Overview of the care of adult patients with nonhealable wounds

INTRODUCTION — The World Health Organization (WHO) defines palliative care as "an approach that improves the quality of life of the patient and their family or other caregivers associated with life-threatening illnesses" [1]. Palliative care of wounds that are not expected to heal (ie, nonhealable) during the patient's life is an important aspect of care in such patients to improve physical comfort and psychosocial wellbeing. The incidence of wounds among those receiving palliative care varies depending on wound etiology and geographic region. According to the National Pressure Injury Advisory Panel (NPIAP), the prevalence is approximately 10 to 11 percent [2]. However, globally, an incidence upwards of 36 percent has been reported for pressure-induced injuries [3].

An overview of the care of the patient with nonhealable wounds is reviewed. An overview of chronic wounds, which given optimal care may be expected to progress toward wound healing, is provided separately (See "Overview of treatment of chronic wounds".)

CLINICAL EVALUATION — The clinical evaluation should include a comprehensive patient history, including the details and prognosis of the advanced disease condition, the type of wound (see 'Typical types of nonhealable wounds' below), as well as risk factors for nonhealing, which may include medication effects. (See 'Medication review' below and "Risk factors for impaired wound healing and wound complications".)

Specific attention should be made to the onset and duration of the wound and any associated symptoms such as pain, drainage, odor, prior treatments, the effects of the wound on the patient's physical functioning and quality of life (QoL). Elevated white blood cell count, erythrocyte sedimentation rate, or C-reactive protein suggest systemic inflammation and possible infection.

Typical types of nonhealable wounds — Wounds that are not amenable to wound healing despite appropriate wound care often arise in the context of advanced disease or life-limiting illnesses. Chronic diseases associated with palliative care include cardiovascular diseases (38.5 percent), cancer (34 percent), chronic respiratory diseases (10.3 percent), acquired immunodeficiency syndrome (5.7 percent), and diabetes (4.6 percent) [1]. For some of these patients, a wound is present and progresses to a point, but complete healing can no longer be expected, or coverage of the wound (eg, skin flap) is not feasible. Such wounds are often associated with pain, infection, and reduced mobility. Typical types of wounds are briefly reviewed below.

Pressure-induced skin and soft tissue injury — Pressure-induced skin and soft tissue injury occurs because of sustained pressure on the skin and underlying tissues, leading to localized tissue damage. Microvascular changes secondary to pressure cause capillary collapse impairing the delivery of oxygen and other nutrients to the tissue resulting in cell injury. (See "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury".)

Pressure-induced skin and soft tissue injuries often cannot be avoided because of comorbidities or necessary treatments. Healing can stagnate regardless of the pressure-induced injury stage (table 1). Contributing factors include immobility, septic shock, impaired circulation and edema, sensory deficits, excessive moisture, and malnutrition [4]. (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

Relief of pressure through repositioning to help offset friction and shear forces, offloading pressure with proper support surfaces, and regular skin inspections are essential to care. (See "Prevention of pressure-induced skin and soft tissue injury".)

End-of-life skin changes — Skin changes occurring during the end-of-life process have been reported. These skin changes are often described as purple discolorations in a butterfly distribution over nonpressure points and can develop into wounds [5].

Various terms have been used to describe these changes including Kennedy terminal ulcer [6], Skin Changes at Life's End (SCALE) [7], and Trombley-Brennan terminal tissue injury [5]. These skin changes are related to the many underlying physiologic changes that accompany the dying process [7]. Various descriptions, controversies over theories of etiology, and consensus documents have been published to identify the gaps regarding the pathophysiology and care plans of these skin changes [8-10]. Despite the gaps, end-of-life goals to address patient comfort and QoL are paramount.

Vascular wounds — Nonhealable vascular wounds can be arterial or venous in origin and often demonstrate clinical features consistent with stagnation in the inflammatory phase of wound healing.

●Ischemic wounds – Ischemic wounds appear pale and have an avascular wound bed with or without an overlying eschar. Although ischemic wounds can often be revascularized (endovascular, surgical), some patients are not candidates from a medical perspective, or they have nonreconstructible arterial disease. Conservative management of ischemic wounds does not necessarily lead to major amputation during the patient's remaining life [11], although with palliative management, distal extremity ischemic wounds may be allowed to autoamputate [12]. Wounds are kept clean and dry and excessive pressure is avoided, which could aggravate ischemia.(See "Management of chronic limb-threatening ischemia", section on 'General care'.)

A variety of other therapies have been tried to stimulate wound healing and avoid amputation [13-18]. These therapies are reviewed separately. (See "Investigational therapies for treating symptoms of lower extremity peripheral artery disease".)

●Chronic venous wounds – Venous stasis ulcers, which are the sequelae of chronic venous hypertension, appear shallow and irregularly shaped and are usually located distally in the leg [19]. The wound bed may appear to have granulation tissue but still not progressing toward healing. Standard management of venous stasis ulcers involves compression therapy to reduce edema and improve venous return, and wound care [20,21]. Addressing superficial venous insufficiency (eg, superficial venous ablation) may or may not be an option. Despite best management, patients may have persistent or recurrent venous leg ulcers, which may be related to the presence of deep venous insufficiency [20]. (See "Evaluation and management of chronic venous insufficiency including venous leg ulcer".)

Surgical wounds — Patients with advanced disease and a surgical wound may have delayed healing due to poor vascular supply, prior irradiation, inadequate oxygenation, compromised immune function, malnutrition, or overall frailty [22]. These factors impair an effective wound healing response. The need for chronic steroid use and other medications may lead to a persistent wound state [22]. Patients with advanced illnesses are also more susceptible to infections, which can further delay wound healing. (See "Risk factors for impaired wound healing and wound complications".)

Atypical wounds — Atypical wounds can have inflammatory, infectious, metabolic, genetic, or external etiologies. Etiologies of such wounds include calciphylaxis, pyoderma gangrenosum, vasculitis, and wounds attributed to autoimmune disease [23].

●Wounds with calciphylaxis are commonly attributed to high parathyroid hormone and phosphate levels, which can lead to calcified lesions and skin necrosis. Autoimmune diseases including vasculitis contribute to up to 23 percent of patients with lower extremity ulcers [24]. (See "Calciphylaxis (calcific uremic arteriolopathy)" and "Calcinosis cutis: Etiology and patient evaluation" and "Overview of and approach to the vasculitides in adults".)

●Pyoderma gangrenosum can appear with a variety of morphologic features, from a cribriform pattern to a variegated violet color [25]. (See "Pyoderma gangrenosum: Pathogenesis, clinical features, and diagnosis".)

●Vasculitis can present with pigmented dermatoses or macules. (See "Evaluation of adults with cutaneous lesions of vasculitis".)

Malignant wounds — Malignant wounds result from the infiltration of cancer cells into the skin and underlying tissues. This can occur due to primary tumor growth, direct extension, or metastasis to the skin. Malignant wounds can present as ulcers, masses, or lesions, with characteristics specific to the primary cancer type. Due to angiogenesis within the tumor, profuse bleeding can occur with dressing changes [26].

Fungating wounds are usually associated with advanced cancer. Fungating wounds can be due to the uncontrolled growth of malignant cells that infiltrate and disrupt the nutrient supply of the skin, or the aggressive replication of cancer cells can form an aggregate mass that ulcerates through the skin [27]. It is estimated that malignant fungating wounds occur in 5 percent of advanced cancers and 10 percent of patients with metastasis [26]. Fungating wounds are commonly associated with breast (62 percent) and head/neck (24 percent) cancers, but other types and sites of the body (14 percent) can also be affected [26]. Fungating wounds can be painful due to nerve involvement [28], and can produce foul-smelling discharge due to the presence of necrotic tissue [26].

Medication review — Medications that can hinder optimal wound healing should be noted. While some of these medications may be necessary to the overall care of the patient, it is imperative to identify those for which the dose can be minimized to reduce their impact on wound healing, or those that can be discontinued altogether. In some cases, an alternative medication that does not compromise wound healing may substitute. Healthcare providers should carefully consider the potential risks and benefits of these medications when managing patients with wounds and may need to adjust treatment plans or monitor wound healing progress closely. Collaboration between clinicians, including pharmacists, wound care specialists, and surgeons, is essential to optimize wound healing outcomes.

Commonly used medications that can impair wound healing include:

●Immunosuppressive medication – Immunosuppressive drugs, often used in transplant recipients or individuals with autoimmune diseases, can weaken the immune system's ability to combat infections in and around wounds, potentially leading to wound complications [29].

●Cancer therapy – Medications used in cancer treatment can have systemic effects that impact overall health and wound healing capacity. These effects vary depending on the specific drug and its dosage [30]. These medications affect cell proliferation and tissue regeneration phases [30]. Leg ulcerations develop in 9 percent of patients undergoing long-term, high-dose hydroxyurea therapy [31].

●Anti-inflammatory agents – Glucocorticoids (eg, prednisone, dexamethasone) are used to reduce inflammation. While used to assist healing some atypical wounds such as pyoderma gangrenosum, prolonged or high-dose treatment can inhibit wound healing.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to relieve pain and inflammation [32]. While nonselective NSAIDs do not appear to affect wound healing, cyclooxygenase-selective NSAIDs can inhibit the inflammatory response necessary for wound healing, potentially leading to delayed healing and increased risk of infection [33].

●Antithrombotic therapies – Excessive bleeding can interfere with the inflammatory phase of clotting and the formation of granulation tissue, which are essential components of the wound healing process [34]. Anticoagulant medications such as warfarin and some heparins can increase the risk of bleeding at the wound site. Antiplatelet medications like clopidogrel and aspirin that inhibit platelet aggregation may also lead to increased bleeding at the wound site, impairing clot formation and initial wound hemostasis.

●Vasoactive drugs – Vasoactive medications can reduce blood flow to the wound site, limiting the delivery of essential nutrients and oxygen needed for healing. The impact of these medications on wound healing can vary depending on factors such as the type of wound, the patient's overall health, the duration and dosage of medication use, and individual response to treatment [35].

●Others – Some antibiotics, such as tetracyclines, may impair collagen synthesis and fibroblast activity, which are essential processes for wound healing [36]. Diabetic medications such as thiazolidinediones have been associated with impaired wound healing in individuals with diabetes [37]. These medications can affect tissue regeneration.

Nutrition evaluation — Adequate nutrition plays a crucial role in wound healing and overall wellbeing. Individualized nutritional assessment and targeted supplementation are key and particularly relevant for patients with limited mobility. Nutritionists or dietitians can optimize a patient's diet for wound healing and pain management [38]. Optimized nutrition can enhance wound healing even in challenging situations. The nutritional plan should be tailored to the type of wound, stage of illness, individual metabolic needs, and wound characteristics. In end-of-life scenarios, nutrition support should promote healing and prioritize patient comfort. (See "Clinical assessment and monitoring of nutrition support in adult surgical patients".)

Nutrition influences immune function and inflammation, both of which can significantly impact wound healing. Adequate protein intake can play a crucial role in preventing and improving pressure-induced skin and soft tissue injuries in critically ill patients, in whom healing is often delayed [39]. Nutrition also impacts physical functioning and resilience to indirectly affect wound healing.

WOUND EVALUATION AND CARE — The conservative treatment of nonhealable wounds represents a clinical challenge with few evidence-based guidelines or established protocols. Management of patients with advanced disease and nonhealable wounds involves addressing underlying medical conditions, optimizing nutrition, and ensuring appropriate wound care to minimize infection and promote healing [22,40]. Wound care is not wholly focused on the goal of healing, rather, treatment is individualized to address the condition of the wound, including wound-specific symptom management such as pain, bleeding, exudate, odor, and infection, but also the impact the wound has on the patient's psychosocial wellbeing, physical function, and quality of life (QoL). The management of wound pain is addressed above. (See 'Wound pain' below and "Overview of treatment of chronic wounds" and "Basic principles of wound management".)

Wound assessment — The clinician should conduct a focused examination on the wound and the surrounding tissues, noting wound pain, tenderness, location, length, width, and depth. The composition of the wound bed, such as granulation tissue, fibrinous exudate, and necrosis, should be noted. Standardized wound assessment tools can be used to help guide comprehensive wound evaluation [4,41-44]. These tools may be generalized and applicable to a variety of wounds or specific to a particular type of wound (eg, ischemic wounds, pressure-induced injury).

Damage to the periwound skin, edema, erythema, or induration may suggest the presence of infection. For wounds that potentially infected, wound cultures may be performed to identify the causative organisms. Deep cultures may help guide antibiotic therapy and identify multidrug-resistant pathogens. Biopsies of fungating wounds may also yield cultures to identify the specific organisms responsible for infection. However, caution is recommended, as these wounds are associated with bleeding. Wound imaging modalities (eg, fluorescence imaging) may help assist in quantifying the number of bacteria present [45-49].

Specific imaging is often not required to adequately manage wounds. However, plain radiography can detect gas in tissues, bone involvement suggestive of infection, or the presence of a foreign body. Heterotopic ossification, which can impair wound healing, can also be seen with radiographs of the lower extremity [50]. Ultrasonography is useful for evaluating the depth and extent of wounds, identifying fluid collections or abscesses, and assessing vascular perfusion. With vascular wounds, Doppler ultrasound can assess blood flow and identify arterial obstruction or venous insufficiency contributing to an ulcer. In some cases, computed tomography may be necessary to assess deeper tissue involvement, especially in complex or malignant wounds with the potential for internal spread. Magnetic resonance imaging can also provide detailed information about tissue involvement and is useful for assessing soft tissue and detecting abscesses or tumor extension.

When malignancy in a wound is suspected, a biopsy of the wound tissue is often performed for histopathologic examination. Histopathology can confirm the presence of cancer, determine its type and grade, and guide treatment decisions [51]. Atypical wounds such as wounds due to immunosuppressive medications or postintervention from radiation and chemotherapy can be challenging to clinically assess. A biopsy may be necessary to confirm the etiology of the wound [51].

Photographic Wound Assessment Tools including digital photography are increasingly used in wound care. Digital photography can document wound progress and share information among healthcare providers. Specific tools and software allow for accurate measurements and visual assessment over time. These tools provide the surface area and volume of the wound as well assessment of tissue type, which can be valuable during a telehealth visit [52].

Wound care and modifications — Effective management of wounds is integral to palliative care, which aims to promote patient comfort and dignity, and reduce symptoms. Treatment depends on wound type and relies on a patient-centered approach. (See "Overview of treatment of chronic wounds", section on 'Specific wound management'.)

The clinician should work with the patient to establish goals for wound management. Proper wound management can make a great deal of difference to the patient and influences their ability to comfortably receive guests, participate in public events, and assist with activities of daily living [53-56]. Although symptom management strategies for comfort may work in tandem with wound healing interventions with the goal of possible wound closure, it is important to recognize when efforts toward wound closure become unrealistic or burdensome for the patient.

Proper wound hygiene and maintenance of key components are important for preventing wound infection and potentially sepsis. Topical wound care and specific dressings are tailored to the individual wound and patient needs. Soaking the dressing before removing can reduce pain upon dressing changes. Gentle washing of the wound and periwound region is essential for removing contaminating bacteria [57]. Wound hygiene may involve the use of a pH-balanced wash or antiseptics. (See "Overview of treatment of chronic wounds".)

Dressing type and the frequency of dressing changes depends on the amount of exudate from the wound and the presence odor, which when present may necessitate more frequent changes (table 2). Nonadherent and absorptive dressings reduce the pain and frequency of change. Discomfort associated with dressing changes can be reduced by using skin protectants to the periwound area and minimizing the use of adhesives when securing dressings . Odor control is an important aspect to address for patient comfort. Antimicrobial dressings and odor reduction dressings such as absorptive dressings, antiseptics such as acetic acid or Dakin solution, and medications including metronidazole can help to control odor [58]. (See "Overview of treatment of chronic wounds".)

Wound pain — A thorough pain assessment is important to understand the patient's experience and the impact of pain on daily activities of life and mood. Early and effective pain management can help with the maintenance of proper wound hygiene as well as provide comfort. Effective pain management involves a multidisciplinary approach, with healthcare providers working together to tailor interventions to the specific needs of the patient.

Pain assessment includes assessment of the characteristics of pain, such as its quality, location, and exacerbating or relieving factors. These are important to understand the patient's experience and the impact of pain on activities of daily life, mood, and sleep [59]. Using validated pain and comfort scales, the contribution of wounds to overall pain and discomfort can be determined [26,60,61].

Topical analgesics – For pain associated with the wound, topical local anesthetics or analgesics may offer some relief; however, the evidence supporting their use is low quality and effectiveness is inconsistent [62,63]. The inconsistent use of pain assessment tools for making comparisons between interventions limits the ability to draw any firm conclusions. Topical creams or gels containing medications such as 2% lidocaine or compounded versions of prilocaine or bupivacaine, or compounded opioids (eg, 10 mg morphine in 8 g hydrogel) can reduce local pain and may be useful during wound debridement [26]. For wound-related inflammation and edema, topical nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ibuprofen foam dressing) or corticosteroids may reduce inflammation and pain. Capsaicin can provide localized pain relief for neuropathic or superficial pain [64]. Topical antimicrobial agents can help control exudate associated with colonization and may also help alleviate pain. In addition, appropriate treatment of wound infection also reduces pain and discomfort. Adverse events associated with topical analgesics can include skin irritation or bleeding.

●Systemic analgesics – Pharmacologic pain management initially involves nonopioid analgesics. Over-the-counter nonopioid pain relievers like acetaminophen and possibly NSAIDs can be effective for mild-to-moderate wound pain. For more severe pain, opioid medications like oxycodone, morphine, or hydromorphone may be prescribed. However, their use is carefully monitored due to the risk of dependency and side effects [65]. Antidepressants including amitriptyline and anticonvulsant medications like gabapentin and pregabalin can be used to manage neuropathic pain, which is common in chronic wounds of the lower extremities [66,67]. Medications not primarily intended for pain management, such as muscle relaxants, can be used as adjuvants to address specific pain-related symptoms such as muscle spasms. (See "Approach to the management of chronic non-cancer pain in adults" and "Pharmacologic management of chronic non-cancer pain in adults".)

●Other strategies to manage pain – The application of heat such as warm compresses or cold such as ice packs can provide relief for certain types of pain, including localized discomfort near the wound site [68].

Some patients find relief through complementary and alternative therapies such as acupuncture, acupressure, or herbal remedies. However, the effectiveness of these approaches is variable [69].

Modalities like transcutaneous electrical nerve stimulation can be used to block pain signals and promote muscle relaxation [70]. Cognitive-behavioral therapy and other behavioral interventions can help patients develop adaptive coping strategies and manage the psychologic aspects of pain [71].

Other options

●Cancer therapy – Malignant and fungating wounds present unique challenges, as they demand not only wound care expertise but also a comprehensive understanding of cancer biology and therapeutics. Treatment aims to control tumor growth and manage wound-related symptoms, including pain and malodor. In addition to local wound care, wound management may involve addressing the underlying cancer through oncologic treatments (eg, radiotherapy, chemotherapy). If consistent with the goals of care, surgical management may be considered.

●Surgery – Surgical interventions aim to address the underlying causes (eg, superficial venous insufficiency, malignant wound), promote wound healing, and improve the patient's overall QoL. Any decision for surgery must be individualized and include careful consideration of the risks and potential benefits of surgery in the context of the overall disease status and burden as well as the individual patient's goals of care.

The specific surgical approach depends on the type and severity of the wound. Surgical options for ulcerated and fungating malignancy-related wounds may include surgical debulking or resection. Wound closure attempts (eg, skin grafting, flap reconstruction) may be especially helpful to maintain function in certain areas of the body, such as in the extremities or groin.

QUALITY OF LIFE — Quality of life (QoL) encompasses a patient's overall sense of wellbeing and life satisfaction [72]. A psychosocial assessment is important to understand the emotional and psychologic impact of the wound on the patient and their caregivers. Addressing the emotional, social, and functional aspects of a patient's life contribute to an improved QoL. (See 'Psychosocial support' below.)

QoL assessment — Patient-reported outcome measures provide a structured way to collect patient-reported data on wound-related outcomes, helping healthcare providers understand the patient's experience beyond clinical parameters like wound size and healing progress. They can be valuable tools in assessing the effectiveness of wound management interventions and improving the overall care and QoL for individuals living with wounds. The choice of a specific patient-reported outcomes measure may depend on the type of wound and the clinical setting. Patient-reported outcome measures specific to the condition may include questions included on any of the following questionnaires:

●The Functional Assessment of Cancer Therapy questionnaire assesses physical and emotional wellbeing in the context of cancer and its treatment [73].

●Lymphedema assessment tools such as the Lymphedema Life Impact Scale focus on evaluating the severity of swelling, impact on daily life, and QoL [74].

●The Wound-QoL questionnaire is designed to assess the impact of chronic wounds, such as venous leg ulcers or diabetic foot ulcers, on a patient's QoL [75]. It covers aspects like physical symptoms, pain, mobility, psychologic wellbeing, and social interactions.

●The Chronic Wound questionnaire is used to evaluate the impact of chronic wounds on patients' daily lives and assess their experiences with wound care [76]. It covers wound-related symptoms, pain, mobility, and psychosocial aspects.

●The WOUND-Q is used to measure the impact of wounds on patients' wellbeing and daily activities. It assesses pain, mobility, body image, and social interactions [77].

●Other wound questionnaires such as the Wound Impact Scale evaluate the psychosocial impact of chronic wounds, including factors like self-esteem, body image, and social activities [78].

In the context of wounds, QoL often relates to a patient's physical function. Wounds can limit mobility and activities of daily living. Effective wound care and physical therapy can help improve function, thereby enhancing a patient's QoL. In addition, pain is a significant factor. Chronic or severe wound-related pain can greatly diminish a person's QoL. Adequate pain management strategies are essential for improving comfort and overall wellbeing. (See 'Wound pain' above and "Overview of treatment of chronic wounds" and "Basic principles of wound management".)

Beyond pain, wounds can produce symptoms such as itching, odor, and drainage, which can negatively affect a patient's QoL. Effective symptom management strategies, including wound care, can alleviate these issues. (See 'Wound care and modifications' above.)

Housing and food insecurity are other concerns that should be explored that can affect overall wellbeing, QoL, and wound healing. Financial instability can occur due to the limitations of the patient's illness or functional limitations due to the wound [79]. For appropriate candidates, hospice programs will incur the cost of dressings, medications, and durable medical equipment [26].

Psychosocial support — Living with a chronic wound, especially those that are slow healing or have complications, can affect social interactions and relationships and be emotionally challenging, leading to heightened levels of anxiety, feelings of distress, frustration, cognitive dysfunction, fatigue, sleep disturbances, and depression [28,59]. The changes in physical appearance and the presence of visible wounds can also impact body image, cause embarrassment, and reduce self-esteem. Patients may also experience social withdrawal or feelings of isolation because of their wound. Psychosocial support aims to identify these feelings and provide emotional assistance and coping strategies.

Effective communication and education about the wound and its management are essential. Clear explanations and ongoing discussions help the patient understand their condition, treatment options, and expected outcomes, thereby reducing anxiety and uncertainty.

Psychosocial support through counseling, support groups, or referral to a mental health professional can help the patient address emotional distress, improve coping skills, and reduce the psychologic impact of pain as well as maintain or rebuild social connections. Support may also include counseling to address body image concerns and boost self-confidence. Interventions may involve teaching relaxation techniques, mindful meditation, stress management, or problem-solving skills to help patients better adapt to their circumstances. Techniques such as deep breathing exercises, guided imagery, meditation, and mindfulness can help patients manage pain and reduce stress [26].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic wound management".)

SUMMARY AND RECOMMENDATIONS

●Nonhealable wounds – The care of wounds that may not be expected to heal (ie, nonhealable) during the patient's life is an important aspect of palliative care. Wounds that may not be amenable to wound healing despite appropriate wound care often arise in the context of advanced disease or life-limiting illnesses. The early identification of nonhealable wounds and an understanding of their management is essential to provide targeted interventions that improve physical functioning, comfort, and psychosocial wellbeing, while addressing specific wound-related challenges. (See 'Introduction' above.)

●Clinical evaluation – The clinical evaluation includes a comprehensive patient history, including the details and prognosis of the advanced disease condition, the type of wound and details of the wound (eg, pain, drainage, odor, prior treatments), as well as risk factors for nonhealing. A comprehensive review of the patient's medications is essential to identify any that may be contributing to wound healing problems (eg, immunosuppressives, cancer therapy, antithrombotic therapies, vasoactive drugs). A complete nutrition evaluation should also be obtained; optimized nutrition may enhance wound healing even in challenging situations. (See 'Clinical evaluation' above.)

●Types of nonhealable wounds – Typical types of wounds include pressure-induced skin and tissue injuries, end-of life skin changes, vascular wounds (ischemic wounds, venous leg ulcers), surgical wounds, atypical wounds, and malignant wounds. Features of these are reviewed above. (See 'Typical types of nonhealable wounds' above.)

●Wound care – Treatment depends on wound type and relies on a patient-centered approach. Proper wound management can make a great deal of difference to the patient and influences their quality of life (QoL). Wound care is not wholly focused on the goal of healing. Symptom management strategies to address wound-specific symptoms (eg, pain, odor, bleeding) may work in tandem with healing interventions with the goal of possible wound closure, but it is important to recognize when efforts toward wound closure become unrealistic or burdensome for the patient. (See 'Wound evaluation and care' above.)

●Pain – A thorough pain assessment is important to understand the patient's experience and the impact of pain on daily activities and mood. Early and effective pain management can aid maintenance of proper wound hygiene as well as provide comfort. Effective pain management requires a multidisciplinary approach, with healthcare providers working together to tailor interventions to the specific needs of the patient. Pain management may include the use of topical analgesics, systemic analgesics, or other strategies. (See 'Wound pain' above and "Overview of treatment of chronic wounds" and "Basic principles of wound management".)

●QoL – Living with a chronic wound can affect social interactions and relationships and be emotionally challenging. Assessing and addressing the emotional, social, and functional aspects of a patient's life through counseling, support groups, or referral to a mental health professional can help contribute to an improved overall QoL. (See 'Quality of life' above.)