Wounds are common at the end-of-life. They may be related to a disease process such as arterial and vascular ulcers, ischaemic changes and malignancy. They may occur as skin tears or pressure injuries.
Pressure injuries are a quality indicator in the National Aged Care Quality Indicator Program for Residential aged care (RAC) commencing in 2016.
Wounds affect quality of life due to:
- restricted mobility, and
- time needed for dressings.
Malodorous wounds and the time involved in managing complex wound care restrict the resident’s opportunity for social interaction and deter visitors.
Wounds may not heal despite best practices in wound management due to factors that can’t be reversed. These factors include:
- advanced disease
- organ failure
- compromised mobility
- weakened immune response to infection
- vascular insufficiency
- diabetic neuropathy, and
The skin is an organ and like other organs can fail at the end-of-life. While research in this area is limited, a consensus document has been published. The Skin Changes at Life's End (SCALE) statement was produced by an international panel describing skin changes at the end-of-life; particularly the sudden appearance of rapidly progressing ulcers.
An international panel of experts has published Prevention and treatment of pressure ulcers: Clinical practice guidelines. This includes guidelines for the management and prevention of pressure injury for older persons and for persons receiving palliative care.
While skin tears are thought to be more numerous than pressure injuries, the evidence for management of skin tears is less well developed.  Twice daily moisturising of skin has been reported to reduce the incidence of skin tears in RACF. 
There is some evidence for management of skin tears The art of dressing selection: A consensus statement on skin tears and best practice.
Palliative approach to wound care
- Thoroughly assess wound(s), identify the type of wound and predisposing factors
- What are the underlying causes, can they be modified?
- What impact is the wound having on the resident?
- Ask 'Does this wound have the potential to heal?' If not, consult with the resident and their family and other members of the care team. Document discussions
- Develop strategies to manage concerns identified
- Refer to wound care specialist for complex wounds or when symptoms are not well controlled.
Goals of care
- Manage pain - regular analgesia, pain relief prior to wound care
- Choose wound cleansers and dressings that reduce the pain associated with wound care
- If possible, select wound dressings that require less frequent change
- Manage odour and exudate - there is information on CareSearch on this topic
- Reduce bacterial load on wound (infection contributes to odour and exudate), topical antiseptics may be indicated
- Mechanical debridement should be avoided if the wound is unlikely to heal
- Debridement increases the risk of haemorrhage and systemic infection [3,4]
- Using warm rather than room temperature cleansing solution may reduce pain.