Palliative wound care
management
S J Fratesi MD
March 9 , 2016
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CARE
Hospice versus palliative care
Palliative care is symptom relief at any time
during any chronic illness , may include aggressive
/curativ T (mostly MD/nurse driven)
Hospice care is palliative ,curative therapy is not
attainable , last 6 months of life and focuses on
symptom relief and comfort(holistic)
Perspectives on Palliative Wound Care
Palliative wound care is a relatively
new field that focuses on the wound
treatment of individuals at the end
Aletha Tippett, MD
of life, those with terminal disease
or those unable to tolerate standard
care
Provide comfort measures and
manage the symptoms associated
with the person’s
condition.
Best quality of life regardless of the person’s
stage of illness
Assess the individual : age ,diagnosis ,expectation, family
support, hospice?
Assess the wound : what type, location, etiology, additional risk
factors, time present?
Drainage, Odor, Pain , Bleeding ?
Define the objectives: what does the patient expect?
how much time do they have?
what interventions will they allow?
what are the family expectations?
Palliatio in wound care involves
Interdisciplinary approach
Consideration of alternative therapies
Assessment of patient
Managing symptoms
and wound
Development of comprehensive strategies
Choosing the correct support surface
Recognition of patient empowerment
It is inappropriate to ignore wounds or declare them
untreatable or unpreventable in individuals at the end of
life.
Palliative wound care is ideal for those wounds in which the
underlying etiology does not respond to treatment or the
demands of treatment are beyond the person’s tolerance or
stamina.
Good palliative care can result in wound healing in nearly
half of individuals receiving treatment.
Skin Failure at end of Life
an event in which the skin and underlying tissue
die due to hypoperfusion that occurs concurrent
with severe dysfunction or failure of other organ
systems. Skin failure can be categorized as acute,
chronic, or end stage. Pressure ulcers, a type of
skin death, frequently occur in persons with a
heavy disease burden, especially those at or near
the end of life, despite good care”
Diane Langemo RN PhD
Definitions
A wound is an break in the continuit of the
skin
The ski
respons to insult is t restor the
integrity of the structure
Wounds are considered acute or chronic and
hea either b primar o secondar intention
The Ski …20 square feet
surface
3 layers….Epidermis
….Dermis
.... Subcutaneous tissue
Stages of Wound Healing
Inflammatory
Proliferative
Maturation or
Remodeling
Healing: cellular communication
Tissue damage
Healing/repair
Hemostasis
PDGF IL-1
Inflammation
MMP-9 MMP-2
PDGF FGF VEGF
TIMP-1 TGF-B
Angiogenesis
TNF-A
PDGF MMP_8
TIMP-2
Granulation tissue
KGF
Epithelialization
EGF
Monaco JL, Lawrence TL. Acute wound
Remodeling
healing; an overview. Clinics in Plastic
Surgery 30 (2003): 1-12..
The no healing wound
Growth factors
Cell proliferation
Proteases
Bioburden
u High levels of harmful
proteases (MMP)
u Low levels of growth
factors
u Bioburden
u Minimal cell proliferation
†Falanga V. The Chronic Wound: Impaired Healing and Solutions in the Context of Wound Bed
Preparation. Blood Cells and Diseases, 2004;32:88-94
No healing
Deficient growth factors
Diminished granulation
Delaye epithelialization
Defective ECM formation
Excessive protease formation
HOW MUCH DOES IT COST ?
WHO IS GOING TO PAY?
Interactive wound dressings
Transparent films
Hydrocolloid
Hydrogels
Exudate absorbers
Combination dressings
Specialized foam dressings
Special impregnated dressings
(carbon/silv
)
Gauze dressings
woven or nonwoven traditional dressing
Highly permeable and relatively non-occlusive
relatively cheap and for one time or short-term use
can be used as primary or secondary dressing
available in many forms
may cause trauma and desiccation to the wound
Gauze alerts:
Dressing of choice for:
maybe difficult to
frequent dressing changes
remove
decrease cost
may leave residue
infected wounds with enzymatic debriding agents
may dehydrate and
wounds requiring packing
desiccate
me act as tourniquet
if rolled gauze used
Impregnated gauze
dressings
usually a mesh gauze dressing impregnated with petrolatum, bismuth or zinc
used a contact layer and requires a secondary dressing
nonadherent
increases the occlusiveness of the standard gauze dressing
Common uses : (Adaptic)
contact layer on a granulating wound bed
Precautions:
painful wounds
may be cytotoxic to the wound
wounds that bleed easily
and surrounding skin
wound was exposed deep tissue
may impair epithelialization
burn wounds
epithelializing wounds
Films
thin, flexible transparent polyurethane with adhesive
permeable to water vapor, O2,CO2,
impermeable to bacteria and water
little absorptive capacity
allows for visualization of wound
highly elastic and conforms to body contour
Common uses:(Opsite, Tegaderm
Disadvantages:
semi-permeable)
may cause maceration
superficial wounds and lacerations
edges often roll
and abrasions areas of friction
difficulty getting a seal
partial thickness wounds and
cannot be used in
donor graft sites
heavily exudative or
granular wounds and yellow
infected
slough wounds with minimal
drainage
Hydrogels
80 to 99% water or glycerin for autolytic debridement
Gels, sheets or impregnated gauze
donates moisture to dry wounds
decreases pain and reduce pressure
non-adhesive and requires a secondary dressing
Uses:
pressure sores
may dehydrate
blisters
unable to be used in heavily draining
minimally draining wounds
or infected wounds
abrasions
skin tears
superficial burns
splint padding
donor sites
Foam dressings
semipermeable foam made from polyurethane has a
hydrophilic wound side and hydrophobic outside
permeable to gas but not the bacteria with a high moisture
vapor transmission rate
provide thermal insulation
less likely to cause trauma upon removal
easy to apply and excellent use on pressure sores
Uses: minimal to heavy exudate wounds
Caution:
granulating or slough covered partial thickness
not to be used in dry or
minor burns
eschar covered wounds or
skin grafts
arterial ulcers
donor sites
not ideal for heel ulcers or
ostomy sites
areas of friction
pressure ulcers
venous ulcers
diabetic ulcers
Hydrocolloids
contain hydrophilic colloidal particles with a a strong film or
foam adhesive backing
absorbs fluid slowly by swelling into gel like mass
residue after removal
provides thermal insulation
impermeable to water oxygen and bacteria
least likely of to get infected
effective barrier against urine and stool ,MRSA, hepatitis B
and HIV and Pseudomonas
Limitations:
traumatize fragile periwound, often needs skin sealant on
normal skin
Uses:
no use in dry wounds ,arterial ulcers,3rd degree burns , minima
pressure sores
draining wounds,over tendons/fascia
venous ulcers
may cause hypergranulation
burns
should not be used in infected/bleeding wounds/heavily
exudating
Calcium alginate dressings
brown seaweed
bsorbs exudate
Maintains moist environment
Forms a gel from serum and exudate
hemostatic properties
Good for draining or purulent wounds
Gel may harden and form plug
No use in the dry wound or contained space
Highly permeable nonocclusiv needing
secondary dressing
Used with skin sealant for
periwound
Not for 3rd degree burns, or
exposed bone or tendon
Absorbs 20X weight
For draining wounds never dry
Needs secondary dressing
Composite dressings
usually multilayered dressing
may be primary or secondary
most have 3 layers
inner layer is the contact layer and is non adherent
middle layer is the absorptive/ moisture control which
prevents maceration but maintains the wound bed
the is a bacterial barrier usually a semipermeable film
Aquacel
Soft hydrophillic ,non woven, hydrocolloid fibres
Aborbs with contact…..Forms a gel
Useful chronic dirty wounds ,wounds healing by
2 * intent
Provides moist environment ,autolytic
debridement and easily removed
When combined with silver gives
immediate/sustained antimicrobial activity
,pseudomonas, staph ,MRSA, VRE
Silver dressings
Aquacel silver,Acticoat silver,Actisol silver
Initially burns, skin grafts, trauma chronic
wounds , ulcers and diabetic feet
Change weekly antimicrobial
Useful for foul malodorous wounds often in
conjunction with charcoal
Iodosorb
Form of Cadexomer iodine
Absorbs fluid
Removes exudate/slough
Forms protective gel
Release of iodine as wound swells-kills BT
Caution with those on thyroid medication
V.A.C therap ?
V.A.C. stand f
:
acuum ssiste losu
V.A. . is a noninvasive, active woun closure
system that uses controlled, localized negative
pressure to promote healing in acute and
chronic wounds.
Solutions
Water
Saline
¼ S Acetic acid
Hygel/1/20
What should we consider?
Pressure sores
Malignant wounds
Chronic wounds .:arterial
: venous
: lymphedema
Radiated wounds
Complex wounds
No specific criteria
Can include both acute and chronic
One or more of the following must be present:
1.
Extensive loss of integument
2.
Infection as a complication
3.
Compromised viability of tissues , necrosis or
circulation
4.
Association with systemic pathology
Most common complex wounds
Wounds in diabetic extremities
Pressure ulcers
Chronic venous ulcers
Arterial ulcers
Chronic wounds o vasculiti or
immunosuppression
TIME
T (tissue)
I (infection or inflammation)
M (moisture balance)
E (edge of wound)
New developments in TIME
Biofilms
Evolution of topical antiseptic therapy(silver,
cadoxemer iodine, PHMB)
Advanced use of NPWT
Molecular biologic processes in chronic wounds
Control of wound drainage an periwound
protection in dressing development
The goals of wound assessment
Wound etiology: arterial/venous
/diabetic/pressure sore
Pathophysiology of wound failure
Factors interfering with healing or treatment
The category and classification of the wound
RESTORATION or MAINTENANCE ?
A wound which likely will not heal
Improvement in quality of life, dignity and self
image
Control of pain , bleeding ,odour and drainage
Treatment must be individualized and involve
the patien andfamily
Wound assessment
location
size
Wound characteristics
Wound location
drainage
tunnel
Wound
Wound size
assessment
Tunneling/undermining
Wound bed
Wound edges
edge
bed
Wound drainage
Wound pain
Wound odour
Wound bed preparation
Bacterial
Exudate
Debridement
burden
management
+
+
Must optimize the wound healing environment to provide a clean, moist , warm granulating
wound bed that also protects the periwound area and skin
Debridement
u Decrease bacterial burden
u Increase effectiveness of topicals
u Increase effectiveness of leukocytes
u Shorten the inflammatory phase
u Free up energy
u Remove barriers to healing
u Decrease odour
General considerations for
debridement
Contraindications
Red granular wound
Patient
Clinician
Wound
Heel ulcers with dry eschar that are not
characteristics
characteristics
characteristics
red, hot edematous or fluctuant
There is no alternative to surgical
debridement
if that is what is needed
Methods of debridement
Sharp
Surgical
Autolytic
Biological
Mechanical
Enzymatic
Debride
YES
NO
u combination of dry
eschar and cellulitis,
u firmly attached, hard dry eschar
exudate or odor
u underlying vascular disease and associated
gangrene(assess & correct)
u antimicrobial therapy
and sharp debridement
u no clear line of demarcation
of the eschar for proper
u dry gangrene may auto-amputate itself
drainage of the wound
u in wet gangrene aggressive debridement may
aggravate further tissue damage and actually
spread the gangrene or make wound more
susceptible to infection and create need for
higher amputation
Infection
Built- in protection from:
Slightly acidic pH
Epithelial cells and lipids
Immune cells
Resident microflora (10 (3)
Bacterial Colon ount
Contamination (N)……….microbes on wound surface……….no clinical effect
Colonization (N)………..replicating microbes on wound surface……no clinical effect
Critical colonization(Abn)…..increasing bioburden reaching critical point…….
plateau or decline in wound status
Infection (Abn)………replicating microbes invade viable tissue(10(6))…..
Decline in wound status ,signs and symptoms of infection
Risk factors for infection
Exposed wound
Chronic wound
Break in skin continuity
Dry or cracked skin or callus
Ischemia
Presence of necrotic debris
Host integrity
Alterations in skin barrier
Infection or inflammation
rubor
Functio
calor
laesa
dolor
tumor
Drainage and decline in status of wound
iagnose infection
Tissue
biopsy
Blood
Swab
tests
cultures
Fluid
aspiration
What do wound dressings do?
Maintain the proper moist environment
If wound is to wet ……must absorb moisture
If wound is dry must add moisture to wound
Wound dressing function
Provide thermal insulation
Provide a barrier to microorganisms
Protect exposed nerves to decrease pain
Eliminate dead space to prevent premature contraction
or abscess formation
Assist the body with removal of necrotic tissue and
debris
Provide gas exchange between the wound and
surrounding environment
ategories of dressings
Primary or contact layer
Secondary layer which acts as a occlusive or absorptive or
protective dressing
Spectrum of wound dressings
Gauze
Hydrogel
Impregnated
gauze
Miscellaneous
dressings
Composite
Film
Foam
Hydrocolloid
Alginate
there are 8 major categories of dressings with over 3000 different products
Evidence base
1. There is no evidence to indicate which dressings are most
effective
2. There is no level A evidence to support specific dressings
3. There is level B evidence that suggests that Hydrocolloid
dressings are better than saline or paraffin for overall healing
and alginates are ideal for heavily exudative wounds
Dressings
1.
Wound healing is optimal in a moist
environment
1. Occlusive and semi-occlusive
dressings were developed to promote
healing time, absorb blood and
exudate and be painless and easy to
apply and remove
Consensus opinion for management
1. Hydrogels are useful in the debridement stage of
wound healing
2. Foam and low adherence dressings are useful for the
granulation stage
3. Hydrocolloid and light foam dressings are useful for
epithelialization
4. Charcoal is useful for malodorous wounds
5. Alginate’s are useful for exudating or hemorrhagic
wounds
6. Low adherence dressings are useful for fragile skin
*There is no evidence or consensus opinion
to support claims that specific dressings
such as silver containing dressings are most
appropriate for selected indications such as
caring for infected wounds or prevention of
infection
Clinical Decisio
aking
Two key questions must be answered to determine the most
appropriate local wound care
Is the wound draining or non-draining?
Is the wound granular or necrotic?
Dressing for
Dressing for non
draining wound
draining wound
Protect periwound
Prevent evaporative
from maceration
fluid loss
Absorb
Provide
moisture
moisture
Granular/Necrotic
Dressing for
Dressing for
granular wounds
necrotic wounds
Protect from
Assist with
trauma
debridement
Decision Grid
Granular
Granular
1. Granular and nondraining
X draining
draining
2. Granular and draining
3. Necrotic and nondraining
4. Necrotic and draining
Necrotic
Necrotic
X draining
draining
Infected wounds
1.
should not be occluded and should be re-bandaged frequently
2.
good dressing choices usually involve a gauze dressing with additional gauze
lairs over alginate’s, semipermeable foams or antimicrobial dressings
NUTRITION
Necessary for epithelialization, collagen
synthesis, immune function , cellular
cohesiveness
Low proteins lead to edema and decreased
resistance to infection
Key factor in wound breakdown and impaired
healing
As we get older...
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As the skin ages:
Decreased fatty layers(more bony prominence
with less protection)
Decreased cro linking of collagen/elastin(poor
recoil)
Decreased dermal thickening(thin skin)
Decreased rete ridges (flatter basement
membrane leading increased skin tears)
Skin in the aging
Loss of elasticity
decreased hydration
decreased nutrition
increased vulnerability
....As such the following occurs :
prone to ski tears,shear and friction
slow to heal (poor nutrition /sensation
Palliative wound care
Pressure sores
Skin Failure
Fungating /malignant wound management
Complex abdomina wounds
Ulcers in end stag arterial,veno
, lymphedema and
diabetic limbs
End stage arterial ischemia (gangrene)
Malignant Fungatin wounds
10% of advanced malignancies have a cutaneous wound
May be primary, metastatic or develop in old scar
wound(radiation, ulcer, burn , lymphedema)
Commonly seen with breast, head and neck and genito-urinary
tumours, plus locally advance skin cancers
Most increase in size/deteriorate
Intent is not to heal/cure rather to improve quality of life
Advanced CA of breast
Ulcer over groin(GU tumour)
The PRESSURE Sore
1. The exertion of pressure greater than 32mmHg. will cause tissue
necrosis due to occlusion of blood flow, ischemia and ultimately cell death
in a healthy patient. It may be much lower in the compromised or bed-
ridden elderly patient
2. High risk patients can develop pressure ulcers within 6 hours or less.
3. Hospital mattresses and basic chair seating can exert pressures from 90 -
150mmHg.
4. Muscle and subcutaneous tissues are more vulnerable to pressure induced
tissue necrosis than are tissues of the dermis and epidermis
5. Pressure is greatest at points where skin and soft tissues are compressed
between bony prominences and the bed or chair.
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n Relieve the pressure
n Mobilize
n Turn frequently
n Lubricants & protective dressings
n Mechanical loading and support
n The above is common knowledge..are we just paying lip service or
too overworked to do?
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Supine position
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Ischial tuberosity
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Pressure
Shear
Friction
Moisture
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?
Friction is surface skin damage caused by
skin rubbing against another surface
Example - elbow and heels rubbing against
the sheet
Exposes the soft, moist epidermal layers
Superficial abrasion
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©Connie Harris E.T. NOW 2003
KCI Medical Canada, Inc. Copyright © 2003.
Tearing and
separation of deep
tissues. Tissue and
bone move in opposite
directions - resulting
in disruption or
angulation of blood
vessels
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n Prolonged exposure to moisture results in
maceration.
n Skin becomes soft and wrinkled.
n Defined white area
n Epidermis becomes more susceptible to
friction and infection.
n Incontinent residents are 5 times more likely
to develop skin breakdown.
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KCI Medical Canada, Inc. Copyright © 2003.
5 Simple steps to reducing the incidence of
skin Breakdown:
n Quic clea u of soiled or diaphoretic skin.
n Routine cleansing of skin to provide daily
inspection
n Moisturize immediately (while skin is still damp)
Barrier Crea to reduce dryness.
n Prompt Rx for redness and rash.
n Avoi massage of bony prominences.
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Disease processes - PVD, diabetes
Mobility and activity
Cognition
Nutrition, hydration
Sensation
Aging
Medication
Pain
Compromised immune system
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KCI Medical Canada, Inc. Copyright © 2003.
Risk Assessment …BRADEN
Ulcer Risk Score
1
2
3
4
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction/ Shear
Assessing a pressure sore
Pressure sore risk Assessment
Scale for palliative Care
Sensation,
Scorecard 7-28
Mobility
12 or under-low risk
13-17-medium risk
Moisture
18-21-high risk
Activity in bed or chair
22 or greater-very high risk
Nutrition and weight change
Skin condition
Do weekly
Friction and shear
1
2
3
4
5 cm
What stage is it?
Wound Evaluation
Granulation
Eschar
Slough
Other (bone, joint, etc.)
Fibrous
Woun Evaluation
Documen the Ulcer
IAET Stage I
IAET Stage I Schematic
IAET Stage II
IAET Stage II Schematic
How would you describe the ulcer base?
Woun Evaluation
Documen the Ulcer
IAET Stage III
IAET Stage III Schematic
IAET Stage IV
IAET Stage IV Schematic
The non -stageable pressure ulcer
The suspected deep tissue injury
Kennedy terminal ulcer
Pressure sore
PRESSURE SORES
n Relieve the pressure
n Mobilize
n Turn frequently
n Lubricants & protective dressings
n Mechanical loading and support
n The above is common knowledge..are we just paying lip service or
too overworked to do?
Evidenc based practice
Reposition q4h on pressure relief system and
q2h on regular surface B grade evidence
Best to have several small feeds daily and allow
patient preference with food an drink,grad C
evidence
* Brown ,G Long term outcomes of full thickness
pressure ulcers: Healing and mortality, Ostomy Wound
Management 2003”
Factors impeding wound healing
Ischemia
Venous insufficiency
Trauma
Deformity
Neuropathy
Bioload
Dressing selection
Systemic (nutrition, diabetes, CRF)
Chronic wounds
Failure to heal(40% at
w )
Failure to proceed through an orderly
or timely repair process
Lack of functional or anatomical
stability
Presence of inflammation, ischemia,
pressure or diabetes
Chronic wound
Often thickened or rolled wound edges (epibole)
Pe wound skin
Examine around the wound then focus on
wound
Look for color, temperature and abnormal
pigmentation
Look for edema or induration
Look for nodules ,fibrosis, induration or
fluctuance
In the US reportable if full thickness
ulcer acquired during hospitalization
Evolve predictably but often delay in
appearance on skin
Not all pressure ulcers are avoidable
Skin Failure/Kennedy Ulcer
Not all ulcer development is avoidable
Ideal expectations
Control odour
Control pain
Control bleeding
Control leakage
Improve both physical/psychological comfort
Odour
Often most concerning to patient and family
May be due to type and frequency of dressing change
May be bacterial overgrowth or necrosis of fungating /malignant
wounds
Assessed only after debridement and cleansing
Subjective
Should only be described as positive or negative
Old bandages , body odour, incontinence ,
infection , treatment modality(VAC ,hydrocolloid)
Odour
Anaerobic BT/necrotic tissue
Putrecine,cadaverine
Klebsiella,pseuomonas, proteus
Characteristic odour
dour
Flagyl (metronidazole), gel or mixture as irrigating solution
Charcoal
Silver dressings/Iodosorb
Honey/sugar paste mixture
Hygel(sodium hypochlorite)
More frequent dressing change(inner/outer)
Pain
Most dreaded complication
Not all can be prevented
Medicate before dressing change
Wet wound before dressing change
Minimize dressing changes
PO/topical analgesia
Morphine gel, ibuprophhen gel and pads
Local anaesethic gel dressing
Gabaclon
Wound bleeding
Major complication of end stage, infected fungating or malignant wounds
Often feeling of impending doom
Occur with dressing change or spontaneous
Alginate, surgicel , silver nitrate adrenalin solutions
MAY BE END OF LIFE SITUATON!
Exudate/ drainage
The importance of periwound
Pouching systems
Absorptive s foams
Alginates
Hydrofiber diapers
New mepilex transfer
Wound drainage
Colour
Type
Consistency
Amount
Clear
Serous
Thin/watery
None
Yellow
Sanguinous
thick
Minimal
Red
Serosanguinous
Moderate
Dark brown
Purulent
Copious
Blue -green
seropurulent
Exudate/Drainage
In malignant wounds may be due to tumour capillary
fragility, necrosis or infection
Un non malignant wounds may be due to complication
of the complex wound/inflammatory response
Breakdown of surrounding periwound (normal tissue)
Clear
Serous
Thin/watery
None
Yellow
Sanguinous
thick
Minimal
Red
Serosanguinous
Moderate
Dark brown
Purulent
Copious
Blue -green
seropurulent
VIT A
VIT C
CA/MG
Nutrition
VIT E
PROTEINS
ZINC
D F cocktail
Vitamin C
Zinc
Argiment
Glutament
HMB
Radiated tissue
Primary, adjuvant or palliative
Dose, volume, frequency
Cumulative weeks to years
edema
blistering
atrophy/ulceration
Radiation burn
End stage lymphedema
Chronic lymphedema
Chronic lymphedema
The diabetic foot
Diabetic ulcer in Charcot foot
Rook boots
Ischemic diabetic foot
CREST syndrome
Ischemic ulcer
End stage arterial disease
End stage arterial disease
End stage ischemic limbs
Chronic venou insufficency
Chronic venous leg ulcer
Pos phlebiti leg
Pressur sor
Heel ulcer
Leg trauma
Advanced CA of breast
Locally invasive skin cancer
Ulcer over groin(GU tumour)
Rook boots
References
“Perspectives on palliative wound care: Interprofessional
strategies for the management of palliative wounds”:Tippett
et al : www.woundsource.com (2012)
“Palliative wound care at the end of life”: Hughes et al: Home
Health Care anagement and practice/April 2005
Wound care essentials : Practice Principles 3rd edition::Baranoski, S and
Ayello, E : “Palliative Wound Care”:Langemo, D