Volume 26 Number 2

Key Points

• Pressure ulcers are the most common wound aetiology requiring a palliative approach to wound care.
• Clinicians identify pain, exudate and odour among the most common challenges encountered in providing care.
• Symptom management including pain, exudate and odour have been identified as priorities for future research
• Palliative wound care requires a multidisciplinary patient centered approach.

Introduction

The European Wound Management Association (EWMA) aims to raise awareness, support education and influence policy related to specific topics in wound management. One of these has been palliative wound care. In 2025, EWMA released the latest of these documents which focused on palliative wound care. In this context palliative wound care is defined as “person and family centred, holistic and interdisciplinary care of wounds that may heal, or not, or may be too onerous to treat; including but not limited to symptom control and management, for individuals who are often vulnerable and have impaired quality of life”.¹ To support the work of this document the authors wished to include the perspectives of clinicians on the priorities for research in the field and to better gauge their concerns when managing patients requiring a palliative wound care approach. Therefore, a survey was conducted. The aim was to determine from clinicians and researchers what type of wounds they encounter that require a palliative approach to care and what concerns they had for management and priorities for research.

Methods

This was a cross-sectional study and will be reported in line with the Consensus-based checklist for Reporting Of Survey Studies (CROSS).²

Data collection methods

Through an iterative process the author group developed an online survey using LimeSurvey. The survey contained a total of 30 questions. Out of these, 8 were demographic questions, focussing on aspects such as profession, years of experiences, country of residence, and level of education in wound care. The remaining 22 questions covered topics including clinical practice challenges in palliative wound care and research priorities. The questionnaire was anonymous and included a consent question at the start, ensuring participants agreed to participate voluntarily. The survey was distributed in December 2023 with one email reminder in early January 2024. The survey was closed at end of January 2024.

Sampling techniques

The final questionnaire was sent with a cover letter to members of EWMA and to co-operating organisations of EWMA for distribution to its members. Upon receipt of the email invitation, members were free to opt to click on the study link or ignore the email. The author group did not request email addresses at any stage in the process and participants had the option to leave the survey at any point. Thus, the authors did not have a sample size and therefore no target response rate was set.

Statistical analysis

Descriptive statistical analysis was completed within LimeSurvey. No attempts were made to correlate response by location, profession or years of experience. Four free text questions were included at the end of the survey. In anticipation of a large variety of responses we planned to export responses into the ChatGPT (large language model) program9 to summarise results. The summarised data were compared to the original data by two authors to check for accuracy and consistency and searches were undertaken within the responses to identify the most frequently occurring words to ensure they concurred with the results.

Ethical considerations

The survey did not collect health-related or personally identifiable data. According to the Swiss Human Research Act (HRA), which governs research involving human subjects in Switzerland, studies that do not involve health-related personal data, biological material, or interventions with human subjects are exempt from mandatory ethical review. Therefore, it was not necessary to seek approval from an ethics committee for this study.

Results

Respondent characteristics

In all 513 people completed the survey, incluing 333 nurses and 102 medical doctors (n=102), making them the most common respondents. Participants had a high level of experience and education in wound care. The level of education was as identified by the respondents with acknowledgement that different institutions and countries use different terms for the duration and level of their studies, see Table 2. Of the respondents 10.4% (n=52) had 1–5 years’ experience since qualification; 12.6% (n=63) had 6–10 years; 24% (n=120) had 11–20 years and 53% (n=53%) had over 20 years’ experience. Respondents were also highly engaged in wound care practice. Asked how much of their working week was spent in wound care 32%, (n=160) reported spending 0–20% of their time on wound care; 19%, (n=96); reported spending 20–40% of their working week; 13% (n=67) reported spending 40–60%; and 35% (n=175) reported spending >60% of their week.

 

Table 1. Profession of participants (presented as number of respondents)

 

Table 2. Respondents’ highest levels of education in wound management.

 

An international perspective was represented as respondents came from 62 different countries with the top 20 presented in Table 3.

The age range of patients treated by respondents represented increasing prevalence with increasing age: 2% (n=11)  said their patients were aged 20–39 years; 12% (n=60) said their patients were aged 40-59; 64% (n=313) said their patients were 60–80 years; and 21% (n=104) said their patients were  >80 years old.

 

Table 3. Top 20 respondents by country

 

Main findings

The frequency with which respondents encountered patients with chronic wounds or non-healable wounds was very high, see Tables 4 and 5.

 

Table 4. Frequency with which you encounter patients with chronic wounds

 

Table 5. Frequency with which you encounter patients with non-healable wounds

 

The location of wounds requiring a palliative approach was mainly the legs followed by the buttocks, see Figure 1. When asked to describe the appearance of the wounds the most frequent was ‘ulcerated’, see Figure 2. Note that for the last question more than one response could be provided.

Finally, the two most frequent aetiologies of wounds requiring a palliative wound care approach were pressure ulcers (n=306) and malignant fungating wounds (n=270), see Figure 3.

 

Figure 1. Most frequent location of wounds requiring palliative wound care

 

Figure 2. Appearance of the wounds requiring palliative care seen in last three months
(more than one answer can be provided)

 

Figure 3. Aetiology of wounds requiring a palliative wound care approach

 

Guidelines

38% of the respondents (n=197) reported having clinical practice guidelines in their area of practice. These were developed by: local groups (34%, n=67); international groups (28%, n=55); national groups (30%, n= 59); other (6%, n=12).

Patient and clinician challenges in managing wounds

On average 450 free text responses were provided for each of the free text questions. Given the range and number of responses the final top 10 most frequently recorded are reported here in descending order.

Q1: In your experience what are the top three challenges patients face in managing wounds requiring palliative care?

Key challenges identified:

1. Pain management:

• Persistent and severe pain, particularly during dressing changes and as a result of chronic wounds.
• Patients often struggle with inadequate pain relief or the need for frequent adjustments to pain management regimens.

2. Odour control:

• Malodourous wounds are a significant source of distress for patients, impacting their dignity, self-esteem and willingness to engage in social interactions.

3. Exudate management:

• High levels of exudate cause discomfort, frequent dressing changes, and difficulties maintaining hygiene. Leakage can further affect quality of life.

4. Emotional and psychological impact:

• Patients often experience shame, embarrassment, or isolation due to their wounds. Visible or odourous wounds can affect body image and contribute to depression and anxiety.

5. Access to resources:

• Limited access to affordable and effective wound care supplies, particularly in resource-constrained settings, was a recurring concern.
• Some patients lack support from trained caregivers or access to healthcare services, especially in rural or underserved areas.

6. Quality of life:

• Non-healing wounds affect daily living, mobility and overall comfort. Patients struggle with maintaining dignity and adapting to their condition.

7. Family and caregiver challenges:

• Family members often lack adequate training to manage wounds at home, contributing to anxiety and difficulties in providing care.
• The emotional toll on caregivers can be high, especially when managing complex or non-healing wounds.

8. Economic burden:

• The high cost of wound care products and services poses significant financial strain on patients and their families.

Q2: In your opinion what are the top three challenges you face in managing wounds requiring palliative care?

Key challenges identified:

1. Pain management: Patients frequently report pain as a significant challenge, both from the wound itself and during dressing changes.

2. Odour control: Managing the smell from wounds is a major concern, as it affects dignity and social interactions.

3. Exudate management: High levels of exudate or fluid discharge lead to discomfort, frequent dressing changes, and difficulties maintaining hygiene.

4. Infection prevention: Preventing and managing infections is crucial due to the compromised health status of palliative care patients.

5. Psychosocial impact: Patients face emotional distress, stigma, and challenges in maintaining a positive body image due to the condition of their wounds.

6. Access to resources: Limited availability of appropriate dressings, financial constraints, and inadequate home care support are significant barriers.

7. Communication and education: Patients and their families often struggle with understanding the prognosis, the goals of care, and the management of chronic wounds.

8. Quality of life: Ensuring comfort and maintaining dignity are recurring themes, with patients desiring holistic care focused on symptom relief and overall well-being.

9. Bleeding risks: For some patients, managing bleeding from wounds, especially fungating or oncological ones, is a persistent challenge.

10. Multidisciplinary support: A lack of coordinated care between healthcare professionals often complicates wound management.

Q3: In your opinion what are the top three concerns you have during the care of patients with palliative wounds.

Most frequent concerns:

1. Pain management: Repeated emphasis on minimising pain during dressing changes, ongoing pain relief, and overall comfort.

2. Infection control: Concerns about preventing and managing infections due to high risk in palliative wounds.

3. Odour and exudate management: Managing the smell and fluid discharge from wounds to preserve dignity and quality of life.

4. Comfort and quality of life: Ensuring patient comfort, maintaining dignity, and addressing both physical and psychological needs.

5. Communication and education: Clear explanation of prognosis, treatment options, and wound care education for patients and families.

6. Bleeding and hemorrhage: Managing risks of uncontrolled bleeding, especially in advanced or fungating wounds.

7. Resource challenges: Availability and cost of appropriate dressings and ensuring access to skilled care.

Q4: What do you consider as a priority for research in the field of palliative wound care?

Key research priorities:

1. Symptom management:

• Effective pain management techniques, including local analgesics and non-pharmacological interventions.
• Strategies for controlling odour and managing high exudate levels.
• Development of dressings that minimise discomfort, manage symptoms, and provide ease of application.

2. Patient-centered approaches:

• Understanding patient priorities, needs and perspectives to align care with their goals.
• Enhancing quality of life through symptom relief and maintaining dignity.

3. Innovative dressing materials:

• Creating multifunctional dressings to address odour, pain and exudate while being cost-effective and easy to use.
• Exploration of advanced materials, such as dressings with integrated analgesic or antimicrobial properties.

4. Guidelines and protocols:

• Development of standardised, evidence-based clinical guidelines for managing palliative wounds.
• Harmonising global practices to ensure consistent care across healthcare settings.

5. Education and training:

• Improving knowledge and skills among healthcare providers, caregivers, and patients.
• Incorporating wound management education into healthcare curricula and professional training programs.

6. Technological and biochemical advances:

• Researching biomarkers and biochemical predictors for wound healing and deterioration.
• Investigating innovative technologies like negative pressure therapy and AI-based wound assessment tools.

7. Multidisciplinary care:

• Exploring the benefits of integrated care models involving multidisciplinary teams.
• Evaluating the impact of such models on patient outcomes, resource allocation, and cost-effectiveness.

8. Psychosocial and emotional support:

• Studying interventions to address the psychological impact of wounds, including body image and social stigma.
• Researching ways to improve caregiver support and family education.

9. Economic considerations:

• Cost-effectiveness of treatments and products, focusing on affordability without compromising quality.
• Addressing resource limitations in low-income settings.

10. Prevention and early diagnosis:

• Investigating methods to prevent wound deterioration and complications.
• Developing tools for early diagnosis and intervention in at-risk patients.

Discussion

This international survey offers a unique perspective by integrating clinician and researcher viewpoints to identify priorities for research in palliative wound care while highlighting the most frequent wound aetiologies requiring a palliative approach. The findings emphasise two key points: first, pressure ulcers are the most common wounds necessitating a palliative approach; second, symptom management, particularly regarding pain, odour, and exudate, remains a critical concern and research priority.

Pressure ulcers as the most common aetiology

The prominence of pressure ulcers among wounds requiring palliative care aligns with existing evidence. A systematic review reports pressure ulcer prevalence rates ranging from 9.9% to 54.7%, and incidence rates from 0% to 37.5% in palliative care settings, with nursing homes (6.9%–16.2%) and inpatient settings (13.8%–19%) experiencing the highest rates.³ The predominance of stage 1 or 2 pressure ulcers (82%) may reflect the limited ability of many patients in palliative care to reposition themselves or effectively manage pressure-relief strategies due to comorbidities and overall health deterioration.^3-5

Despite the prevalence of pressure ulcers, there is a noticeable gap in evidence-based interventions for their management. Current strategies often rely on general wound care principles rather than specific approaches tailored to the complexities of palliative patients, who may require a focus on comfort rather than healing.

Malignant fungating wounds and their challenges

Malignant fungating wounds, the second most common wound type identified, bring their own challenges. Consistent with the literature, these wounds are frequently associated with symptoms such as exudate, bleeding, odour, and pruritus. A review of patients admitted to specialised palliative care units revealed that 8.2% had malignant fungating wounds, most often located on the breast, head, or neck.⁶ Symptoms such as exudate (49.4%), bleeding (27.6%), and odour (18.6%) were frequently reported, with multiple symptoms often co-occurring.⁶ These findings are mirrored in other studies, which also highlight pain (31.3%–77.3%), odour (11.9%), and exudate (17.9%) as dominant concerns.³

The physical, emotional, and psychological burden of these wounds is profound, affecting both patients and caregivers. Despite their impact, there remains a paucity of robust research into interventions that address these symptoms effectively.

Gaps in evidence for symptom management

The survey results highlight the persistent unmet need for effective management of pain, odour, and exudate in palliative wound care. Evidence supporting interventions for these symptoms remains sparse. For instance, a systematic review of topical interventions for wound pain identified only eight RCTs, with ibuprofen-impregnated dressings showing some promise but limited by low-quality evidence.⁴ Similarly, a review of interventions for wound odour management found only five RCTs, characterised by small sample sizes and inconsistent outcome measures.⁵ These gaps underscore why clinicians continue to identify symptom management as a critical priority for research.

The importance of patient-centered and multidisciplinary approaches

The findings also reveal the broader challenges of managing palliative wounds, including access to resources, infection prevention, and communication. These issues underscore the need for patient-centered care that focuses not only on symptom relief but also on improving quality of life, maintaining dignity, and addressing psychosocial concerns. Multidisciplinary collaboration is essential to address these complex needs effectively, yet such approaches remain underutilised in many settings.

What is concerning in the current state of research into symptom management in wounds is the lack of interventions evaluated at the level of randomised controlled trials to manage such distressing symptoms. A review of topical interventions for the management of wound-related pain identified only eight randomised controlled trials, and while ibuprofen-impregnated dressings were identified as holding potential to manage pain at the wound site the strength of evidence was low.⁷ For the management of wound odour, the strength of evidence is even less. A review of topical interventions for the management of wound odour identified only five randomised controlled trials with small sample sizes and inconsistency in how and when outcomes were measured.⁸ It is unsurprising therefore that clinicians still identify these as a concern and a priority for research.

Strength and limitation

We recognise that while respondents overwhelmingly identified pain, odour and exudate management together with quality of life as a priority for research, this study did not aim to challenge this through a formal consensus development exercise and thus should be considered as the opinion of 450 people involved in palliative wound care practice. Notwithstanding this limitation, it does add impetus to the need to recognise that our patients and clinicians are still struggling to manage core symptoms and this needs to be addressed.

Conclusion

There is an urgent and critical need to address the complex challenges faced by both patients and clinicians in managing wounds that require a palliative approach to care. These challenges primarily revolve around three distressing symptoms—pain, odour, and exudate—while also profoundly impacting the quality of life for patients and their families. Palliative wound care extends beyond end-of-life management, as patients at various stages of illness may require such specialised interventions. Notably, pressure ulcers represent the most prevalent wound type necessitating palliative care, underscoring the imperative to implement proactive strategies to reduce their incidence, prevent complications, and advance awareness and research in this area. Equally important is the need for policy changes that support a standardised, evidence-based approach to palliative wound management, ensuring equitable access to appropriate resources, education, and multidisciplinary support. By prioritising evidence-based interventions and advocating for policy reform, we can ensure that patients receive dignified, compassionate and effective care throughout their journey.

Author(s)

Sebastian Probst¹ DClinPrac, MNS, RN, Elena Conde Montero² MD, PhD, Jan Kottner³ PhD, Hayley Ryan⁴ RN, MBA, PGWM, AICGG, Cert IV TAA, PhD(c), Georgina Gethin⁵* PhD, MSc Clinical Research, PG Dip Wound Healing, RGN, FAAN, FFNM RCSI

¹Full Professor of Tissue Viability and Wound Care, Geneva School of Health Science, HES-SO University of Applied Sciences and Arts, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland; Care Directorate, Geneva University Hospitals, Switzerland; Faculty of Medicine Nursing and Health Sciences, Monash University, Australia; College of Medicine Nursing and Health Sciences, University of Galway, Ireland. ORCID 0000-0001-9603-1570
²Dermatologist. Hospital Universitario Infanta Leonor y Virgen de la Torre, Madrid, Spain
³Professor of Nursing, Charité-Universitätsmedizin Berlin, Germany. ORCID 0000-0003-0750-3818
⁴School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Australia.ORCID 0000-0002-5134-1927
⁵Professor in Nursing and Midwifery, School of Nursing and Midwifery, University of Galway, Ireland; Director, Alliance for Research and Innovation in Wounds, University of Galway, Ireland; Research Associate, Geneva School of Health Science, HES-SO University of Applied Sciences and Arts, Western Switzerland, Geneva Switzerland. ORCID 0000 0001 5859 8357

*Corresponding author email georgina.gethin@universityofgalway.ie

References

1. Sezgin D, et al. Defining palliative wound care: A scoping review by European Association for Palliative Care wound care taskforce. J Tissue Viability. 2023;32(4):627–634.
2. Sharma, A, et al. A Consensus-Based Checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med. 2021;36(10):3179–3187.
3. Ferris A, Price A, Harding K. Pressure ulcers in patients receiving palliative care: A systematic review. Palliat Med. 2019;33(7):770–782.
4. Dissemond J et al., [Wound treatment without curative intention: position paper of the Initiative Chronische Wunden (ICW) e. V.]. Dermatologie (Heidelb), 2022;73(7):550-555.
5. Kottner J, Beeckman D. Incontinence-associated dermatitis and pressure ulcers in geriatric patients. G Ital Dermatol Venereol. 2015;150(6):717–729.
6. Takamizawa S, et al. Psychological symptom burden associated with malignant wounds: Secondary analysis of a prospective cohort study. Palliat Support Care. 2024;22:396–403.
7. Ffrench C, et al. Systematic review of topical interventions for the management of pain in chronic wounds. Pain Rep. 2023;8(5):e1073.
8. Gethin G, et al. Systematic review of topical interventions for the management of odour in patients with chronic or malignant fungating wounds. J Tissue Viability. 2023;32(1):151–157.