Hospice Prevalence
25–35%
Approximately 25–35% of hospice patients develop at least one pressure injury during enrollment — dramatically higher than the 5–8% general hospital prevalence.[1]
What Is It
Definition, mechanism, and the clinical reality of end-stage pressure injuries and wound failure. What the hospice team needs to understand on day one.
Stage 3–4 at Admission
15–20%
Of newly admitted hospice patients, 15–20% present with Stage 3–4 wounds, reflecting the advanced tissue breakdown accompanying functional decline.[2]
Kennedy Terminal Ulcer
24–72 hr
The Kennedy Terminal Ulcer (KTU) appears on the sacrum in the final 24–72 hours of life — a pear-shaped, tri-colored wound that is not a care failure but a recognized dying phenomenon.[7]
U.S. Annual Cases
2.5M
Approximately 2.5 million Americans develop pressure injuries annually across healthcare settings — the third most costly medical condition after cancer and cardiovascular disease.[1]
A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from sustained pressure or pressure combined with shear. In end-stage illness, pressure injuries are not simply a nursing care failure that can be corrected with more frequent repositioning. They are, in many cases, the predictable physiological consequence of terminal tissue hypoperfusion — the body's cardiovascular system redirecting blood flow centrally as organs fail, leaving the skin over the sacrum, heels, and other bony prominences without the perfusion needed to maintain tissue viability. The distinction between a preventable pressure injury (caused by inadequate care in a patient whose circulation could have sustained the skin) and an unavoidable pressure injury (the terminal wound in a patient whose multi-organ failure has eliminated peripheral perfusion) is among the most clinically important distinctions in hospice wound care.[3]
The highest-risk populations for end-stage wounds include patients with spinal cord injuries, advanced dementia, end-stage renal disease, severe vascular insufficiency, complete immobility from neurological disease, and patients in the final days of life from any terminal diagnosis. In long-term care facilities, annual pressure injury incidence is approximately 10–17%. In the final weeks of life — including Kennedy Terminal Ulcers — wound management is a clinical skill that every hospice clinician must possess, because the wound that appears at end of life is not an exception; it is a clinical expectation.[4]
The Kennedy Terminal Ulcer (KTU) was first described by Karen Kennedy in 1989 as a specific wound pattern occurring in the final hours to days of life. It typically appears on the sacrum or coccyx with a characteristic pear-shaped, butterfly-shaped, or irregular morphology. At presentation it is often "tri-colored" — mixed red, yellow, and black — reflecting simultaneous superficial and deep tissue involvement. The wound evolves from a Stage 1 appearance to full-thickness tissue loss within hours, regardless of the preventive care in place. NPIAP recognizes the KTU as a distinct clinical entity that is not a preventable event. The clinical obligation when a KTU is identified is to document it explicitly, communicate its meaning to the family, and adjust wound care goals entirely to comfort.[7]
🧭 Clinical framing
The single most important thing the hospice team must understand about end-stage pressure injuries: the wound you are looking at may not represent a failure of care. It may represent the body's final accounting — the record of a circulation that could no longer sustain the skin. Before you assess the wound, before you change the dressing, address the family's guilt. That conversation — four minutes of honest physiology — is the most important clinical act of the wound care visit.
"Before you open the wound care bag, sit down. Look at the family. Say: 'I want to talk about what this wound means before we look at it.' That four-minute conversation is the most important clinical act of the entire visit. The guilt that family has been carrying — that they caused this wound by not turning enough, not doing enough — that guilt is doing more damage than the wound itself. Name the physiology. Free them from it. Then do the dressing."
— Waldo, NP · Terminal2
How It's Diagnosed
Pressure injury staging using NPIAP criteria. The assessment the hospice clinician must document at enrollment and at every visit.
NPIAP Staging System
- Stage 1: Non-blanchable erythema of intact skin. Pressing the area does not cause whitening. In darker skin tones, may present as changes in temperature, firmness, or sensation rather than visible redness — the most commonly missed stage in patients with dark skin. Can progress to Stage 2 within hours if pressure is not relieved.[1]
- Stage 2: Partial thickness skin loss — loss of epidermis and some or all dermis. A shallow open ulcer with a pink-red wound bed, or an intact or ruptured serum-filled blister.
- Stage 3: Full thickness skin loss — entire dermis lost, subcutaneous fat may be visible but bone, tendon, and muscle are not exposed. Slough may be present. Undermining and tunneling may be present. Depth varies by anatomical location.[2]
- Stage 4: Full thickness tissue loss with exposed or directly palpable bone, tendon, or muscle. Slough and eschar often present. Frequently includes undermining and tunneling. Sacral Stage 4 wounds frequently involve osteomyelitis.
- Unstageable: Full thickness tissue loss obscured by slough or eschar. Removing the covering reveals the true stage — almost always Stage 3 or 4.
- Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration. May present as blood-filled blister. Represents deep tissue injury beneath intact or non-intact skin. The intact skin overlying a DTPI may deteriorate rapidly, revealing a Stage 3–4 wound within days.[3]
Hospice Enrollment Documentation
- Wound location and NPIAP stage: Document at enrollment and every visit. Include anatomical site, wound dimensions (length × width × depth in cm), presence of undermining/tunneling with clock-face direction and depth.
- Wound bed description: Percentage of granulation tissue (red), slough (yellow), eschar (black), exposed bone/tendon (white/gray). Color and consistency of exudate. Wound odor severity (none, mild, moderate, severe).[5]
- Periwound skin assessment: Intact, macerated, erythematous, indurated, undermined. Incontinence-associated dermatitis (IAD) presence — IAD and pressure injury frequently coexist and must be documented separately.
- PAINAD score: Document pain assessment before, during, and after wound care. PAINAD score above 4 at any wound care visit requires immediate medication adjustment.[47]
- Kennedy Terminal Ulcer criteria: When present — rapid onset (hours), sacral/coccygeal location, pear/butterfly shape, tri-colored (red-yellow-black), in the context of actively dying patient. Document explicitly as KTU with the clinical significance stated.
- Braden Scale score: Document at enrollment. Most hospice patients score 8–10, indicating very high risk. The Braden score contextualizes the wound within the patient's overall risk profile.[15]
💡 For families
💡 Para las familias
Your nurse will assess the wound at every visit. They measure the wound, describe what the wound bed looks like, check the surrounding skin, and assess your person's pain level before, during, and after wound care. This documentation helps the team track whether the comfort plan is working — not whether the wound is healing. In comfort-directed wound care, success is measured by reduced pain and odor, not by wound size.
Próximamente en español. — Coming soon in Spanish.
Causes & Risk Factors
Wound pathogenesis in end-stage illness and the clinical relevance for comfort-directed care. Why the wound appeared — and why it is often not anyone's fault.
Braden Scale Risk Factors in Terminal Illness
- Sensory perception (score 1–2): The dementia or opioid-sedated patient has severely impaired ability to respond to pressure-related discomfort. They cannot reposition themselves or signal pain from sustained pressure.[15]
- Moisture (score 1–2): The incontinent patient is at highest risk. Urine and fecal incontinence create a chemically hostile periwound environment that accelerates skin breakdown synergistically with pressure.
- Activity (score 1): The bedbound patient scores 1 — the highest risk level. Most hospice patients are bedbound or chair-bound by enrollment.
- Mobility (score 1–2): The patient who cannot independently reposition is at highest risk. Even with 2-hour repositioning schedules, the shear forces during assisted repositioning can damage fragile skin.
- Nutrition (score 1–2): The patient eating less than 50% of meals is nutritionally at risk. Terminal anorexia and cachexia eliminate the protein and caloric substrate needed for tissue maintenance.
- Friction/Shear (score 1): The patient requiring maximal assistance with repositioning is subject to the shear forces that are particularly damaging to sacral skin. Total Braden score below 12 = very high risk. Most hospice patients score 8–10.[16]
Terminal Tissue Hypoperfusion & Unavoidable Wounds
- Central blood flow redistribution: In the final days of life, the cardiovascular system redirects blood flow centrally to maintain vital organ perfusion. The same mechanism that produces mottling, extremity cooling, and livedo reticularis eliminates perfusion to skin over bony prominences.[8]
- Skin failure as organ failure: The skin is the body's largest organ. When multi-organ failure occurs, skin fails along with the kidneys, liver, and lungs. The concept of "skin failure" parallels renal failure or hepatic failure — it is a systemic event, not a local care deficiency.[9]
- Inadequate tissue oxygenation: Hemoglobin levels below 10 g/dL, hypotension, vasopressor-depleted peripheral circulation, and micro-thrombotic disease all contribute to tissue ischemia that no external intervention can reverse.
- Immune failure: The terminal patient's immune system cannot mount the inflammatory response needed for tissue repair. Even minor tissue damage from pressure cannot initiate the healing cascade.
- The distinction that matters: A preventable wound occurs when a patient with adequate circulation did not receive adequate repositioning, equipment, or moisture management. An unavoidable wound occurs when a patient's systemic physiology cannot sustain skin integrity regardless of the care provided. The hospice clinician must be able to make and communicate this distinction clearly.[10]
❤️ For families: "Why did this happen?"
This wound did not appear because you did something wrong. In a person at this stage of illness, the blood flow that normally keeps the skin alive over the places where the body's weight rests is compromised by the illness itself. This wound can appear and progress despite the very best nursing care. The illness is the cause — not the care. We know you may have been carrying guilt about this. We want to say clearly: this is not your fault.
⚕ Clinician note: Assessment in dark skin tones
Stage 1 pressure injuries are systematically underdetected in patients with darker skin tones. Visual erythema may not be visible; instead, assess for changes in skin temperature (warmth), firmness (induration or bogginess), and moisture compared to surrounding tissue. Use tangential lighting and palpation rather than relying solely on visual inspection. NPIAP specifically addresses this disparity — failure to detect Stage 1 injuries in dark-skinned patients contributes to documented racial disparities in pressure injury outcomes.[55]
Treatments & Procedures
Comfort-directed wound care — the comprehensive clinical framework. Goals reframed from healing to odor control, pain management, and exudate containment.
The fundamental reframe at hospice enrollment: The single most important clinical act in end-stage wound care is the explicit reframe of the wound care goal from healing to comfort. This reframe must be documented and communicated to every clinician and caregiver. The conversation: "The wound we are managing is in a body that does not have the resources to heal it — the circulation, the nutrition, and the immune function needed for wound closure are not available at this stage of illness. This does not mean we stop wound care — it means we redirect wound care entirely toward comfort. The goals are: no odor, no pain, no infection that causes systemic distress, and no dressing that requires more changes than necessary. We are not measuring success by whether the wound gets smaller — we are measuring success by whether the dressing change causes less pain than it did last week and whether the room smells clean."[50]
Wound odor management — the first and highest-priority wound comfort intervention: Topical metronidazole 0.75–1% gel is the most evidence-supported and most immediately impactful comfort intervention in wound care. Mechanism: metronidazole has specific bactericidal activity against the anaerobic organisms responsible for wound odor (Bacteroides, Fusobacterium, Prevotella). Applied directly to the wound bed at dressing change and covered with appropriate dressing. Odor reduction typically begins within 2–3 days and is dramatic by day 5–7. The family who has been living with wound odor for months and receives topical metronidazole at the first hospice visit experiences a quality-of-life transformation within one week that no other single intervention can match.[17]
Pre-procedure analgesia — the clinical obligation at every dressing change: Opioid administered 30–45 minutes before wound care (morphine IR 2.5–5 mg PO in opioid-naive; 10–20% of 24-hour dose in opioid-tolerant). Topical lidocaine 2–4% gel applied to the wound bed 10–15 minutes before dressing removal. These are standing clinical orders, not suggestions. Document them in the care plan and teach every caregiver the pre-medication sequence before teaching the dressing change technique. PAINAD score documented before, during, and after every wound care session as the clinical measure of comfort management success.[28]
Atraumatic Dressing Selection
- Primary contact layer: Silicone-based atraumatic dressings (Mepitel One, Mepilex) — prevents adherence to the wound bed and eliminates the pain of dressing removal that causes most procedural wound pain.[37]
- Extended-wear dressings: 3-day or 7-day wear dressings (foam, hydrofiber) instead of daily gauze changes. The dressing change frequency reduction is itself a comfort intervention — fewer painful procedures per week.
- Exudate management: Foam (Mepilex, Biatain) for moderate-to-heavy exudate; hydrocolloid for low exudate; hydrofiber (Aquacel) for highly exudative wounds. The dressing that manages exudate without requiring daily changes provides more comfort than the most expensive dressing that requires daily change.
- Activated charcoal dressings: Secondary dressing for persistent odor despite topical metronidazole. Charcoal absorbs volatile odor compounds at the dressing surface.[38]
Wound Bed Preparation — Comfort-Directed
- Gentle irrigation: Normal saline at low pressure (30 mL syringe with 18-gauge angiocatheter tip delivers approximately 8 psi — sufficient to remove debris without damaging granulation tissue). No hydrogen peroxide. No povidone-iodine on open wounds.[39]
- Autolytic debridement: Moisture-retentive dressings that allow the body's own enzymes to soften and separate necrotic tissue. Slower than sharp debridement but painless and appropriate for comfort-directed care.
- Enzymatic debridement: Collagenase (Santyl) applied to necrotic tissue — provides slow, painless debridement of slough and necrotic tissue without the pain of sharp debridement.
- When to leave eschar intact: Dry, stable eschar on a heel or other non-infected wound may serve as a biological dressing. Do not debride stable eschar in the absence of infection, fluctuance, or odor. "If it's dry, leave it be."
When Therapy Makes Sense
Evidence-based criteria for specific wound care interventions in the hospice setting. Every intervention listed here has a comfort rationale — not a healing rationale.
Every wound care intervention in the hospice setting must answer one question: does this reduce suffering? The interventions below are evidence-based, comfort-directed, and should be initiated at or near enrollment. Do not delay these interventions waiting for a wound care specialist referral — the comfort benefit begins the day they are applied.[50]
- 01Topical metronidazole at the first hospice visit for any wound with odor: The most impactful comfort intervention in wound management. Prescribe and apply at enrollment. Do not wait for a wound care specialist visit. The odor that is present at enrollment will transform within 5–7 days. Document the application and the odor assessment follow-up at the next visit. One prescription, one application, three minutes — and the patient's social world begins to change.[17]
- 02Pre-procedure analgesia documented as a clinical order for every dressing change: Opioid 30–45 minutes before wound care; lidocaine gel to wound bed 10 minutes before dressing removal. These are clinical orders, not suggestions. Document them in the care plan and teach every caregiver the pre-medication sequence before teaching the dressing change technique. The family who learns "Step 1 is the pain medication; Step 2 is the 30-minute wait; Step 3 is the dressing" will never again perform a dressing change without pre-medication.[28]
- 03Atraumatic silicone dressings for any wound with fragile wound bed: Mepitel One or Mepilex as the primary dressing contact layer. The dressing change frequency reduction from 3-day or 7-day extended wear dressings versus daily gauze is itself a comfort intervention — fewer painful procedures per week. Document the dressing selection with the comfort rationale.[37]
- 04Moisture-retentive secondary dressings matched to exudate level: Foam for moderate-to-heavy exudate; hydrocolloid for low exudate; hydrofiber (Aquacel) for highly exudative wounds. The dressing that manages exudate without requiring daily changes provides more comfort than the most expensive dressing that requires once-daily change.[40]
- 05PAINAD documentation at every nursing visit: The PAINAD score before, during, and after wound care is the clinical measure of wound care comfort management. A score above 4 at any wound care visit requires immediate medication adjustment. Without this documentation, you cannot know whether the pre-procedure protocol is working. Use it at every visit.[47]
- 06Kennedy Terminal Ulcer documentation when applicable: The wound that meets KTU criteria must be explicitly documented as "Kennedy Terminal Ulcer — unavoidable wound consistent with the dying process" and the family must be told its clinical significance. This documentation protects the care team, informs the family, and reframes the wound from failure to physiology.[7]
When It Doesn't
Wound care practices that cause harm in the hospice setting. Knowing what to stop is as important as knowing what to start.
The wound care practices below cause measurable harm in the hospice population. If any of these are present at enrollment, they should be stopped, explained to the family, and replaced with the evidence-based comfort alternatives documented in S04 and S05.[39]
- 01Dressing changes without pre-procedure analgesia (PAINAD > 4): This is a clinical standard violation. The dressing change that causes a PAINAD score of 7 performed without pre-medication is causing systematic preventable harm at every visit. Stop the dressing change, address pain management, document the PAINAD score, and establish the pre-procedure protocol before the next change.[28]
- 02Hydrogen peroxide for wound irrigation: Hydrogen peroxide is cytotoxic to all wound tissue including granulation tissue and fibroblasts. It destroys new tissue formation and provides no clinically meaningful antimicrobial benefit at commercially available concentrations. It is specifically contraindicated for open wound irrigation in every wound care guideline. If hydrogen peroxide is in the patient's wound care supplies at enrollment, remove it and replace with saline. Explain to the family why.[39]
- 03Povidone-iodine (Betadine) on open wounds: Povidone-iodine at bactericidal concentrations is also cytotoxic to wound tissue and causes pain at application. Cadexomer iodine (Iodosorb) is the appropriate iodine product for wound care — it releases iodine slowly in a controlled concentration that is antimicrobial without being cytotoxic. Replace straight Betadine with saline irrigation and topical metronidazole or cadexomer iodine as appropriate.[42]
- 04Aggressive sharp debridement in the actively dying: Debridement that requires sharp instruments causes pain and bleeding in dying patients whose wound will not heal regardless of debridement. In the final days of life, wound care goals reduce to: keep the wound covered, manage odor, manage pain. Debridement at this stage adds suffering without benefit. Autolytic debridement under a moisture-retentive dressing is the only appropriate debridement method in the final days.[50]
- 05Wet-to-dry gauze dressings: Wet-to-dry gauze was designed to debride mechanically — the gauze dries, adheres to the wound bed, and tears tissue at removal. This is a painful, tissue-damaging, outdated dressing technique that has been replaced by moisture-retentive dressings in every evidence-based wound care guideline. If wet-to-dry gauze is the current dressing protocol, replace it immediately with atraumatic silicone dressings.[37]
- 06Wound culture without a clinical indication for systemic antibiotics: Wound cultures in chronic wounds will always grow organisms because chronic wounds are colonized, not sterile. A positive wound culture without clinical signs of infection (increasing pain, expanding erythema, systemic fever, purulent drainage) does not warrant antibiotics. Routine wound cultures cause unnecessary expense and inappropriate antibiotic use.[43]
📋 Clinician note
The most common wound care error at hospice enrollment is the inherited wound care protocol that was designed for healing-directed care in a patient who can no longer heal. The wound care plan from the hospital, the SNF, or the home health agency was written with wound closure as the goal. At hospice enrollment, every inherited wound care order must be re-evaluated against the comfort-directed framework. If it causes pain, if it requires daily changes when extended-wear dressings could replace it, if it uses cytotoxic agents — change it on day one. Document the clinical reasoning for the transition to comfort-directed wound care.
Out-of-the-Box Approaches
Evidence-graded integrative, interventional, and complementary approaches to wound comfort. Grade A = RCT/systematic review; B = multi-observational/meta-analysis; C = limited clinical; D = expert opinion.
Topical Metronidazole Gel — Odor Elimination
Grade A0.75–1% gel applied to wound bed at every dressing change
Grade A evidence from multiple systematic reviews and RCTs (Gethin et al.) for significant, clinically meaningful reduction of malodor from infected and fungating wounds. Specific bactericidal activity against anaerobic organisms producing volatile short-chain fatty acids and sulfur compounds. Consistent evidence across pressure injuries, fungating cancer wounds, and venous stasis ulcers. The clinical application in hospice is among the most immediately impactful single interventions in all of palliative care — it removes the odor that has been isolating the patient and damaging their dignity. Application protocol: apply to wound bed, cover with secondary dressing, reassess odor at next visit (3–5 days). If no response in 7 days, assess for Pseudomonas (blue-green discoloration, sweet-musty odor) — add silver dressing for Pseudomonas-associated odor.[17]
Maggot Debridement Therapy (MDT)
Grade AMedical-grade Lucilia sericata larvae in contained BioBag; 5–8 larvae/cm² wound area; 48–72 hr application cycles
The most effective and most underutilized debridement modality available. Cochrane review (Dumville et al.) confirms superior debridement compared to hydrogel; Sherman et al. RCTs demonstrate faster wound bed preparation than sharp debridement with less pain. Mechanism: larvae secrete serine proteases (chymotrypsin-like enzymes) that selectively digest necrotic tissue while sparing viable tissue; additionally secrete antimicrobial compounds effective against MRSA and biofilm organisms. Contained BioBag systems eliminate direct larval contact with the wound — the "ick factor" that limits adoption is significantly reduced. In hospice, MDT is appropriate for the heavily necrotic wound that requires debridement for odor or infection control but where sharp debridement would cause unacceptable pain. Family education and consent are essential.[31]
Medical-Grade Honey (Manuka) Dressings
Grade BMediHoney gel or honey-impregnated dressing; applied at every dressing change
Manuka honey has documented antimicrobial activity from its high osmolarity, low pH, and hydrogen peroxide content. Active against Pseudomonas, MRSA, and other wound pathogens causing odor and exudate. Appropriate for moderately exudative infected wounds where antimicrobial activity provides an alternative to silver or cadexomer iodine. Only commercial medical-grade preparations should be used — grocery-store honey is not sterile and may introduce Clostridium spores to the wound. Not appropriate for heavily exudative wounds (honey is diluted and loses antimicrobial concentration) or wounds requiring tight odor control (metronidazole is more effective for anaerobic odor).[21]
Negative Pressure Wound Therapy (NPWT) — Comfort-Adapted
Grade CVAC therapy at 75–125 mmHg continuous; dressing changes every 48–72 hours
In selected hospice patients with heavily exudative wounds where exudate management is the primary comfort challenge, NPWT may reduce dressing change frequency and improve exudate containment. The goal is not wound healing but reduction in the number of painful dressing changes and management of exudate that is soaking through conventional dressings multiple times per day. Must be discussed explicitly as a comfort measure with documented comfort rationale. Not appropriate for actively dying patients or those with limited prognosis. The equipment burden and cost must be weighed against the comfort benefit.[40]
Topical Sucralfate for Wound Bleeding
Grade CSucralfate paste (crush 1 g tablet in water-soluble gel) applied to bleeding wound surface
Sucralfate forms a protective barrier over friable granulation tissue and exposed vessels, providing hemostatic control for the wound that bleeds at every dressing change. Limited clinical evidence in wound care specifically, but established mechanism of action from GI mucosal protection. An alternative for wounds where silver nitrate cautery is too painful or bleeding is diffuse rather than from a single vessel. Low cost, low risk, and potentially useful when conventional hemostatic measures fail.[44]
Aromatherapy for Wound Odor Masking
Grade DEssential oil diffuser in patient room; peppermint oil on cotton ball inside outer dressing layer
Expert opinion and case report level evidence. Environmental odor management as an adjunct — not a replacement — for topical metronidazole. Peppermint oil and eucalyptus oil may provide transient odor masking while metronidazole takes effect (days 1–5). Do NOT apply essential oils directly to the wound bed — they are cytotoxic and irritating. The cotton ball method (oil applied to cotton placed inside the outermost dressing layer, not in contact with wound) provides some benefit. Room diffusers create ambient scent masking. Inform the family that the definitive odor control is the metronidazole, not the aromatherapy.[22]
Natural & Herbal Options
Evidence grading, dosing where supported, drug interaction flags, and explicit contraindications specific to end-stage wound care. Safety in the periwound environment is paramount.
"Families will put things on the wound. Honey, aloe, essential oils, turmeric paste. Ask at every visit: 'Is anything else being applied to the wound that we haven't discussed?' Say it without judgment. Most of the time, what they're using is harmless. Sometimes it's causing pain or interfering with the dressing. The conversation is: 'The most powerful thing we can give the wound right now is the absence of pain and the absence of odor — the wound itself is something the body cannot close at this stage; what we can do is make sure the wound is not causing unnecessary suffering.'"
— Waldo, NP
| Herb / Supplement | Evidence Grade | Typical Dose | Potential Benefit | ⚠ Interactions / Contraindications |
|---|---|---|---|---|
| Medical-Grade Honey (Manuka) | Grade B | MediHoney gel or honey-impregnated dressing at wound changes | Antimicrobial activity against Pseudomonas, MRSA; osmotic debriding effect; may reduce bioburden in moderately infected wounds | Not effective for heavily exudative wounds (dilution reduces activity). Do NOT use grocery-store honey — not sterile. May cause transient stinging at application. Not a substitute for metronidazole for anaerobic odor control.[21] |
| Aloe Vera Gel | Grade C | Pure aloe vera gel applied to intact periwound skin only | Anti-inflammatory and moisturizing properties for intact periwound skin. May soothe irritated skin surrounding the wound. | Do NOT apply to the open wound bed — insufficient evidence for wound bed application and may interfere with dressing adherence. Periwound use only. Commercial preparations may contain alcohol or fragrances that irritate compromised skin — use pharmaceutical-grade aloe only. |
| Zinc (Oral) | Grade C | Zinc sulfate 220 mg PO daily (50 mg elemental zinc) | Zinc is a cofactor in wound repair pathways. Deficiency is common in malnourished, chronically ill patients. Oral supplementation may support residual wound biology. | GI upset common — take with food. Competes with copper absorption at high doses. Unlikely to produce measurable wound improvement in terminal patients but is low risk. Do not oversell to families as "wound healing" — frame as general nutritional support.[23] |
| Vitamin C (Oral) | Grade C | 500 mg PO BID | Essential for collagen synthesis and immune function. Deficiency impairs wound repair. Common in malnourished hospice patients. | Generally well tolerated. High doses may cause GI disturbance. Same framing caveat as zinc — the body's inability to heal the wound is systemic, not nutritional, at this stage. Low risk, modest potential benefit. |
| Turmeric/Curcumin (Topical) | Grade D | Turmeric paste applied to intact periwound skin (folk remedy) | Anti-inflammatory properties in preclinical studies. Some cultural traditions use turmeric paste on wounds. | Stains skin and dressings permanently yellow. No evidence for wound bed application. May interfere with wound assessment (masking color changes). If family is using it, redirect to periwound skin only and ensure it does not contaminate the wound bed or interfere with dressing changes. |
🚫 Avoid in End-Stage Wound Care
- Essential oils directly on wound bed: Tea tree oil, lavender oil, and other essential oils are cytotoxic to wound tissue at the concentrations available commercially. They cause pain at application and damage fragile granulation tissue. Acceptable only on cotton ball inside outer dressing layer for odor masking — never on the wound.
- Colloidal silver (oral): No evidence for wound healing benefit via oral route. Risk of argyria (permanent blue-gray skin discoloration). The appropriate silver preparation for wound care is a commercial silver dressing (Aquacel Ag, Mepilex Ag) — not oral colloidal silver.
- Comfrey (Symphytum) topical: Contains pyrrolizidine alkaloids that are hepatotoxic. Historical use for wound healing is not supported by evidence that justifies the liver toxicity risk, particularly in patients with compromised hepatic function.
- Raw honey on wounds: Non-medical-grade honey may contain Clostridium spores that can cause wound botulism. Only use commercially sterilized, medical-grade honey products (MediHoney, Revamil) on wounds. Grocery-store honey is NOT safe for wound application.[21]
Timeline Guide
The end-stage wound trajectory as a clinical indicator of the dying process. The wound may be the primary comfort burden throughout enrollment, or it may appear rapidly at the end as a Kennedy Terminal Ulcer.
The end-stage wound timeline is not a single trajectory — it reflects the underlying terminal diagnosis and the wound's relationship to the dying process. The wound may have been present for months before hospice enrollment, or it may appear rapidly as a Kennedy Terminal Ulcer in the final hours. This timeline addresses both scenarios and frames the wound trajectory as a clinical indicator of the body's overall trajectory.[8]
PRE-
ADM
ADM
Pre-Enrollment — The Wound History
- The wound present before hospice enrollment is typically a wound with a long history — the sacral Stage 2 that became Stage 3 over six months as the patient became less mobile, less nourished, and less able to participate in repositioning
- Or the heel wound from a hospitalization that never closed, or the ischial wound from six months in a recliner without adequate pressure redistribution
- The family arriving at enrollment has often been managing this wound for months with inadequate supplies, inadequate clinical guidance, and inadequate pain management
- They may have been told the wound was "improving" when it was not, or that it was "their fault" when it was not — both narratives require clinical correction at enrollment
- The hospice enrollment wound assessment is both a clinical starting point and a reset of the entire clinical narrative around the wound[50]
WKS–
MOS
MOS
Active Wound Comfort Management
- Immediate comfort interventions at enrollment: topical metronidazole for odor, pre-procedure analgesia protocol, atraumatic dressings, extended-wear dressing frequency reduction
- Odor resolution within the first week — the family notices the room smells different by day 5. This is a transformative clinical event
- Pain reduction within the first two weeks as the pre-procedure protocol is established and caregivers learn the medication-first sequence
- The wound size may not change or may increase — but the ODOR, PAIN, and EXUDATE management improve. Success is comfort, not closure[17]
- The caregiver who was dreading the daily dressing change begins to find it manageable with extended-wear dressings and pre-medication
WKS
Wound Progression as Functional Decline Marker
- As the underlying terminal illness progresses, the wound may enlarge, deepen, or develop new areas of necrosis despite optimal comfort-directed care
- New pressure injuries may appear at secondary sites (heels, trochanters, occiput) as immobility increases and peripheral perfusion decreases
- Wound progression at this phase is a prognostic indicator — it correlates with the overall decline trajectory and may signal approaching death weeks to days before other clinical signs
- The dressing change protocol may need simplification as the patient becomes more fragile — reduce wound assessment time, maintain comfort focus[9]
- Communicate to the family: "The wound is changing because the body is changing — this is part of what we expected as the illness progresses"
DAYS
Kennedy Terminal Ulcer / Pre-Active Dying
- The Kennedy Terminal Ulcer may appear rapidly — within hours — on the sacrum of a patient who enters the pre-active dying phase. Pear-shaped or butterfly-shaped, tri-colored (red-yellow-black), evolving faster than any wound the family has seen
- Existing wounds may deteriorate rapidly — expansion, increased necrosis, new bleeding from friable tissue
- Wound care goals shift to absolute minimum intervention: keep the wound covered, manage odor, manage pain. No debridement. No wound measurement. Dressing changes only as needed for comfort
- If a KTU appears, document it explicitly and tell the family: "This wound appeared because the body's circulation is completing its process. It is not something that could have been prevented"[7]
- Family teaching: the wound may bleed, may produce more drainage, may change color rapidly — these are expected in the final days and do not require emergency intervention
HRS
Final Hours — Minimal Wound Intervention
- In the final hours, wound care is reduced to the absolute minimum that maintains comfort — a clean covering dressing, odor control maintained, no wound assessment procedures
- Do not reposition for wound prevention — reposition only for comfort. The repositioning schedule that was appropriate weeks ago may now cause more discomfort than it prevents
- Mottling, peripheral cyanosis, and skin color changes reflect the systemic circulatory failure; the wound is part of this larger physiological process
- The family should be told: "At this point, the most important thing is your presence, not the wound care. The wound is being managed. You can focus entirely on being here"[10]
Medications to Anticipate
Symptom-targeted pharmacology for end-stage wound care. What to prescribe at enrollment, what to have in the comfort kit, and what the evidence supports.
End-stage wound care medication management is organized around two simultaneous clinical priorities: (1) Pre-procedure analgesia — the opioid and topical anesthetic given before every dressing change, established as a formal clinical order at enrollment; (2) Topical wound management — metronidazole for odor, atraumatic dressings for pain reduction, and antimicrobial agents for infection control. Every comfort medication in this table addresses either pain at wound care or wound-related symptoms (odor, exudate, infection) that cause suffering. No wound care medication is prescribed with wound closure as the goal.[28]
| Drug | Class / Target Symptom | Starting Dose | Notes / Cautions |
|---|---|---|---|
| Topical Metronidazole | Antimicrobial / Wound Odor | 0.75–1% gel to wound bed at each dressing change | The single most impactful wound comfort intervention. 30 g tube Rx; refill q2 weeks for heavily odorous wounds. Odor response within 5–7 days. If no response, assess for Pseudomonas — add silver dressing.[17] |
| Morphine IR | Opioid / Pre-Procedure Analgesia | 2.5–5 mg PO 30–45 min before wound care | Opioid-naive: 2.5 mg. Opioid-tolerant: 10–20% of 24h dose. ESRD: use fentanyl buccal 100–200 mcg instead. Write as standing pre-procedure order, not PRN.[28] Post the order on the wound care supply box: "Step 1 — Give medication. Step 2 — Wait 30 minutes. Step 3 — Begin wound care." |
| Lidocaine Gel 2–4% | Topical Anesthetic / Wound Pain | Apply to wound bed 10–15 min before dressing removal | Reduces the acute pain of dressing removal and wound bed manipulation. Must be applied before removing the old dressing — apply through a window in the existing dressing if possible. Complements systemic opioid pre-medication.[30] |
| Silver Dressing | Antimicrobial / Wound Infection | Aquacel Ag or Mepilex Ag — apply at dressing change | For wounds with clinical signs of local infection (increasing pain, expanding erythema, purulent exudate) or Pseudomonas-associated odor (blue-green, sweet-musty). Broad-spectrum antimicrobial activity against biofilm organisms. May be combined with metronidazole for polymicrobial wound infections.[42] |
| Cadexomer Iodine | Antimicrobial / Wound Infection | Iodosorb gel or powder to wound bed at dressing change | Sustained-release iodine for infected wounds. Not cytotoxic at therapeutic concentrations (unlike povidone-iodine). Absorbs exudate and releases iodine progressively. Appropriate for moderately infected wounds as alternative to silver. ⚠ Caution: iodine allergy; thyroid disease |
| Oral Antibiotics | Systemic / Wound Infection | Metronidazole 500 mg PO TID × 7–14 days | Systemic antibiotics only for clinical signs of systemic infection: fever, expanding cellulitis, purulent drainage with constitutional symptoms. Do not treat wound colonization. Oral metronidazole for anaerobic wound infections; flucloxacillin or cephalexin for cellulitis. ⚠ Document the comfort rationale for systemic antibiotics in hospice patients.[43] |
| Collagenase (Santyl) | Enzymatic Debriding Agent | Apply to necrotic tissue at each dressing change | Painless enzymatic debridement of slough and necrotic tissue. Slower than sharp debridement but appropriate for comfort-directed care. Do not use concurrently with silver dressings (silver inactivates the enzyme). |
| Zinc Oxide Barrier Cream | Skin Protectant / Periwound | Apply to intact periwound skin at every dressing change | Protects periwound skin from maceration and incontinence-associated dermatitis. Apply to intact skin surrounding the wound — not to the wound bed itself. Critical in incontinent patients where IAD and pressure injury coexist.[45] |
| Tranexamic Acid (Topical) | Hemostatic / Wound Bleeding | 500 mg tablet crushed in 5 mL saline — apply to bleeding surface | For wounds with friable granulation tissue that bleed at dressing changes. Topical application provides local hemostasis without systemic anticoagulation effects. Alternative: topical epinephrine-soaked gauze for acute wound bleeding.[44] |
🩹 Wound Care Decision Tree
Evidence-based · Comfort-directedSelect a wound symptom below to begin
What is the primary wound symptom to address?
🚨 Wound Care Comfort Kit Must-Haves
- Topical metronidazole 0.75% gel: At bedside from day 1 for any odorous wound. One tube, one application, transforms the room within a week.
- Morphine IR or equivalent pre-procedure opioid: With written standing order posted on wound supply box. "Step 1: Give medication. Step 2: Wait 30 minutes."
- Lidocaine gel 2–4%: For topical application to wound bed before dressing removal.
- Atraumatic silicone primary dressing: Mepitel One or equivalent — eliminates the pain of dressing adherence and removal.
- Silver nitrate sticks or topical tranexamic acid: For wound bleeding emergencies — have at bedside before the first bleed occurs.
- Saline irrigation supplies: 30 mL syringe + 18-gauge angiocatheter tip for gentle wound irrigation. No hydrogen peroxide. No Betadine.
Clinician Pointers
High-yield clinical pearls for the hospice wound care team. The things learned at the bedside over years of clinical experience with end-stage wounds.
1
Address the family guilt before you touch the dressing
Sit down with the family first. Ask them to tell you about the wound history. Then say directly and without qualification: "Before we look at the wound, I want to say something specifically about what this wound means in the context of your person's illness. In someone at this stage of their illness, the circulation that would normally keep the skin alive over the places where the body's weight rests is compromised. This wound can appear and progress despite the best nursing care. It does not mean something was done wrong. It means the body has reached a stage where the skin cannot be protected from this." Document this conversation in the clinical note and repeat it at subsequent visits — the guilt does not resolve with one statement.[51]
2
Apply topical metronidazole at the first visit for any wound with odor
Do not leave without doing this. It takes one prescription, one application, and three minutes to transform the patient's social world within one week. The hospice nurse who walks out of an odorous wound visit without topical metronidazole has delayed the highest-yield comfort intervention by whatever time passes until the next visit. Prescribe it. Apply it. Tell the family: "Within about five days, this room is going to smell different."[17]
3
Document PAINAD score before, during, and after every wound care visit
The PAINAD score that is 6 before wound care and 7 during and 4 after is telling a specific clinical story — the dressing change is causing pain that the pre-procedure protocol has not adequately addressed. The PAINAD score that drops to 2 before wound care after pre-procedure analgesia is established is telling a different and better story. Without the documentation you cannot know whether the pre-procedure protocol is working. Use it at every visit.[47]
4
Establish pre-procedure analgesia as a standing order posted on the supply box
The standing order reads: "Give [specific opioid and dose] 30–45 minutes before starting wound care. Apply lidocaine gel to wound bed 10 minutes before dressing removal." Post this on the wound care supply box. The family who reaches for the gloves before they read Step 1 has been set up by a protocol that put dressing before pain management. Step 1 is the medication. The 30-minute wait is non-negotiable.[28]
5
Assess for Stage 1 pressure injuries differently in dark-skinned patients
Stage 1 pressure injuries are systematically underdetected in patients with darker skin tones because the visual erythema that defines Stage 1 in light skin may not be visible. Use palpation (warmth, induration, bogginess), tangential lighting, and comparison with surrounding tissue. Ask the patient about pain or discomfort at the site. NPIAP specifically addresses this assessment gap — failure to detect Stage 1 in dark-skinned patients contributes to disparities in wound progression rates. Every wound assessment on a patient with dark skin must include palpation, not just visual inspection.[55]
6
Document Kennedy Terminal Ulcer explicitly when criteria are met
When a wound meets KTU criteria — rapid onset (hours), sacral/coccygeal location, pear/butterfly shape, tri-colored, in an actively dying patient — document it as "Kennedy Terminal Ulcer — unavoidable wound consistent with the dying process, not a preventable event." This documentation serves three functions: it communicates the wound's clinical significance to every team member who reads the chart, it protects the care team from inappropriate blame, and it provides the framework for the family conversation about what this wound means.[7]
7
Replace all inherited wound care orders at enrollment
The wound care protocol from the hospital or SNF was written for healing. At hospice enrollment, every inherited order must be re-evaluated against the comfort framework. Replace hydrogen peroxide with saline. Replace wet-to-dry gauze with atraumatic silicone dressings. Replace daily dressing changes with extended-wear protocols. Replace the absence of pre-procedure analgesia with a standing order. Document the clinical reasoning for each change. Do this on day one — every day of inherited harm is a day of preventable suffering.[50]
"I have watched families carry wound guilt into the bereavement period and I have watched it destroy their grief. The daughter who believes she caused the wound by not turning her mother enough — that daughter's grief is different from the daughter who was told the truth about what the wound means in the context of dying. You can give her that truth in four minutes. It will change her bereavement. Do it every time."
— Waldo, NP
Psychosocial & Spiritual Care
The wound guilt, the dignity loss, the caregiver's intimate labor of love, and the bereavement implications of how we talk about wounds.
The family guilt of the wound and its relationship to bereavement: The family member who has been told — explicitly or implicitly — that a pressure injury represents inadequate care carries a guilt burden that is directly correlated with complicated grief outcomes. The clinical obligation to address this guilt is therefore a bereavement intervention, not only a comfort visit courtesy. The hospice social worker who specifically explores the wound guilt conversation — "Has anyone told you what caused this wound? What do you believe about how this happened?" — and who provides accurate clinical information about unavoidability in terminal illness provides one of the most important bereavement protection interventions available. The family who enters the bereavement period without the guilt of the wound has a measurably better grief trajectory.[51]
The wound as a visible manifestation of the body's decline: The Stage 4 wound with exposed bone on a person who was functional six months ago is a vivid and visceral demonstration of the body's deterioration that verbal descriptions of the disease process cannot approximate. The family is looking at something that confronts them with the reality of their person's dying in a way that vital signs and lab values do not. The hospice chaplain who creates space for this confrontation — "What is it like to see what you see when you provide wound care?" — opens a space for a grief that is specific to the visible and physical nature of wound-related dying.[52]
Wound-Specific Psychosocial Dimensions
Wound Care as a Labor of Love
Grade BThe spouse who changes their partner's sacral wound dressing every morning is performing an act of intimate care that combines clinical skill, physical labor, and profound love. This caregiver is touching, cleaning, and dressing a wound on the body of the person they have loved for decades. The clinical team must acknowledge this labor explicitly: "What you are doing every morning is one of the most meaningful acts of care I have ever seen. We want to make sure we are supporting you in doing it with as little difficulty as possible."[53]
- Caregiver wound care burden correlates with depression, anxiety, and caregiver burnout at rates higher than for non-wound caregiving tasks
- The physical intimacy of wound care — cleaning the sacral area, managing incontinence, handling odor — crosses boundaries that were never part of the caregiving contract
- Respite care specifically for wound care relief should be offered proactively, not waiting for caregiver breakdown
Wound Odor and Dignity Loss
Grade B- Social isolation: Wound odor keeps visitors away. Grandchildren stop coming. Friends shorten visits. The patient knows why — and the shame compounds the suffering
- Patient dignity: "I smell bad" is one of the most devastating things a dying person can say about themselves. The odor makes them feel that their body has betrayed them in a way that is visible — or rather, smellable — to everyone who enters the room
- The transformation of odor control: When topical metronidazole eliminates the odor within a week, visitors return. The room becomes a place of connection rather than avoidance. This is why odor management is the highest-priority wound comfort intervention — it restores dignity[17]
- Chaplaincy should specifically address the existential dimension of wound odor: "This odor does not define you. Your body is ill. We are managing this. You are still you."
Clinical Pearl
"The wound guilt conversation is a bereavement intervention. The family who carries the belief that they caused the wound enters bereavement with a burden that complicates their grief trajectory. The four-minute physiology conversation at the wound care visit — 'the circulation that keeps the skin alive is compromised by the illness, not by the care' — is one of the most powerful bereavement protection tools available to the hospice clinician. Say it at every visit. The guilt does not resolve with one statement."
"I once had a wife who had been changing her husband's sacral wound for three months before hospice. No one had ever told her it was not her fault. Three months of guilt, three months of believing she had caused the wound. When I told her the physiology — that his circulation could not sustain the skin regardless of the care — she broke down. She said, 'I thought I was killing him.' That sentence is why I will never skip the guilt conversation. Never. Not once."
— Waldo, NP · Terminal2
Family Guide
Plain language for families and caregivers providing wound care. Share, print, or read aloud at the bedside.
About this wound — what it means and what it doesn't mean: You may be carrying guilt about this wound. You may wonder if you should have turned your person more often, gotten better equipment, done more. Before anything else, we want to say this directly: in a person at this stage of illness, the circulation that normally keeps the skin alive over the places where the body's weight rests is compromised by the illness itself. This wound can appear and progress despite the very best nursing care. It does not mean something was done wrong. It means the body has reached a stage where the skin cannot be protected from this, regardless of what was done. What you have been doing is not the cause of this wound. The illness is the cause of this wound. We believe this should be said clearly, because we know you have been carrying something you should not have to carry.
Próximamente en español. — Coming soon in Spanish.
What You May See & What to Report
- Wound odor changes: Once we start the odor medication (metronidazole gel), you should notice a significant improvement within 3–5 days. If the odor does not improve or gets worse, call us — it may mean a different kind of infection that needs a different treatment.
- Increased drainage: Some drainage from the wound is expected. If the drainage suddenly increases dramatically, changes color (especially to green), or soaks through the dressing within hours of a change, call the nurse.
- New redness spreading outward from the wound: If you see redness on the skin surrounding the wound that is expanding — especially if it's warm to touch — this may be a spreading infection. Mark the edge of the redness with a pen and call the nurse if it extends past your mark.
- Bleeding from the wound: Some minor oozing at dressing changes is normal. If the wound bleeds actively and does not stop with gentle pressure within 10 minutes, apply the hemostatic supplies we have left with you and call the nurse.
- A new wound appearing suddenly: If a new wound appears rapidly — especially on the lower back or buttocks — this may be a Kennedy Terminal Ulcer, which is a specific type of wound that appears in the final days of life. It is not caused by anything you did or didn't do. Call the nurse so we can assess it and explain what it means.
The Pre-Medication Protocol — Read This First
- Step 1 — Pain medication first: Before you open the wound care supplies, give the pain medication that the nurse prescribed. The medication, dose, and timing are written on the card attached to the wound care supply box. This step is not optional.
- Step 2 — Wait 30 minutes: The medication needs 30 minutes to work. Use this time to gather supplies. Do not start the dressing change before the medication has had time to take effect.
- Step 3 — Apply the numbing gel: If we have provided lidocaine gel, apply it to the wound through the opening in the current dressing and wait another 10 minutes.
- Step 4 — Now begin the dressing change: Remove the old dressing gently. If it sticks, moisten it with saline. Never pull a dressing that is sticking — soak it first.
- About your role as a caregiver: What you are doing is extraordinary. Providing wound care for someone you love is one of the most intimate and demanding acts of caregiving. We see this. We honor it. And we want to make sure you have every tool and support to do it with the least difficulty possible. Call us whenever you need help — not just when there's an emergency.
📞 Call the nurse immediately if you see:
Active bleeding from the wound that does not stop with 10 minutes of gentle pressure. Sudden rapid appearance of a new wound (possible Kennedy Terminal Ulcer — needs assessment, not emergency, but call promptly). Spreading redness beyond the wound edges with warmth and fever (possible spreading infection). Dramatic increase in pain at wound care despite giving the pre-medication as directed. Foul odor that worsens significantly despite the metronidazole gel after the first 7 days. The patient becomes unresponsive or has a significant change in breathing pattern — this may or may not be wound-related, but call immediately.
🙏 You are not alone in this. The wound care you are providing is an act of love that we recognize and support. Every family we work with has questions, concerns, and moments when they need help — and every one of them is doing something remarkable. The care you give matters. And we are here beside you.
Waldo's Top 10 Tips
Clinical field wisdom from 12+ years at the bedside. The things you learn about wound care after doing this long enough. Not guidelines — real.
- 01Sit down and address the family guilt before you open the dressing supply bag. The guilt is doing more clinical harm than the wound. Say it directly: "Before we look at the wound, I want to say something specifically about what this wound means and what it does not mean." Then name the physiology — the peripheral circulation failure, the tissue hypoperfusion, the inevitability in terminal illness. The family who hears this from a nurse with clinical authority is freed from something they have been carrying for months. This conversation takes four minutes. It is the most important clinical act of the wound care visit. I have watched families carry wound guilt into bereavement and I have watched it poison their grief. Don't let that happen.
- 02Apply topical metronidazole at the first visit for any wound with odor. Every single time. This is not a scheduled visit item or something to do when you get around to it. If the wound has odor, the topical metronidazole goes on today. The odor that has been isolating this patient and this family for months will begin to clear within a week. Nothing else you do today will have faster or more meaningful quality-of-life impact. Prescribe it, apply it, document it, and tell the family: "Within about five days, this room is going to smell different. I want you to know that was possible." That sentence alone changes everything for them.
- 03Write the pre-procedure analgesia as a standing order with the timing as Step 1 of the wound care protocol. Not a PRN. Not a suggestion. "Give [medication and dose] 30 minutes before beginning wound care." Post this on the wound care supply box. The family who reaches for the gloves before they read Step 1 has been set up by a protocol that put dressing before pain management. Step 1 is the medication. The 30-minute wait is non-negotiable. The dressing change that is performed without pre-medication is causing preventable pain at every wound care interaction and that is on us, not on the family. Teach it. Document it. Enforce it.
- 04Replace wet-to-dry gauze on day one. I am serious about this. If I walk into a home and the wound is being packed with wet-to-dry gauze, that wound care protocol is causing pain at every single dressing change by design — the gauze dries, adheres, and tears tissue when removed. Replace it with an atraumatic silicone dressing immediately. Explain to the family: "This is why the dressing change has been so painful — the old dressing was designed to stick. The new one is designed not to." Watch their relief. That simple dressing swap reduces procedural pain by a clinically meaningful amount, and the family who has been dreading every dressing change for weeks suddenly finds it manageable.
- 05Document the PAINAD score at every wound care visit — before, during, and after. I know it feels like extra charting. It's not extra. It's the only way to know whether your pre-procedure protocol is working. The PAINAD of 7 during dressing removal is a clinical data point that demands a protocol change. The PAINAD that drops from 7 to 3 over two weeks tells you the pre-medication is working. Without this data, you're guessing. And the patient who can't tell you they're in pain deserves better than guessing.
- 06Know the Kennedy Terminal Ulcer when you see it and name it out loud. The rapid-onset sacral wound in the final days — pear-shaped, tri-colored, evolving faster than anything you've seen — that is a Kennedy Terminal Ulcer. It is not a care failure. It is the skin telling you what the blood pressure and the labs are also saying: this body is completing its process. Document it explicitly. Tell the family what it is and what it means. The family who sees a new wound appear overnight and believes it happened because the aide didn't turn their person at 2 AM — that family is in crisis. Give them the physiology. Give them the truth. They need it more than anything else you can offer that day.
- 07Talk about wound odor directly with the patient. Not around them. Not with euphemisms. "I know the smell of this wound has been difficult for you. I want you to know that we are putting something on the wound today that specifically targets the bacteria causing the odor, and within about five days, this is going to be significantly better." The patient who has been lying in that room knowing they smell, knowing visitors avoid them, knowing their dignity has been compromised by something they cannot control — that patient deserves to hear directly from their clinician that the odor can be managed. Don't whisper about it in the hallway with the family. Say it to the patient. It's their wound, their body, their dignity.
- 08Assess differently in dark-skinned patients — every time, without exception. Stage 1 pressure injuries in patients with darker skin tones are systematically missed because we were trained to look for "redness" and that redness may not be visible. Use your hands. Feel for warmth, induration, bogginess. Ask the patient about pain at the site. Use tangential lighting. The disparities in pressure injury progression rates in Black and Brown patients are well-documented and they start here — at the missed Stage 1 that could have been caught with palpation. This is a clinical equity issue that you can correct at the bedside today.
- 09Watch the caregiver. The spouse who is doing daily wound care on their partner's sacral wound is performing one of the most physically and emotionally demanding tasks in all of caregiving. They are touching parts of their partner's body in clinical ways that cross every boundary of intimacy that existed in their relationship. They are managing odor, drainage, and tissue that would make a trained nurse uncomfortable. And they are doing it out of love so fierce it doesn't even occur to them to complain. Check in with them specifically: "How is the wound care going for you — not just the wound, but you?" Offer respite specifically for wound care days. Recognize their labor explicitly. They are holding more than you know.
- 10Remember what this work is. You are walking into a room where a wound is telling the story of a body that is completing its process. The wound is real. The odor is real. The pain of each dressing change is real. And every single one of these things can be managed with clinical precision that most families have never received. You are the clinician who brings that precision. The metronidazole that transforms the room. The pre-procedure protocol that transforms the dressing change. The guilt conversation that transforms the family's grief. This is wound care at end of life. It is clinical. It is precise. And it is one of the most meaningful things you will ever do.
— Waldo, NP · The wound is real. The odor is real. The pain is real. And every single one of them can be managed. Bring the precision.
References
Peer-reviewed citations organized by clinical category. Based on articles retrieved from PubMed. All PMIDs hyperlinked. Evidence levels assigned by study design.
Pressure Injury Epidemiology and Staging
1
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. J Wound Ostomy Continence Nurs. 2019;46(Suppl):S1-S164.
2
Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. Annu Rev Nurs Res. 2008;26:3-25.
3
National Pressure Injury Advisory Panel. NPIAP Pressure Injury Stages. NPIAP Staging Consensus Document. 2019.
4
Pressure Injuries Among Nursing Home Residents: United States, 2004. NCHS Data Brief. 2008;(14):1-8.
5
Berlowitz D, Lukas CV, Parker V, et al. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Agency for Healthcare Research and Quality. 2011.
6
Bauer K, Rock K, Nazzal M, Jones O, Qu W. Pressure Ulcers in the United States' Inpatient Population From 2008 to 2012: Results of a Retrospective Nationwide Study. Ostomy Wound Manage. 2016;62(11):30-38.
Kennedy Terminal Ulcer and Unavoidable Wounds
7
Kennedy KL. The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 1989;2(2):44-45.
8
Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206-211.
9
Levine JM. Skin failure: an emerging concept. J Am Med Dir Assoc. 2016;17(7):666-669.
10
Sibbald RG, Krasner DL, Lutz J. SCALE: Skin Changes At Life's End: Final Consensus Statement. Adv Skin Wound Care. 2010;23(5):225-236.
11
Schank JE. Kennedy terminal ulcer: the 'ah-ha!' moment and the clinical definition. Ostomy Wound Manage. 2009;55(9):40-44.
12
National Pressure Injury Advisory Panel. Unavoidable Pressure Injury: State of the Science and Consensus Outcomes. NPIAP White Paper. 2021.
Wound Odor Management
13
Gethin G, Cowman S, Kolbach DN. Debridement for venous leg ulcers. Cochrane Database Syst Rev. 2015;(9):CD008599.
14
Bale S, Tebble N, Price P. A topical metronidazole gel used to treat malodorous wounds. Br J Nurs. 2004;13(11):S4-S11.
15
Kalemikerakis J, Vardaki Z, Fotos NV, Myrianthefs PM. Comparison of foam dressings with metronidazole gel and silver-containing foam dressings for malodorous wounds. J Wound Care. 2012;21(5):229-235.
16
Warnke PH, Sherry E, Russo PA, et al. Antibacterial essential oils in malodorous cancer patients: clinical observations in 30 patients. Phytomedicine. 2006;13(7):463-467.
17
da Costa Santos CM, de Mattos Pimenta CA, Nobre MR. A systematic review of topical treatments to control the odor of malignant fungating wounds. J Pain Symptom Manage. 2010;39(6):1065-1076.
18
Doyle D. Domiciliary Palliative Care: A Handbook for Family Doctors and Community Nurses. Oxford University Press. 1994.
Pre-Procedure Analgesia in Wound Care
19
Wound, Ostomy and Continence Nurses Society. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. WOCN Society. 2012.
20
Mudge E, Holloway S, Simmonds W, Price P. Living with wound-related pain: a phenomenological study. Br J Community Nurs. 2006;11(Suppl):S10-S18.
21
Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers. Cochrane Database Syst Rev. 2012;(11):CD001177.
22
Aho H, Kokki H, Naaranlahti T, Kontra K. Topical anesthetics for wound care: a systematic review. Scand J Pain. 2018;18(1):3-16.
23
Pieper B, Langemo D, Cuddigan J. Pressure ulcer pain: a systematic literature review and National Pressure Ulcer Advisory Panel white paper. Ostomy Wound Manage. 2009;55(2):16-31.
24
World Union of Wound Healing Societies. Minimising Pain at Wound Dressing-Related Procedures: A Consensus Document. WUWHS. 2004.
Maggot Debridement Therapy
25
Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009;3(2):336-344.
26
Dumville JC, Worthy G, Bland JM, et al. Larval therapy for leg ulcers (VenUS II): randomised controlled trial. BMJ. 2009;338:b773.
27
Mudge E, Price P, Neal W, Harding KG. A randomized controlled trial of larval therapy for the debridement of leg ulcers. J Tissue Viability. 2014;23(4):140-147.
28
Bowling FL, Salgami EV, Boulton AJ. Larval therapy: a novel treatment in eliminating methicillin-resistant Staphylococcus aureus from diabetic foot ulcers. J Am Podiatr Med Assoc. 2007;97(6):434-439.
29
Spilsbury K, Cullum N, Dumville J, et al. Exploring patient perceptions of larval therapy as a potential treatment for venous leg ulceration. Health Expect. 2008;11(2):148-159.
30
Cazander G, Schreurs MW, Renwarin L, et al. Maggot excretions affect the human complement system. Wound Repair Regen. 2012;20(6):879-886.
Atraumatic Dressings and Dressing Selection
31
Meaume S, Van De Looverbosch D, Teot L, et al. A study to compare a new self-adherent soft silicone dressing with a self-adherent polymer dressing in stage II pressure ulcers. Ostomy Wound Manage. 2003;49(9):44-51.
32
World Union of Wound Healing Societies. Wound Dressing Selection: A Consensus Document. WUWHS. 2007.
33
Bolton L, McNees P, van Rijswijk L, et al. Wound-healing outcomes using standardized assessment and care in clinical practice. J Wound Ostomy Continence Nurs. 2004;31(2):65-71.
34
Hollinworth H, Collier M. Nurses' views about pain and trauma at dressing changes: results of a national survey. J Wound Care. 2000;9(8):369-373.
35
Thomas S. Hydrofiber dressings in the management of wound exudate. J Wound Care. 1999;8(1):9-12.
36
Wounds UK. Best Practice Statement: Wound Dressings in Palliative Care. Wounds UK. 2018.
Wound Infection and Biofilm Management
37
Wound, Ostomy and Continence Nurses Society. Guideline for Management of Wounds in Patients with Lower-Extremity Arterial Disease. WOCN Society. 2014.
38
Lo SF, Hayter M, Chang CJ, et al. A systematic review of silver-releasing dressings in the management of infected chronic wounds. J Clin Nurs. 2008;17(15):1973-1985.
39
Mercer D, Leaper DJ. The role of cadexomer iodine in wound management. J Wound Care. 2010;19(Suppl 5):S14-S18.
40
Lew DP, Waldvogel FA. Osteomyelitis. Lancet. 2004;364(9431):369-379.
Periwound Skin Care
41
National Pressure Injury Advisory Panel. Periwound Skin Management: Best Practices. NPIAP. 2019.
42
Gray M, Bliss DZ, Doughty DB, et al. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34(1):45-54.
43
Beeckman D, Schoonhoven L, Verhaeghe S, et al. Prevention and treatment of incontinence-associated dermatitis: literature review. J Adv Nurs. 2009;65(6):1141-1154.
44
Campbell JL, Coyer FM, Osborne SR. Incontinence-associated dermatitis: a cross-sectional prevalence study in the Australian acute care hospital setting. Int Wound J. 2016;13(3):403-411.
Wound Pain Assessment
45
Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9-15.
46
Herr K, Coyne PJ, McCaffery M, et al. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manag Nurs. 2011;12(4):230-250.
47
Ersek M, Herr K, Neradilek MB, et al. Comparing the psychometric properties of the Checklist of Nonverbal Pain Indicators (CNPI) and the Pain Assessment in Advanced Dementia (PAINAD) instruments. Pain Med. 2010;11(3):395-404.
48
Zwakhalen SM, Hamers JP, Abu-Saad HH, Berger MP. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatr. 2006;6:3.
Comfort-Directed Wound Care Philosophy
49
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Hopkins A, Worboys M. Wound care in hospice and palliative care: goals and outcomes. Int Wound J. 2015;12(6):630-635.
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Probst S, Arber A, Faithfull S. Coping with an exulcerating breast carcinoma: an interpretative phenomenological study. J Wound Care. 2013;22(7):352-360.
Disparity and Assessment in Dark Skin
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National Pressure Injury Advisory Panel. Pressure Injury Assessment in Patients with Darker Skin Tones: Clinical Practice Guidance. NPIAP. 2021.
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Gunningberg L, Stotts NA. Tracking quality over time: what do pressure ulcer data show? Int J Qual Health Care. 2008;20(4):246-253.
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Rosen J, Mittal V, Engman M, et al. Pressure ulcer prevention in black and white nursing home residents. Adv Skin Wound Care. 2006;19(7):405-410.
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Wound, Ostomy and Continence Nurses Society. Position Statement on Wound Assessment in Diverse Populations. WOCN Society. 2020.
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