Historically, there has been much debate on how we manage and treat wounds at the EoL; do we proactively treat or manage conservatively, ensuring that patient comfort and dignity are maintained? Schofield (2014) argues that there is evidence to suggest that skin management at the EoL is often an ignored ‘phenomenon’. However, it cannot go unnoticed that potential loss of skin integrity in this patient group poses a risk. Patients who are approaching EoL have a compromised circulatory system, as the blood attempts to reach the most vital organ first and foremost. In turn, this impacts on skin perfusion, hence the skin has a reduced ability in maintaining integrity (Ripley, 2006).

Patients with an advanced disease are predisposed to loss of skin integrity (Maida et al, 2012). This is due to several complex factors including lack of nutrition, poor circulatory function and poor immune function. It is also worth noting that pain medication can also impact on skin integrity at the EoL.

In a study completed by Martin et al (2010), cited in Egydio, (2011) it was identified that the chronic use of morphine impacts on the immune system, preventing immune cells from reaching the wound site, hence the delay in wound healing. Therefore, attention needs to be given to the ethical principles to weigh up the balance of wound management to alleviating the patient’s symptoms and ensuring quality of life (Nursing and Midwifery Council, 2018). For those patients with fungating tumours, healing is not a realistic goal, therefore, the management of pain, anxiety, malodour and potential bleeding is a more appropriate patient-centred approach.

Wound care is a complex and multi-dimensional aspect of nursing; as well as assessing and monitoring the wound the nurse needs to assess the patient’s psychological and emotional well-being. The nurse’s role in management of patients at the EoL is a supportive one. It is fundamental that everyone involved in patient care is educated and understands that complete wound healing may not be achieved. For this to be accomplished appropriate communication and interpersonal skills need to be utilised. Communication is by far the most powerful tool of the practitioner — it cannot be under-estimated. Effective communication skills will inform and educate both patient and family in a sensitive, compassionate and empathic manner, as well as building and developing the desired therapeutic relationship.

Scott (2010) identified that there are public and professional concerns that nurses have lost the ability to build therapeutic contact with patients. Educators and clinical settings have a duty to ensure that learners are taught the importance of the most basic, yet fundamental skill in nursing to ensure maximum patient experience and outcome.
 
Regardless of nursing role, we adhere to the same professional code ‘…that set standards to preserve safety, practice effectively and promote trust and professionalism (NMC 2018)’. 
 

It is recognised that pressure ulcer prevalence is significantly higher in EoL patients, therefore, prevention is key. We should question, is the risk tool in place, how often is this updated, is the patient nursed on appropriate equipment, taking into consideration the imminent deterioration, have we educated the patient, family and carers on the importance of pressure relief? Unfortunately, there are some incidences when pressure ulcers or loss of skin integrity cannot be avoided in the dying patient. It is worth noting that wounds in EoL patients are not solely confined to pressure ulcers, damage to skin integrity may include surgical wounds, lymphoedema, and leg ulcers all of which need to be managed to ensure patient comfort and dignity.

The management of malodorous wounds is often a challenging area of wound management; it can be distressing for all involved; clinician, patient and family. It has significant psychological impact on the patient and can leave them feeling social isolated, anxious, and depressed. The nurse needs to have the skills, knowledge and empathy to manage this aspect of wound care. Malodour needs to be addressed as part of the wound assessment, what is the cause of the malodour? Is it simply that the wound needs more frequent dressing change or is it that bacterial burden needs topical antimicrobial treatment?

Annesley (2019) recognised that early referral to specialise tissue viability services is imperative to ensure that we achieve the best outcome for the patient at the end of life. However, in today’s climate and with current challenges to services within the NHS, it is essential that the community nurses have the skills to manage these patients too. As community specialist practitioners, these clinicians are specialist within their own fields and this needs to be utilised to its maximum benefit.  With an ever-increasing elderly population and more people expressing a wish to die at home this will be an ever-increasing issue, hence a proactive management now will reap the benefits in the future. The influence of a multi-disciplinary approach at the end of life can have a positive impact on both patient and family, the sharing of skills and knowledge to achieve the most desirable outcome - patient comfort, dignity and quality of life maintained, with a family and care givers feeling supported and valued.
Wound care at the end of life care is a complex and challenging aspect of nursing, however, there is only ONE opportunity to get it right; there is no practice or rehearsal. In the words of the pioneer who recognised the importance of holistic care…. ‘How people die remains in the memory of those who life on’ Dame Cicely Saunders (cited in Department of Health, 2011).