Promoting and Maintaining Skin Integrity in End-of-Life... : Advances in Skin & Wound Care

• Updated on: 2025-02-25
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Because of methodological heterogeneity, results were synthesized narratively, and no meta-analysis was performed.
Conclusions 
The information contained in the recommendations will assist nurses in promoting and maintaining skin integrity in patients at the end of life. More research is needed on end-of-life skin care, with an emphasis on patient-centered, holistic strategies that improve patient well-being and quality of life. In most current research, recommendations are limited to literature reviews and level V evidence. Skin care must balance the promotion and maintenance of skin integrity, wound prevention, and management while promoting patient dignity and quality of life.
INTRODUCTION
The end of life is the stage of life when death is expected within months because of a progressive, life-limiting illness. Whereas end of life refers to a time frame, “terminally ill” refers to the patient’s condition during this phase of life. 1 In the terminal stages of life, vital body systems may be affected. These include changes related to a decrease in cutaneous perfusion and local hypoxia at the tissue, cellular, or molecular level. These changes reduce the availability of oxygen and the body’s ability to utilize vital nutrients. 2,3 The skin, which is one of the largest organs in the body, consists of a layered structure that serves to protect from external damage and helps maintain internal homeostasis. The skin must be functionally competent to compensate for internal and external dangers. 2,3 Kottner and colleagues 4 defined skin integrity as “the combination of an intact cutaneous structure together with a highly functional capacity to preserve it.” Like other organs, the skin can lose function and decline in its ability to work. At the end of life, the increasing frailty of the skin is referred to as skin failure. Skin failure can be defined as “an event in which the skin and underlying tissues die due to the hypoperfusion that occurs.” 5,6 As a result, skin integrity can no longer be maintained. 7
Care transitions at end of life are of vital importance. The National Cancer Institute defined transitional care as “the support given to patients when they move from one phase of disease or treatment to another, such as from hospital care to home care. It involves helping patients and families with medical, practical, and emotional needs as they adjust the goals of care.” 8 A holistic approach is often taken to improve the quality of life of patients and their family by providing them with legal, psychosocial, emotional, or spiritual support in addition to meeting their immediate physical needs. 9,10 Despite the focus of care shifting from (more) curative to (more) supportive, with an increased realistic understanding of what can be achieved, it is important to maintain and improve skin integrity and skin health at this particular stage of life. 6
Skin care is one of the cornerstones of professional care and can have a significant impact on patient outcomes. 11 Skin care also occupies an important place in the last stages of a person’s life. 4,12 Carers need to be mindful of what they can do to ensure safe skin care at the end of life and how they can contribute to the patient’s quality of life. 13 A descriptive cross-sectional study conducted between October 1, 2012, and September 30, 2013, found that two of the most common skin care interventions performed in the last 48 hours of life were repositioning and washing. 14 Other end-of-life skin care measures include skin cleansing; application of lotions, creams, and other skin care products; and use of dressings, medical devices, and topical agents. 5
Currently, recommendations for promoting and maintaining skin integrity in end-of-life care are scattered across different types of evidence, such as expert opinion, guidelines, and reviews. Although some literature focuses on specific recommendations for skin injury in end-of-life care, such as pressure injuries (PIs), 15 skin failure, 6 and Kennedy terminal ulcerss, 16 other literature focuses on general recommendations. 17 The aim of this systematic review is to summarize the interventions used to promote and maintain skin integrity at the end of life and their level of evidence.
METHODS
Design
A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement. 18 To identify relevant literature, the authors systematically searched MEDLINE (PubMed interface), CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and The Cochrane Library using a combination of key terms including end-of-life care, skin care, skin hygiene, and skin cleansing. The search strategy was optimized with the assistance of a library technician to match the recommendations of the various search engines. In addition, the reference lists of all included articles were screened to identify additional articles.
Study Eligibility
Three researchers independently checked all identified records for title and abstract eligibility. Articles were included if they (1) described skin care recommendations, including but not limited to the use of skin care products and interventions such as cleansing procedures, and (2) included adult patients who were expected to die within 12 months or less. There were no restrictions on study design, study setting, or language. Articles with a publication date before 2000 were excluded. All titles, abstracts, and full texts were exported into Rayyan. 19
Data Extraction
Two data extraction forms were developed. The first included information on the author, publication year, evidence type, review topic, sample, sample size, setting, limitations of the study, and its level of evidence and quality. The second included recommendations for promoting and maintaining skin integrity in patients at the end of life. Data extraction was performed independently by the three researchers. In the case of clinical practice guidelines or consensus statements, only recommendations that related to patients at the end of life were extracted. Disagreements were discussed until consensus was reached. Because of methodological heterogeneity, results were synthesized narratively and no meta-analysis was performed.
Quality Assessment
The Johns Hopkins Evidence-Based Practice Research Appraisal Tool was used to assess the strength and quality of the included articles. The strength of evidence is categorized into five levels, and within each level, quality ratings are defined as high, good, or low. 20 The quality assessment was carried out independently by the three assessors. The degree of agreement between the assessments was calculated using the Fleiss κ correlation. 21 Disagreements were discussed until a consensus was reached. The goal of the review was to provide a broad range of skin care recommendations. Based on this consideration, articles were not excluded based on quality assessment.
RESULTS
A total of 9,112 records were retrieved ( Figure ). Duplication resulted in 6,436 potentially relevant records. After title and abstract screening, 79 records were evaluated for full text screening. Of these, 54 were excluded and 25 articles were included in the review. No additional articles were included after screening the reference lists. Two additional references were included on the recommendation of the reviewers.
Figure 1:
STUDY SELECTION FLOWCHART
The types of articles (n = 27) included systematic review (n = 1), literature reviews (n = 16), integrative reviews (n = 2), a case study (n = 1), a clinical practice guideline (n = 1), a consensus document (n = 1), expert opinion (n = 1), a quasi-experimental study (n = 1), and the combination of a case study with a literature review (n = 2) or integrative review (n = 1). Review topics included palliative wound care in general (n = 15); malignant fungating wounds (n = 5); PIs (n = 9), one of which was specific to Kennedy terminal ulcers; diabetic foot ulcers (n = 1); and skin changes at the end of life (n = 2). An overview of the included articles can be found in Supplemental Table 1 ( https://links.lww.com/NSW/A106 ).
Quality Appraisal
Twenty-two articles 13,16,22–40,44 were rated as level V, three articles 7,41,42 as level IV, one article as Level III, 45 and one article 43 as level II. Most articles were considered to be high (A) or good (B) quality. Two articles 31,33 were deemed low (C) quality. The level of agreement between the authors (Fleiss κ correlation) was 0.87.
Because of methodological heterogeneity, the results were synthesized narratively. In the following sections, recommendations for maintaining and promoting skin integrity in end-of-life patients were categorized as follows: (1) assessment, (2) skin care management, (3) dressings, (4) symptom control, (5) debridement, (6) patient and family involvement, and (7) wound management. The categories are composed of general recommendations and specific recommendations by wound type.
Assessment
Fifteen articles contained recommendations for assessment. Ten reported on general health assessment, six on skin assessment, and eight on wound assessment. The use of a wound assessment tool was recommended in nine articles and pain assessment tools in four articles. Six articles provided recommendations on assessment frequency. A complete overview of the recommendations can be found in Table 1 .
- 2–4 wk after first admission
- With each contact by hospice nurse practitioner or hospice medical director
Comprehensive reassessment if the PI does not show some signs of healing within 2 wk despite interventions
Abbreviations: BWAT, Bates-Jensen Wound Assessment Tool; FRAIL, For Recognition of the Adult Immobilized Life; HoRT, Hospice Pressure Ulcer Risk Assessment Scale; KTU, Kennedy terminal ulcer; MEASURE, Measure (length, width, depth, and area), Exudate (quantity and quality), Appearance (wound bed, including tissue type and amount), Suffering (pain type and level), Undermining (presence or absence), Re-evaluate (monitoring of all parameters regularly), and Edge (condition of edge and surrounding skin); PI, pressure injury; PUSH, Pressure Ulcer Scale for Healing; QoL, quality of life; S(AD) SAD, size (area, depth), sepsis, ateriopathy, and denervation; TELER, Treatment Evaluation by A Le Roux's Method; TIME, Tissue, Infection/Inflammation, Moisture balance, Edge of wound; WoSSAC, Wound Symptoms Self-Assessment Chart.
aNo recommendations were made for skin tears.
Recommendations for general health assessment focused on a patient-centered approach by assessing physical health, mental health, environmental resources, and overall quality of life (evidence levels IV-A and V-A/B). The physical assessment included information on comorbidities, medications, nutrition status, and results of diagnostic tests (evidence levels IV-A and V-B/C). Recommendations included documentation of all health problem areas, in accordance with patient/family/friend/support wishes and condition (evidence levels IV-A and V-B/C). In the case of PIs, recommendations included assessment of immobility, loss of appetite, weight loss, incontinence, reduced immune function, and peripheral vascular function (evidence level IV-A). For malignant fungating wounds, recommendations included assessment of mental health, anxiety, depression, and spiritual beliefs (level of evidence V-B).
Recommendations for skin assessment focused on documentation of the skin condition and history, such as skin-related diseases. Documentation of skin condition included information such as skin texture, temperature, and wound-related risk factors (evidence levels IV-A and V-C). In addition, a recommendation was made to assess patients’ knowledge of their skin condition (evidence level IV-A). For PIs, an overall assessment of the skin with particular attention to bony prominences was recommended (evidence level IV-A).
Recommendations for the assessment of existing wounds included documentation of the etiology, necrotic tissue, type of exudate, odor, and psychological impact of the wound (evidence level V-A to C). In addition, a pain assessment (evidence level V-B) and identification of the risks and benefits of various treatments (evidence level V-A) were recommended. In the case of a malignant fungating wound, recommendations included assessment of the existing wound, exploration of its psychological impact, and pain assessment (evidence level V-B). A multidisciplinary approach was recommended to address wound management in PIs (evidence level IV-A). An additional assessment of comfort and tolerance of compression was recommended for venous leg ulcers (evidence level V-A), and an additional assessment of the risks and indicators of nonhealing wounds was recommended for skin tears (evidence level V-A). Three tools were recommended to assess existing wounds:
(1) The “TIME” framework: Tissue, Infection, Moisture balance, and Edge of wound assessment (evidence level V-A/B),
(2) The “MEASURE” framework: Measure, Exudate, Appearance, Suffering, Undermining, Re-evaluate, Edge assessment (evidence level V-A/B), and
(3) The “FRAIL” framework: For Recognition of the Adult Immobilized Life (evidence level V-A/B).
The Treatment Evaluation of LE Roux's and Wounds Symptoms Self-Assessment Chart were recommended for the assessment of fungating wounds (evidence level V-A).
Ten instruments were recommended for the assessment of PIs: (1) the Braden scale, (2) the Norton scale, (3) the Hunters Hill Marie Curie Centre pressure score risk assessment tool, (4) the Hospice Pressure Ulcer Risk Assessment Scale, (5) the Pressure Sore Risk Assessment Scale for Palliative Care, (6) FRAIL, (7) the Palliative Performance Scale, (8) the Toronto Symptom Assessment System for wounds, (9) the Bates-Jensen Wound Assessment tool, and (10) the Pressure Ulcer Scale for Healing (PUSH; evidence levels IV-A and V-A to C). For the assessment of diabetic foot ulcers, S(AD) SAD (Size [Area, Depth], Sepsis, Ateriopathy, and Denervation) was recommended (evidence level V-A). Five assessment tools were recommended for the assessment of pain: (1) a visual analog scale, (2) a numeric rating scale, (3) the Faces Pain Rating Scale, (4) a descriptive scale, and (5) the Edmonton Symptom Assessment System-Revised (evidence level V-B/C).
It was recommended that patients be assessed at the first visit/admission (evidence levels IV-A and V-B), weekly, or when their condition changes (evidence levels IV-A and V-B/C). Skin assessment was recommended as an ongoing check as part of daily management (evidence level IV-A). Additional advice for PIs included comprehensive reassessment if there were no signs of healing within 2 weeks (evidence level IV-A). For malignant, fungating wounds, assessment by a hospice nurse or physician was recommended at the initial visit/admission, 2 to 4 weeks thereafter, and at each contact (level of evidence V-B).
Skin Care
Recommendations on skin care management were provided in 23 articles. Twelve articles provided recommendations on skin cleansing, 10 on wound cleansing/irrigation, 9 on skin moisturization, 9 on skin protection, 12 on patient repositioning, and 14 on the use of medical devices. A complete summary of the recommendations can be found in Table 2 .
Table 2 - OVERVIEW OF RECOMMENDATIONS REGARDING SKIN CARE 16,22,24,25,27–37,39–41,43,44
Additional Recommendations Based on Wound Type a
Recommendations
- Avoid adult diapers in bed
- Change underpads promptly when soiled
Abbreviations: KTU, Kennedy terminal ulcer; PI, pressure injury.
aNo recommendations were made for skin tears.
Skin cleansing included recommendations on products/materials, drying the skin, and what to avoid. Recommended products and materials for skin cleansing included the use of warm drinking water (evidence level V-A/B) in combination with liquid body wash, soap-free products, or a pH-neutral soap (evidence levels IV-A and V-A/B). Alternatively, cleansers with nonionic surfactants or pH-balanced, no-rinse cleansers were recommended (evidence levels IV-A and V-A to C). Two articles recommended the use of disposable nonwoven wipes or pouch baths (evidence levels IV-A and V-C). Additional recommendations per wound type included the use of warm saline for malignant fungating wounds (evidence level V-A) and the use of unscented bath oils for diabetic foot ulcers (evidence level V-B). For drying the skin, it was recommended to blot the skin with a soft towel (evidence level IV-A) and to take special care to dry the feet well in diabetic foot ulcers (evidence level V-A/B). Recommendations for what to avoid when cleaning the skin included traditional washing with soap and water (evidence levels IV-A and V-B/C), using cold liquids and antiseptics (evidence level V-A/B) or overdrying with hot water (evidence levels IV-A and V-A), rubbing (evidence levels IV-A and V-A), and excessive washing (evidence level V-A/B). In the case of diabetic foot ulcer, it was recommended to avoid the use of lanolin, aloe, and perfume and lotions between the toes (evidence level V-A).
Wound cleansing included recommendations on products/materials, frequency, and what to avoid. Recommended products and materials for wound cleansing included drinking water, normal saline, or a nontoxic cleanser (evidence level V-B/C). Two articles recommended wound irrigation with oral antifibrinolytics or Dakin solution (evidence level V-A/B). Warm saline was recommended for cleansing venous leg ulcers and malignant fungating wounds (evidence level V-B). Recommendations on frequency advised cleaning wounds at each dressing change (evidence level V-A/B). For malignant fungating wounds, scrubbing (evidence level V-B), wiping over the wound (evidence level V-B), and dabbing (evidence level V-B) should be avoided.
Skin moisturization included recommendations on products and methods. Recommended products included pH-balanced, fragrance-free, and nonsensitizing leave-on products (evidence levels IV-A and V-B) such as emollients, humectants, or lubricants and gels (evidence level V-B). If necessary, additional ingredients with moisturizing properties were recommended (evidence level IV-A). In the case of PIs, barrier creams were recommended (evidence level V-A). Recommended products for diabetic foot ulcers included allergen-free moisturizers (evidence level V-B) without lanolin, aloe, and perfumes (evidence level V-A). It was recommended that moisturizing products be applied regularly and in appropriate amounts by gently patting the skin and using a moisture-wicking fabric (evidence level IV-A). Articles also recommended that products be applied to all skin areas that come into contact with urine and/or feces (evidence level IV-A) and, in the case of PIs, to all high-risk areas (such as the sacrum; evidence level V-B/C).
Recommended products for skin protection included alcohol-free barrier films (evidence level V-A/B) such as zinc oxide, acrylates (evidence level V-A/B), silicone, polymers, petrolatum, cyanoacrylate, and hydrocolloids (evidence grade V-B). One article recommended RGN107 powder, a novel wound powder made from a mixture of Calendula officinalis L., Arnica montana, Mentha arvensis, and Santalum album to protect the skin (evidence level II-B). Liquid barrier films or creams such as liquid polymer acrylates, dimethicone, zinc oxide-based skin protectants, and petrolatum-based skin protectants have been recommended for the protection of malignant fungating infected wounds (evidence level V-B). Recommendations for frequency of repositioning included turning the patient every 3 to 4 hours except in the last few hours, during which patients should be turned every 8 hours (evidence level V-B) or as determined by individual tissue tolerances, mobility, (skin) condition, and treatment goals (evidence levels IV-A and V-B). The recommendations described raising the head end of the bed to a maximum of 30° (evidence level V-B/C) and considering the patient’s wish to sit in a chair (evidence level IV-A). If tolerated, it was recommended that patients with PIs be repositioned every 2 hours (evidence level V-A to C) or according to the patient’s condition and preference (evidence levels IV-A and V-B). The recommendations were that patients be repositioned with more than one person (evidence level V-B) and with the use of sliding/lifting sheets (evidence level V-A to C). For patients with venous leg ulcers, it was recommended to elevate the legs if tolerated by the patient (evidence level V-A).
Recommendations for the use of medical devices were made for adhesive tapes, pressure-relieving devices, linens, and incontinence materials. If adhesive tape is used, it was recommended to choose an appropriate tape (eg, based on silicone technology; evidence level IV-A). Postoperative bras or garments to secure dressings have been recommended for malignant fungating wounds (evidence level V-B). Bedding surfaces and pressure-redistributing pads were recommended as pressure-relieving aids (evidence level V-B). For PIs, high-specification foam mattresses, pressure-redistributing mattresses/pads (evidence level V-B/C), or other support surfaces (evidence level V-B) were recommended. Other articles recommended the use of a cushion under the knee (evidence level V-A to C) or heel protectors (evidence level V-B/A). When medical devices are used, it was recommended that they be properly positioned and maintained and that thin hydrocolloids, film dressings, barrier products, or pressure-reducing dermal gel pads be used when appropriate (evidence level IV-A).
Articles recommended keeping linens dry and wrinkle-free (evidence level V-A/B) and changing incontinence materials frequently (evidence level V-B/C). For patients with PIs, it was recommended to avoid adult diaper use in bed and to change underpads promptly if they become soiled (evidence level V-A).
Dressings
Recommendations on the use of dressings were provided by 17 articles. The articles gave recommendations on types of dressings (n = 16), how to apply/remove them (n = 8), how often to apply them (n = 2), and what to avoid (n = 1). Types of dressings were categorized into those (1) for general use, (2) according to the amount of wound exudate, (3) for malodorous wounds, (4) for bleeding wounds, and (5) for painful wounds ( Table 3 ).
Table 3 - OVERVIEW OF RECOMMENDATIONS REGARDING DRESSINGS 16,22–24,28–37,40,41,43,44
Additional Recommendations Based on Wound Type a
Recommendations
Abbreviations: KTU, Kennedy terminal ulcer; PI, pressure injury.
aNo recommendations were made for diabetic foot ulcers.
In general, conforming, nonadhesive dressings that do not limit mobility were recommended (evidence levels IV-A and V-A/B). Nonbulky and skin-colored dressings were recommended to ensure patient comfort (evidence level V-A/B). Alternatively, a permeable, nonadherent contact layer with a secondary absorbent or multilayer dressing was recommended (evidence level V-A/B). Other recommendations included dressings suitable for direct contact with skin in the wound environment (evidence level IV-A) that are bacteria-proof, have a long wearing time, and can absorb excess exudate (evidence level V-A/B). For malignant fungating wounds, nonadherent, vapor-permeable, absorbent dressings (evidence level V-A/B), nonfibrous dressing materials (evidence level V-B), or soft silicone dressings (evidence level V-A/B) were recommended. In addition, dressings with long wearing time (evidence level V-A), comfort, and aesthetics were advised (evidence level V-A/B). For PIs, pressure-relieving/protective dressings/foils or hydrocolloids were recommended (evidence level V-B). Recommendations for skin tears included the use of a nonadherent gauze dressing or a low-adherent dressing such as silicone dressings or low-adhesive foam dressings (evidence level V-A).
Recommendations for dressing selection according to the amount of wound exudate were categorized into dressings for (1) dry wounds, (2) or minimally exuding wounds, (3) mildly to moderately exuding wounds, and (4) moderately to severely exuding wounds. Recommendations for dry wounds include film dressings (evidence level A/B), hydrocolloid dressings (evidence level V-B), hydrogel dressings (evidence level V-B), and composite dressings (evidence level V-B). For minimally exuding wounds, hydrogel (evidence level A/B), hydrocolloid (evidence level V-B), or composite (evidence level V-B) dressings were recommended. For PIs, hydrogels were recommended (evidence level V-A).
Recommendations for mildly to moderately exuding wounds included hydrocolloid foam (evidence level V-A/B), foam dressings (evidence level V-A/B), soft silicones (evidence level V-A), calcium alginates (evidence level V-B), and composite dressings (evidence level V-B). Foam dressings were recommended for malignant fungating wounds (evidence level V-A/B).
Recommendations for moderately to severely exuding wounds included calcium alginates (evidence level V-A/B), composite dressings (evidence level V-B), foam dressings (evidence level V-B), and hydrofiber dressings (evidence level V-B). For malignant fungating wounds, calcium alginates (evidence level V-A/B) and hydrofiber dressings (evidence level V-B) were recommended. For venous leg ulcers, composite dressings (evidence level V-A) or lipidocolloid soft polymer silicone dressings (evidence level V-A) were recommended for wounds with low to high levels of exudate.
Recommendations for malodorous wounds included silver charcoal dressings (evidence levels II-B and V-A/B), cadexomer iodine-based topical dressings (evidence level V-A/B), and honey-based dressings (evidence level V-A). For malignant fungating wounds, foam dressings, calcium alginates (evidence level V-B), and dressings with silver (evidence levels II-B and V-A/B), charcoal (evidence levels II-B and V-A/B), and sugar paste (evidence level V-B) were recommended. For PIs, charcoal and antimicrobial dressings such as cadexomer- or iodine-based dressings (evidence level V-A) were recommended. Clot-active dressings (evidence level V-A) and calcium alginates (evidence level V-A/B) were recommended for bleeding, malignant fungating wounds, and slow-release ibuprofen foam dressings (evidence level V-B) were recommended for painful wounds. In case of painful, malignant fungating wounds, petrolatum-based dressings or antimicrobial dressings were recommended (evidence level V-B).
If traditional adhesives must be used, the adhesive should be applied on a border with a hydrocolloid around the wound to reduce topical epidermis stripping (evidence level V-A). Other recommendations for dressing application included the use of skin barrier products before application (evidence level IV-A) and marking dressings with an arrow to indicate the correct direction for removal (evidence level IV-A). For malignant fungating wounds, the use of a burn net, garments, or paper tape were recommended to secure dressings and the use of skin barrier products to protect the skin (evidence level V-B). Recommendations for venous leg ulcers included covering the wound with a moist dressing during the change (evidence level V-A), applying a barrier product (evidence level V-A), and using appropriate compression bandaging techniques (evidence level V-A). In the case of a skin tear, it was recommended to replace and secure the epidermal flap, place an arrow on the dressing indicating the direction of removal, and, if necessary, use a gauze roll and tubular dressing (evidence level V-A).
Prior to dressing removal, it was recommended to apply topical analgesics (evidence level V-B), use adhesive remover (evidence level IV-A), and/or moisten dressings (evidence level V-B/C) with warmed saline and gentle pressure, gauze soaked with 1:10,000 ephrin solution, topical low-dose thromboplastin, or silver nitrate (evidence level V-A/B). When removing dressings, it was recommended to take time, remove the dressing slowly (evidence levels IV-A and V-B), and gently pull the dressing away from the patient (evidence level V-A/B). It was advised that the frequency of dressing changes should be reduced by choosing dressings with a longer wearing time (evidence level V-A) or by changing the dressing when exudate leaks through (evidence level V-A). Dried dressings, adhesive products, wrapped gauze, and exposure to air should be avoided (evidence level V-A).
Topical Agents for Symptom Control
Recommendations on topical agents for symptom control were offered by 15 articles. The articles provided recommendations for pain control (n = 7), odor control (n = 15), prevention/treatment of bleeding (n = 4), and pruritus (n = 1). A complete summary of recommendations can be found in Table 4 .
Table 4 - OVERVIEW OF RECOMMENDATIONS REGARDING TOPICAL AGENTS FOR SYSTEM CONTROL 16,22–24,30–32,34–36,38,40,43–45
Additional Recommendations Based on Wound Type a
Recommendations
- Topical anesthetics such as lidocaine
Abbreviations: KTU, Kennedy terminal ulcer; PI, pressure injury.
aNo recommendations were made for skin tears or venous leg ulcers.
Recommended topical agents for pain control included topical analgesics such as morphine in hydrogel or a mixture of lidocaine and prilocaine (evidence level V-A/B), hydromorphone in lidocaine gel or ointment, methadone powder in stoma powder, diamorphine in hydrogel, ketamine gel, ketamine with bupivacaine, and topical lidocaine/lidocaine patch (evidence level V-B). Additional recommended agents per wound type included topical lidocaine in zinc oxide cream for malignant fungating wounds (evidence level V-A/B) and capsaicin cream for diabetic foot ulcers (evidence level V-A).
Recommended topical agents for odor control included topical metronidazole gel or cream (evidence levels III-A, II-B, and V-A to C) and antiseptics such as cadexomer iodine and povidone-iodine (evidence levels V-B), yogurt or buttermilk (evidence level V-B/C), honey (evidence level V-B), and essential oils (evidence levels V-B). Additional recommended agents for each wound type included Dakin solution (0.25% concentration) for malignant, fungating wounds (evidence level V-B).
Sucralfate (evidence level V-A/B) or topical medications such as aminocaproic acid and epinephrine 1:1,000 applied to a gauze (evidence level V-A/B) were recommended to treat or prevent bleeding. Recommended agents to reduce and treat pruritus were topical medications (such as doxepin hydrochloride, diphenhydramine, and steroids) or topical anesthetics (such as lidocaine-prilocaine cream, lidocaine, capsaicin, and menthol; evidence level V-A). Additional recommended agents per wound type included silver nitrate for malignant fungating wounds (evidence level V-B).
Debridement
Ten articles provided recommendations for debridement, categorized as surgical (n = 6), autolytic (n = 8), and enzymatic/chemical (n = 5) debridement. Three articles provided additional advice on debridement. A complete review of the recommendations can be found in Supplemental Table 2 ( https://links.lww.com/NSW/A107 ).
Articles advised performing surgical debridement with a scalpel or scissors (evidence level V-A/B). Surgical debridement was not recommended for malignant fungating wounds (evidence level V-A/B). Moisture-maintaining dressings (evidence level V-A/B) or antimicrobial dressings (evidence level V-C) were recommended to perform autolytic debridement. For malignant fungating wounds with hard scabs, hydrogels were recommended (evidence level V-B). For PIs, Drawtex (Beier Drawtex Healthcare, Centurion, South Africa) was recommended, covered with an OPSITE dressing (Smith and Nephew, Watford, England). Enzymatic/chemical debridement with topical agents (evidence level V-B) or sugar paste and honey (evidence level V-A/B) was recommended. Larvae were recommended for biological debridement (evidence level V-A/B).
Additional recommendations included the use of a local anesthetic cream during and after sharp debridement (evidence level V-A/B) and performing debridement only to the soft scab in patients with short life expectancy and poor healing (evidence level V-B).
Patient/Family Involvement
Recommendations for patient/family involvement were made by 10 articles. Recommendations were categorized as education (n = 6) and communication (n = 6). A complete overview of the recommendations can be found in Table 5 .
Table 5 - OVERVIEW OF RECOMMENDATIONS REGARDING PATIENT/FAMILY INVOLVEMENT 7,13,22,28,29,32,36,38,40,41,44
Additional Recommendations Based on Wound Type a
Recommendations
Prepare patient and family that skin failure/pus are possible
Abbreviations: KTU, Kennedy terminal ulcer; PI, pressure injury.
aNo recommendations were made for skin tears.
Recommendations for involving patients and their families in education included teaching/encouraging coping skills (evidence level V-A/B); education about wound prevention, stabilization, care options, and choices (evidence level V-A/B); and education about pain management (evidence level V-B). Additional recommendations for malignant fungating wounds included education on their management (evidence level V-B) and on the performance of dressing changes (evidence level V-A/B). In the case of PIs, additional recommended education included a focus on adequate nutrition and exercise (evidence level V-A) and maintaining skin integrity and managing PIs (evidence level V-B). In the case of venous leg ulcers, the family must be educated about the use of compression bandaging and the performance of lymphatic massage (evidence level V-A). Education recommendations for diabetic foot ulcers included proper footwear, inspection of the lower extremities and foot, glycemic control, smoking, exercise, and diet (evidence level V-A).
Communication recommendations include preparing the patient and family that the skin is failing and that wound closure may not be possible (evidence levels IV-A and V-A/B), assessing anxiety and addressing coping skills (evidence level V-A), talking with the patient during dressing changes (evidence level V-A), recognizing the patient’s comfort and discussing goal setting (evidence levels IV-A and V-A/B), and assessing psychological and cultural issues (evidence level V-A). An additional recommendation in the case of PIs included preparing the patient and family that skin failure and PIs are sometimes unavoidable (evidence level IV-A and V-A). For malignant, fungating wounds, the decision to involve a social worker, psychologist, or psychiatrist should be made with the patient and family, and financial stability should be assessed (level of evidence V-B).
Wound Management
Approaches to guide wound management were provided by five articles. The recommended approaches included “SPECIAL” (S = Stabilize the wound, P = Prevent new wounds, E = Eliminate odor, C = Control pain, I = Infection prophylaxis, A = Advanced absorbent wound dressing, L = Less dressing changes; evidence level V-A), MEASURE (evidence level V-A), symptom management (evidence level V-A), principles of palliative wound management (evidence level V-B), the five P’s for determining appropriate interventions (evidence level IV-A), “SOAPIE” (S = Subjective skin and wound assessment, O = Objective observation of skin and wound, A = Assess and document etiology, P = Plan of care, I = Implement appropriate plan of care, E = Evaluate and educate all stakeholders; evidence level IV-A), and the holistic wound care in palliative care approach (evidence level V-B). The approaches and their components are listed in Supplemental Table 3 ( https://links.lww.com/NSW/A108 ).
DISCUSSION
This review aimed to identify recommendations for promoting and maintaining skin integrity in end-of-life care and their level of evidence. At the end of life, the focus of care shifts from curative care to promoting comfort and dignity, alleviating suffering, and improving the patient’s quality of life. 5,46,47 The same transition applies to skin and wound care. 5,40 The skin of patients at the end of life is fragile and sensitive and put at risk by wound exudate, body fluids, pressure, and friction. 41 Skin integrity can no longer be maintained, and wound healing is unlikely. 5,6 However, patients and families need to be reassured that curative treatment cessation is not the end of all treatments. 44
The focus of skin care is directed toward palliation and concentrates on strategies that provide patients with the greatest comfort in controlling symptoms such as pain, odor, and bleeding. 16,22–24,31,32,34–36,38,40,43–45 As patients enter the last months of their lives, the quality of their lives must be understood from their subjective perspective in relation to their physical, functional, emotional, and social situation. 29
To achieve this goal, the guidelines recommend that caregivers take a holistic approach that begins with a patient-centered assessment. 45 Any areas of concern can be documented, and a patient-centered care plan, including skin and wound care, can be developed to meet the patient’s (and family’s) wishes. 7,13,23,29–31,35,36,40–42 Although (wound) healing is no longer the goal, it is important to set realistic goals in the care plan. 5,6,22,24 Education and communication play an important role in preparing the patient and family for the fact that the skin is failing and wound closure may not be possible. 7,22,36,40
Skin failure may elicit an emotional response, as wounds are generally aesthetically unattractive and cause pain and odor when skin failure is evident to the patient and family members. 6 Milberg et al 48 described how trust in caregivers at the end of life serves as a secure basis. It is important for caregivers to treat the patient as a unique individual and to see them as a person rather than a patient with a wound. 49
The recommendations reported in this review focused primarily on wound care, wound healing, and the management of wound-related symptoms. The use of some of the topical strategies reported and the use of the PUSH tool and the Bates Jensen tool may create an expectation toward healing despite the patient’s terminal condition. Once healing is expected or recommended, this will encourage caregivers to do everything in their power to heal the wound despite the patient’s comfort and wishes. End-of-life skin care consists of recognizing the patient’s concerns, setting realistic goals, and enhancing quality of life by improving patient comfort. Care should be flexible and focus on the patient’s wishes and the management and control of symptoms. 5 For example, seemingly important interventions such as dressing changes need to be limited because they can cause unnecessary harm and pain. Despite recommendations advising interventions such as debridement, it is important that the caregiver first assess whether the intervention will contribute to the patient’s quality of life. 49,50
Further research is needed on end-of-life skin care, with a focus on patient-centered, holistic strategies that improve patient comfort and quality of life. In most current research, recommendations are limited to literature reviews and level V evidence. More research with a higher level of evidence is needed in the field of skin care to identify and test strategies to maintain and improve skin integrity.
Limitations
Most articles included in the review were classified as level V (n = 22/27). Further, because of the methodological heterogeneity of the extracted data, only a narrative synthesis was possible. However, the aim of this review was to provide a broad range of skin care recommendations. Therefore, no limitations were placed on study design or level of evidence. Although four major databases were searched in this review, it is possible that relevant articles were not identified. However, the search strategy was optimized with the help of a library technician to match the recommendations of the various search engines, and the reference lists were screened to find additional articles.
CONCLUSIONS
The information contained in the recommendations will assist caregivers in promoting and maintaining skin integrity in patients at the end of life. However, the recommendations in this review focus specifically on wound care and the management of wound-related symptoms. Current research is limited to literature reviews and level V evidence. Further research with a high level of evidence is needed in the field of skin care to identify and test strategies to maintain and improve skin integrity in patients at the end of life.
REFERENCES
1. Hui D, Nooruddin Z, Didwaniya N, et al. Concepts and definitions for “actively dying,” “end of life,” “terminally ill,” “terminal care,” and “transition of care”: a systematic review. J Pain Symptom Manage 2014;47:77–89.