For the first time in WHS guideline history, the 2023 pressure ulcer update addresses a question clinicians face every day but rarely find clear guidance on: how do you care for a wound when the patient’s goal is comfort, not cure?
Pressure ulcers affect roughly 2.5 million people in the United States at any given time, and hospital-acquired pressure injuries cost the health system an estimated $26.8 billion annually. Despite decades of prevention efforts, that incidence has not meaningfully declined.
Part of the reason is demographic. A growing share of patients with pressure ulcers are older, critically ill, or living with serious progressive diseases. For these patients, the wound is not the primary problem. It is one dimension of a larger picture, and wound care decisions must reflect what the patient actually wants from the time they have left.
The Wound Healing Society’s 2023 pressure ulcer guideline update, published in Wound Repair and Regeneration, was the first in the WHS guidelines series to formally address this reality. The new palliative wound care section, developed by an interdisciplinary team of wound specialists, nurses, geriatricians, and palliative medicine providers, offers evidence-based guidance for clinicians navigating some of the most complex moments in wound care practice.
What Palliative Wound Care Means in Practice
Palliative wound care is not the abandonment of wound care. It is a reorientation of it. Rather than optimizing every intervention toward tissue healing, the goal shifts to relieving wound symptoms, including pain, odor, and exudate, and making decisions that honor a patient’s goals even when those goals mean accepting some risk of wound progression.
The guidelines acknowledge that much of the evidence in this section is Level III, reflecting the genuine difficulty of conducting rigorous research in critically ill and dying patients. That gap is explicitly framed as a research opportunity, not a limitation of the guidelines themselves.
Risk Assessment Tools for Seriously Ill Patients
Two validated tools are most relevant for this population. The Jackson-Cubbin Scale was developed specifically for ICU patients and has been shown to have stronger predictive value than the Braden Scale in critically ill settings. It evaluates age, weight, skin condition, mobility, hemodynamics, nutrition, and continence, with scores below 24 indicating high risk.
For home-based and hospice patients, the Palliative Performance Scale (PPS) offers a comparable tool. A 2008 study found the PPS had similar predictive value to the Braden Scale in palliative populations. Patients scoring 40% or lower on the PPS are considered high risk for pressure ulcer development, and the scale requires ongoing reassessment as patients may decline quickly.
Prevention Strategies Adapted for Comfort-Focused Care
- Support surfaces: Level I evidence from Cochrane analysis supports reactive and active surfaces over standard foam mattresses. For seriously ill patients, active alternating pressure mattresses carry an additional benefit: they can allow for less frequent repositioning, which matters when turning causes significant pain or distress.
- Repositioning: Standard turning guidelines apply where possible, but in palliative care, repositioning schedules should be individualized to a patient’s comfort, tolerance, and goals. Conditions like incident pain on movement, pathological fractures, or dyspnea may justify reduced turning frequency. When repositioning is necessary but painful, the guidelines recommend premedication with an analgesic or sedative approximately 20 to 30 minutes before the planned turn.
- Prophylactic dressings: Level I evidence from ICU-based RCTs supports multi-layer silicone foam dressings over bony prominences to prevent sacral and heel pressure ulcers. One study of 440 critically ill patients found a significant reduction in pressure ulcer incidence alongside meaningful cost savings.
- Nutrition: Daily nutritional assessment is recommended for critically ill patients, as roughly half of ICU patients fail to meet nutritional targets due to procedural interruptions and altered feeding routes. Preliminary data suggest that meeting nutritional goals within the first 72 hours in the ICU may reduce pressure ulcer risk, though specific protein and calorie targets need further research.
Pain and Odor: The Symptoms That Shape Patient Experience
Pain must be assessed at every visit and with every change in condition. Patient self-report is the gold standard. For patients with cognitive impairment or altered consciousness, tools like the Wong-Baker FACES Scale provide a workable alternative.
Procedural pain from dressing changes is often underestimated. Getting a specific history matters: is the pain from tape removal, wound exposure to air, or dressing contact with the wound bed? Non-pharmacologic strategies include soaking dressings before removal, using skin adhesive removers, selecting silicone-based dressings, and giving patients explicit control over pacing. Topical lidocaine solution is a widely recommended option for procedural pain.
Wound odor is primarily driven by anaerobic bacteria and can profoundly affect a patient’s social connection and dignity. Topical metronidazole, including crushed tablets applied directly to the wound, is inexpensive and effective. Dakin’s solution addresses anaerobes but carries cytotoxic risk. Activated charcoal dressings absorb odor, though they are costly. For patients at home, simple environmental strategies such as peppermint oil diffusers or coffee grounds nearby can provide meaningful relief.
Nutrition at End of Life: What the Evidence Shows
Families often equate feeding with caring, making artificial nutrition one of the most emotionally charged conversations in palliative wound care. The WHS guidelines draw on a Cochrane review of 14 controlled studies involving more than 37,000 participants. The findings are clear: in patients with advanced dementia or those in their final month of life, tube feeding does not lower mortality, reduce pain, improve quality of life, or reliably prevent aspiration. In the final stages of life, artificial nutrition can make patients uncomfortable by causing tissue edema, diarrhea, and generalized discomfort.
The guidelines generally recommend that patients with advanced dementia not receive feeding tubes, and that artificial nutrition not be initiated in the last month of life. Hand feeding for comfort and connection remains appropriate.
Skin Failure and Shared Decision-Making
One of the most significant concepts in the new guidelines is skin failure. Like any organ, the skin can fail as part of multiorgan dysfunction or the dying process, as systemic circulatory changes reduce perfusion to peripheral tissues. Several terms describe this phenomenon, including the Kennedy Terminal Ulcer and Skin Changes At Life’s End (SCALE). A 2022 survey of wound healing clinicians reached an 80 to 85% consensus that skin failure at end of life is unavoidable and not attributable to substandard care. No validated diagnostic criteria currently exist, making this one of the field’s most pressing research needs.
For clinicians, this concept is practically important. Not every wound that develops near death represents a prevention failure, and helping families understand skin failure as a physiologic event rather than a care failure can reframe difficult conversations toward greater compassion and clarity.
Wound prevention and management requires shared decision-making. The guidelines are consistent on this point: positioning adjustments, pain management decisions, nutrition choices, and turning frequency should emerge from honest conversations with the patient and family, and every decision should be documented so that the full care team can work from the same plan.
Access the Full Guidelines
The complete WHS Guidelines for the Treatment of Pressure Ulcers (2023 Update) are published open-access in Wound Repair and Regeneration and available through PubMed Central: https://pmc.ncbi.nlm.nih.gov/articles/PMC11403384/
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The Wound Healing Society is the premier scientific membership organization for wound healing researchers and clinicians, founded in 1989. WHS publishes Wound Repair and Regeneration and convenes the annual scientific meeting to advance wound healing science from bench to bedside.
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The content in this article is intended for informational and educational purposes only and does not constitute medical advice. The information presented is based on published scientific research and clinical guidelines and should not be used as a substitute for professional medical judgment, diagnosis, or treatment. Clinicians should apply their own clinical expertise and consider individual patient circumstances when making treatment decisions. Researchers should consult primary sources and exercise independent judgment when interpreting findings. The Wound Healing Society does not endorse any specific product, treatment, or commercial entity referenced in this content.