1. food and drink
2. food
3. condiments and dressings

European guideline on palliative wound care – current research on
how to deliver palliative wound care
Dr. Sebastian Probst, DClinPrac, RN,
Zurich University of Applied Sciences,
Institute of Nursing, Winterthur, Switzerland
[email protected]
Overview
Introduction – Why did we write this document
Management of malignant fungating wounds – HOPES
Symptom management of malignant fungating wounds
Conclusions
Page  2
Introduction
 Patients living with a MFW are vulnerable to tissue break down that may
not always be preventable.
 There is little evidence about the palliative management of a MFW
 most of the literature has been based on problem solving.
Woo, K.Y. and R.G. Sibbald, Local wound care for malignant and palliative wounds. Adv Skin Wound Care,
2010. 23(9): p. 417-28; quiz 429-30.
Benbow, M., Quality of life is starting to take precedence. Br J Nurs, 2009. 18(15): p. S3.
Page  3
Introduction - Included studies
n included studies
45
40
35
30
25
n included studies
20
15
10
5
0
Descriptive
Page  4
Qualitative
Review
RCT
Management of malignant fungating wounds (MFW)
Palliative wounds and assessment
A comprehensive assessment that takes account of
 physical,
 psychosocial and
 psychological considerations
will provide a substantive baseline upon which to develop a
management plan.
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of malignant
fungating wounds. 2015. EONS. In press
Page  5
Introduction - Approach
 Taking care of MFW a systematised and comprehensive approach is
required.
Page  6
Management of MFW - HOPES
Woo, K.Y. and R.G. Sibbald, Local wound care for malignant and palliative wounds.
Adv Skin Wound Care, 2010. 23(9): p. 417-28; quiz 429-30.
Page  7 Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of
malignant fungating wounds. 2015. EONS. In press
Management of MFW
Patient assessment (1)
 Impact of the wound in terms of psychosocial
 Impact of the wound and wound management on the caregiver
 Underlying aetiology-(cancer) type, if known
 Wound location and appearance
 What are the past and current treatments of the cancer and the wounds?
 What co-morbidities (e.g. diabetes, immunosuppression, peripheral
vascular disease or other diagnoses) does the patient have?
 Major symptoms arising from the wound and arising from their
underlying disease and co-morbidities
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of
malignant fungating wounds. 2015. EONS. In press
Page  8
Management of MFW
Patient assessment (2)
 Does the patient have any allergies/sensitivities to dressing products
and/or adhesive tape?
 What medications are being prescribed to manage symptoms arising
from the MFW?
 What dressings have been tried but not found suitable for the patient?
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of malignant
fungating wounds. 2015. EONS. In press
Page  9
Assessment tools for MFW
MFW five assessment scales are described in the literature:
 Toronto Symptom Assessment System for Wounds,
 Schulz Malignant Fungating Wound Assessment Tool,
 Wound Symptoms Self-Assessment Chart,
 TELER System
 Hopkins Wound Assessment Tool.
Maida, V., M. Ennis, and C. Kuziemsky, The Toronto Symptom Assessment System for Wounds: a new clinical and
research tool. Adv Skin Wound Care, 2009. 22(10): p. 468-74.
Schulz, V., et al., The malignant wound assessment tool: a validation study using a Delphi approach.
Palliat Med, 2009. 23(3): p. 266-73.
Naylor, W., Malignant wounds: aetiology and principles of management. Nurs Stand, 2002. 16(52): p. 45-53; quiz 54, 56.
Grocott, P., Blackwell, R, Pillay, E, Young, R. Digital TELER: Clinical Note-Making and
Patient Outcome Measures. Wounds International, 2011. 2.
Haisfield-Wolfe, M.E. and L.M. Baxendale-Cox, Staging of malignant cutaneous wounds:
a pilot study. Oncol Nurs Forum, 1999. 26(6): p. 1055-64.
Page  10
Integrative approach of palliative wound care
Symptommanagement
Psychosocial
Wellbeing
Multidisciplinary
team
Patient / Family
Goals
Page  11
Emmons, K. R. & Lachman, V. D. (2010). J Wound Ostomy Continence Nurs. 37(6), 639-644.
.
Wound-related symptoms – managing odour
 Malodorous wounds can have a profoundly negative impact on the
quality of life
 feelings of guilt, repulsion and leading to social isolation and depression
 Patients are often embarrassed
 compared to the smell of rotting meat
 Management of malodour involves both containment of odour and
treatment of its cause.
Price, E., Wound care. The stigma of smell. Nurs Times, 1996. 92(20): p. 70-2.
Van Toller, S., Invisible wounds: the effects of skin ulcer malodours. Journal of Wound Care, 1994. 3(2): p. 103-105.
Probst, S., et al., Caring for a loved one with a malignant fungating wound.
Support Care Cancer, 2012. 20(12): p. 3065-70.
Gethin, G., Managing wound malodour in palliative care. Wounds UK Palliative
Wound Care Supplement, 2010: p. 12-15.
Page  12
Wound-related symptoms – managing odour
AGENT
Wound cleaning and use of dressings for exudate control is important to help
reduce odour
Metronidazole (orally or topically) can
be helpful
Metronidazole 500 mg bid or tid PO/IV
Gel or injectable metronidazole can be
applied (not injected) on the wound with
each dressing change
Dressings
Activated-charcoal and antimicrobial
(silver) dressings can help absorb and
reduce odour when the dressings
completely cover the wounds and
contain the volatile substances
responsible for the malodour
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of malignant
fungating wounds. 2015. EONS. In press
Page  13
Wound-related symptoms – managing odour
AGENT
ACTION
Shaving foam
Cat litter
Charcoal coals
Odour absorption
Room Deodorisers
Room deodorisers
Aromatherapy Oils (e.g. lavendar,
bergamot, patchouli,…)
Dried sage
Aceto balsamico
Odour masking
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of malignant
fungating wounds. 2015. EONS. In press
Page  14
Wound-related symptoms – managing pruritus
 Apply cool hydrogel sheets or products with menthol or capsaicinointment (0.25-0.75‰ only by intact skin conditions)
 Additives to baths such as specialized non- perfumed oils or oatmeal
only by intact skin conditions
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of malignant
fungating wounds. 2015. EONS. In press
Page  15
Wound-related symptoms – managing exudate
 To manage exudate a variety of dressings have been designed for non
malignant wounds.
 It can be difficult to find a dressing that conforms to the wound shape,
size and the body contours.
 The aim is achieve a close fitting
dressing with a good seal to
prevent leakage.
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of malignant
fungating wounds. 2015. EONS. In press
Page  16
Wound-related symptoms – managing exudate
Element
Comment
Low Exudate
Usually a healing wound should have
yellowish/ slightly reddish exudate. This
is serosanginous. If it is red it could be
blood or just yellow- pus.
 maintain moist environment
 prevent dressing adherence and
bleeding
High Exudate
 absorb and contain exudate
 prevent dressing adherence in areas
of wound with decreased exudate





Alginates
Foams
Gauze
Polymers
Superabsorbent dressings
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of malignant
fungating wounds. 2015. EONS. In press
Page  17
Prevention of maceration and irritation
 Large amounts of exudate and/or occlusive dressings may cause
maceration of the surrounding skin.
 It is recommended that the skin is protected with suitable barrier
products in liquid, paste or solid form
 Possibilities of dressing fixation:
 gauze bandage
 tubular gauze
 sport bras
 bandages with a silicon layer
 dressing retention garments.
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of
malignant fungating wounds. 2015. EONS. In press
Page  18
Wound-related symptoms – managing haemorrhage / bleeding
 The risk of trauma and subsequent bleeding may be reduced by using:
 Care must be taken when removing dressings to avoid bleeding.
 Use warmed normal saline irrigation to moisten the dressing and prevent
trauma during dressing changes.
 Use non-adherent dressings and moist wound products when possible
 If bleeding occurs there are a number of haemostatic agents available e.g.
 Fibrinolytic antagonists (Tranexamic acid)
 Natural haemostats (calcium alginates,…)
 ….
 Radiotherapy and electrochemotherapy may sometimes help to control
repetitive bleeds.
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of
malignant fungating wounds. 2015. EONS. In press
Woo, K.Y. and R.G. Sibbald, Local wound care for malignant and palliative wounds.
Adv Skin Wound Care, 2010. 23(9): p. 417-28; quiz 429-30.
Page  19
Wound-related symptoms – physical pain
• Physical pain is a significant and complex phenomenon in MFW.
• Pain in MFW is caused through:
• the pressure of the tumour on other body structures
• damage to the nerves caused by the growing tumour
• swelling resulting from impaired capillary and lymphatic drainage
• infections
• exposure of dermal nerve endings
• mismanaged change of wound dressing.
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of
malignant fungating wounds. 2015. EONS. In press
Page  20
Wound-related symptoms – physical pain
RECOMMENDATIONS
Prior to the dressing change
Administer an analgesic or booster dose
of their usual opiate
Analgestic drugs
World Health Organisation guidelines
Wound cleansing
Irrigation of the wound with warm saline
(room temperature) with a syringe
rather than cleaning with a gauze swab
Dressings
non-adherent and wound dressings
moistened with saline
Topical application of opioids
10mg morphine in 8g hydrogel [54]
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of
malignant fungating wounds. 2015. EONS. In press
Page  21
Conclusions
 Managing MFWs is challenging for patients, families and health care
professionals.
 A palliative approach should be used to provide a good quality of life for
the patient and their families.
 The care should be planned individually as the feeling of every individual
is subjective.
 The wound-related symptoms like malodour, exudate, bleeding, pain
and itching should be managed in an effective way.
 The psychological aspect of the wound should not be underestimated.
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of
malignant fungating wounds. 2015. EONS. In press
Page  22
References (1)
Benbow, M., Quality of life is starting to take precedence. Br J Nurs, 2009. 18(15): p. S3.
Emmons, K. R. & Lachman, V. D. (2010). J Wound Ostomy Continence Nurs. 37(6), 639-644.
Gethin, G., Managing wound malodour in palliative care. Wounds UK Palliative Wound Care Supplement,
2010: p. 12-15.
Grocott, P., Blackwell, R, Pillay, E, Young, R. Digital TELER: Clinical Note-Making and Patient Outcome
Measures. Wounds International, 2011. 2.
Haisfield-Wolfe, M.E. and L.M. Baxendale-Cox, Staging of malignant cutaneous wounds: a pilot study. Oncol
Nurs Forum, 1999. 26(6): p. 1055-64.
Maida, V., M. Ennis, and C. Kuziemsky, The Toronto Symptom Assessment System for Wounds: a new
clinical and research tool. Adv Skin Wound Care, 2009. 22(10): p. 468-74.
Naylor, W., Malignant wounds: aetiology and principles of management. Nurs Stand, 2002. 16(52): p. 45-53;
quiz 54, 56.
Price, E., Wound care. The stigma of smell. Nurs Times, 1996. 92(20): p. 70-2.
Probst, S., Grocott, P. Graham, T. and Gethin, G. EONS Recommendations for care of malignant fungating
wounds. 2015. EONS. In press
Page  23
References (2)
Probst, S., et al., Caring for a loved one with a malignant fungating wound. Support Care Cancer, 2012.
20(12): p. 3065-70.
Schulz, V., et al., The malignant wound assessment tool: a validation study using a Delphi approach. Palliat
Med, 2009. 23(3): p. 266-73.
Van Toller, S., Invisible wounds: the effects of skin ulcer malodours. Journal of Wound Care, 1994. 3(2): p.
103-105.
Woo, K.Y. and R.G. Sibbald, Local wound care for malignant and palliative wounds. Adv Skin Wound Care,
2010. 23(9): p. 417-28; quiz 429-30.
Page  24
Thank you for your attention
[email protected]
Page  25