97
A fungating wound is caused by local tumor infiltration or direct metastatic tumor spread into the skin, blood, and lymphatics. Fungating wounds occur because the oxygen to the tissue is cut off, leading to eventual necrosis.87,97-99 Fungating tumors occur in 5% to 10% of individuals who have metastatic cancer,73,100 with a higher incidence in elderly individuals.73,100 Fungating tumors most frequently develop in the last months of life, but also can develop and be present for years.14 The breast is the most frequent location, although tumors also can occur on the head, neck, and in an area of melanoma. Given the location of these tumors and the fact that the tissue is fragile and bleeds easily, providing care can be challenging.
Care of the fungating wound. Fungating wounds rarely heal, making management long-term. Care centers on symptom control, comfort enhancement, and quality-of-life maintenance to the extent possible.101,102 As with any wound, assessment and management necessitates excellent interdisciplinary care and patient-caregiver communication.
When debridement is necessary, a nonsurgical (autolytic or enzymatic) approach is recommended to minimize bleeding and “seeding” of malignant cells.70,72,97 The tissue is friable and predisposed to bleeding; platelet function often is impaired and hemorrhage is a common emergency.72,97 Bleeding can be minimized by using nonadherent dressings, maintaining a moist wound bed, and gently irrigating rather than swabbing.73 Dry dressings should be avoided, because they can cause bleeding on removal.70,97 An alginate dressing enhances the clotting cascade and can absorb large amounts of exudate. Caution upon removal is needed; this is a time when bleeding can occur.103 In case of bleeding, a hemostatic surgical sponge can be placed on the wound and left in place for a time.14
Radiation therapy targets a high-energy x-ray beam to an area of treatment: the tumor, the area surrounding the tumor, or an area where a tumor has been surgically removed. A specific depth of tissue is targeted; however, the tissue overlying the site can be damaged as well.104,105 Tissue damage can occur during, immediately after, or an extended time after the radiation therapy.104,105 Radiation skin problems continue to be observed many years after radiation treatments because targeting of tissues was less specific in previous decades.
Radiation wounds can be small or large, sometimes with a draining sinus.84 Most radiation wounds are fairly superficial, but some can be much deeper.