Company Blog
  • Register

Blog articles are provided as informational purposes only and are not intended to constitute medical advice. Medication protocols are subject to patient’s medical provider’s authorization.

There are many types of chronic, non-healing wounds.  These include pressure ulcers, diabetic ulcers, arterial insufficiency ulcers, venous ulcers, and malignant wounds. 

Pressure ulcers are the most common type of wound we encounter as patients decline, become bed bound, and approach end-of-life.  Stage 1 and 2 pressure ulcers cause superficial skin changes, and Stage 3 and 4 pressure ulcers affect the deep tissue framework.1. Pressure ulcers should be staged depending on damage and presence of certain characteristics.  It is important to note that if a wound is healing, reverse staging is not done.  If a patient has a stage 3 ulcer that is getting better, we would say that the patient has a “healing” stage 3 pressure ulcer.2.

A patient’s initial assessment should include a review of their skin and existing wounds, if any, and an assessment of the risk factors that are affecting wound healing.  The Braden Scale for Predicting Pressure Sore Risk is one tool used when assessing patients. It is based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.  Keep in mind, most tools used to predict risk do not account for end-of-life decline, so hospice/palliative care patients may be at greater risk than the scales show.3  Other risk factors for chronic non-healing wounds include obesity, tobacco use, vascular issues, diabetes, elderly, radiation therapy, poor self-care, alcohol use, and neurological issues.  After the initial assessment, a plan should be developed that aligns with the patient and family’s goals.  If there are emotional or spiritual issues that are contributing to poor self-care or alcohol/substance abuse, consider calling on other members of your multi-disciplinary team (i.e., social worker or clergy) for assistance.  Therapy goals, which aim to improve quality of life, should be based on patient prognosis, patient factors, heal-ability of existing wound, type of wound, and patient and family wishes.  Goals should include preventing new wounds or worsening of existing wounds, prevent/relieve distressing symptoms, reduce discomfort, reduce risk of infection, bleeding, and odor.3

The TIME mnemonic can help us improve wound care. 

If a wound has non-viable, deficient tissue, it may need to be debrided.  However, stable eschar should be painted with Betadine® and never be debrided.12.  There are many types of debridement techniques including mechanical, autolytic, enzymatic, sharps, surgical, and biologic.10 Many types of debridement are not appropriate and do not align with goals of care in hospice patients.  There are some non-healable wounds that should NOT be debrided.  These include arterial wounds in people with Peripheral Artery Disease (PAD) (stable dry gangrene, dry ischemic wound), wounds at risk for bleeding, malignant or inflammatory wounds, lower limb pressure ulcers if arterial insufficiency is present, and wound on patients who are acutely palliative.10   Most hospice patients have non-healable wounds that should only be debrided if necessary to manage bacterial burden, exudates, and odor.10

To promote health of the wound, moisture balance must be maintained.  The correct dressing will help with this. Dressing choice is based on drainage, non-stick vs absorbent, as well as other factors.  Dead space, undermining, and tunneling must be loosely packed or filled with an appropriate dressing.  The table below shows the different dressing categories, examples, descriptions, and uses.

Re-evaluate the wound care plan within 2 weeks or if issues arise, or if there are changes in the patient’s condition or patient/family goals.  Looking at the edge of the wounds aids in evaluation.  Healthy wound edges are attached open and migrating/contracting.  Non-healing edges don’t advance or are undermined.  Improperly dressed wounds may get tunneling, undermining, and rolled edges.  Keep in mind that some patients and family may have difficulty with compliance or procedures and need additional education and support. 

Possible wound complications include pain, bleeding, odor, and infection.  Moistening dressings before removal, using non-stick dressings, and doing less frequent dressing changes can all help with pain.  Using lidocaine 2% gel topically during wound care and/or pretreating with oral morphine or another oral narcotic 30-60 minutes prior to wound care can also help.  For pain after dressing changes, consider applying a small amount of viscous lidocaine to the dressing side that contacts the wound. 

Malignant wounds are associated with a greater risk of bleeding than other types of wounds.  If bleeding is anticipated, it should be discussed with the patient and family, and a plan should be in place.  Dark basins, towels and bed linens (not red) can be used to minimize the impact of bleeding.  Bleeding can be traumatic for the patient and family.  Consider calling on other team members to help provide emotional support if needed. When a wound is at risk for bleeding, use gentle irrigation to cleanse the wound4 and stop anticoagulants including aspirin3.  Avoid unnecessary dressing changes and debridement.  Soak dressings with warm normal saline prior to removal if they adhere to the wound13 and use non-stick dressings4.  If bleeding occurs, calcium alginate dressings can be placed on the wound and direct pressure should be applied for 10-15 minutes.  If appropriate, the position can be changed or ice packs can be placed over the wound.  Silver nitrate sticks can be used for small localized areas of bleeding.  Minimize dressing changes (only changing the dressing if it is saturated with blood).  If these methods don’t work, sometimes a sucralfate paste is used to help stop the bleeding.13

If wound odor is present, cleanse the wound, treat the cause if possible, and control infection.9  Crushed metronidazole (Flagyl®) tablets sprinkled over the wound with dressing changes is an off-label use, but can be effective at controlling odor at a reduced cost.  If the wound is in an area where it is hard to sprinkle the crushed metronidazole, it can be mixed with a water-based lubricant and then applied to the wound.  For deep tissue infection and odor, oral metronidazole can be used.  Honey (Medihoney®) may also be effective for odor, wound pain, and debriding.  If these options are ineffective, cadexomer iodine gel or an impregnated dressing (pad) is helpful for odor, beneficial for exudate, and also debrides.Aromatics can be used in the room to hide the odor. Adsorbents like charcoal (briquettes) or cat litter can be placed discreetly in the room.  Baking soda may also be applied between dressing layers.  Odor may cause embarrassment, shame, and result in patient isolation.9  Multidisciplinary team members can assist in supporting the patient emotionally and spiritually.  Taking steps to control odor and talking about it with the patient/family and visitors before they arrive, can be helpful.  Chewing spearmint gum, placing peppermint oil under the nose or using Vicks vapor rub can be helpful for the patient and visitors to hide the odor.

Wounds should be continuously assessed for local and systemic infection.12  Wound swabs cannot diagnose an infection.2  All wounds have contamination and many are colonized with bacteria.  That does not mean there’s an active infection.12  Wound cultures are not appropriate for most hospice patients.  They can be very painful and are difficult to perform correctly and without contamination.  The pus and necrotic tissue in a wound do not indicate the bacteria contained within the tissue.  Also, once a culture is obtained, if not delivered to the lab within an hour, must be refrigerated.8 

The NERDS and STONEES mnemonic is a useful tool to assess for superficial and deep infection.


Localized infections can be cleansed with topical antiseptics.  Consider chlorhexidine, which has low toxicity, povidone-iodine (Betadine®) if broad spectrum is needed, and acetic acid (vinegar diluted 1:5 to 1:10) for suspected pseudomonas.  Some topical antiseptics can interfere with wound healing.  If the wound is healable, try to limit use and discontinue once infection has been controlled.8. After cleansing, topical antimicrobial agents can be used.  Crushed metronidazole9 and cadexomer iodine that were used for odor, can also be used for localized infection.  If these are not effective, silver dressing can be used for a short time, but it is a more expensive option and can cause tissue toxicity and resistance with longer use.8 

Deep tissue infection may cause further systemic infections.  Oral antibiotics can be used to treat systemic infections.  The choice to use oral antibiotics depends on if the wound is healable, maintenance or non-healable, and the goals of care.  If used, the goal is not to heal the wound, but to control the systemic infection.  Expected bacteria in our hospice patients’ wounds are gram positive and negative bacteria including anaerobes.  Dual oral therapy is used in order to address all of the different types of bacteria anticipated.  The antibiotics used in order of preference are: 

  • Amoxicillin/Clavulanate (Augmentin®), plus Trimethoprim/Sulfamethoxazole (TMP/SMX) (Bactrim®)
  • Clindamycin plus Ciprofloxacin
  • Doxycycline plus Metronidazole
  • TMP/SMX (Bactrim®) plus Metronidazole

In summary, it is important to do a thorough assessment of all patients for risk of developing chronic wounds and worsening of existing wounds.  The main goal for wound care is to improve quality of life.  Using the mnemonics TIME and NERDS & STONEES can help improve wound care. Oral antibiotics should only be considered for wounds with deep tissue or systemic infection, and in cases where treatment is preferred by the patient and family.  Members of the multidisciplinary team can help support the patient and family and help increase the quality of life for patients with chronic wounds.   

Written by: Karen Bruestle-Wallace, PharmD, BCGP, RPh


  1. Ayello, E. A. (2014, May 12). Pressure ulcer staging. Pressure Ulcer Staging Quality Initiatives. Retrieved January 14, 2022, from 
  2. Daley, B. J. (2021, April 3). Wound care. Wound Care. Retrieved January 18, 2022, from 
  3. Emmons, K. R., Dale, B., & Crouch, C. (2014). Palliative wound care, Part 2: Application of Principles. Home Healthcare Nurse32(4), 210–222. 
  4. Ferris, F., & von Gunten, C. F. (2015, May). #46 Malignant wounds. Palliative Care Network of Wisconsin. Retrieved January 19, 2022, from 
  5. Ferris, F., & von Guten, C. F. (2015, May). Pressure ulcer management: Staging and prevention. Palliative Care Network of Wisconsin. Retrieved January 14, 2022, from 
  6. Kulikov, P. (2018, December 25). Improving Wound Care Using the TIME Framework. The University of San Francisco USF Scholarship: a digital repository @ Gleeson Library | Geschke Center. Retrieved January 19, 2022, from 
  7. Nurses Association of Ontario, R. (2019). Project ECHO Skin and Wound Infection Enabler.pdf. Infection Control. Retrieved January 22, 2022, from 
  8. Nurses Association of Ontario, R. (Ed.). (2016, May). Assessment and Management of Pressure Injuries for the Interprofessional Team. Clinical Best Practices Guidelines. Retrieved January 20, 2022, from 
  9. Patel, B., & Cox-Hayley, D. (2015, August). #218 Managing Wound Odor. Palliative Care Network of Wisconsin. Retrieved January 19, 2022, from 
  10. Regional Wound Care Program, S. (Ed.). (2015, April 6). Guideline and Procedures: Wound debridement. SWR Wound Care Program. Retrieved January 19, 2022, from 
  11. Tippett, A. (2018, April 12). The Use of Lidocaine in Managing Wounds. WoundSource Blog. Retrieved January 21, 2022, from 
  12. Vera, M. (2020, May 6). Wound Bed Preparation and Beyond. WoundSource. Retrieved January 18, 2022, from 
  13. Winnipeg Regional, H. A. (Ed.). (2021, April). Malignant fungating wounds - WRHA professionals. Malignant Fungating Wounds, Clinical Practice Guidelines. Retrieved January 18, 2022, from 

Cannabis (marijuana) has recently garnered significant national attention as more states vote to legalize both medicinal and recreational forms of the substance. Cannabis use in end-of-life care is increasingly being sought by patients, and organizations are caught between strict federal regulations and waning state laws.  Many states have legalized marijuana’s medical use and some have recognized its recreational use as well. However, federally, it is still a Schedule I substance.

Cannabinoids and the Endocannabinoid System

Cannabis exerts its effects on the body by interacting with the endocannabinoid system, which consists of cannabinoid (CB) receptors. There are two main CB receptors in the body, the CB1 and the CB2. CB1 receptors can mainly be found in the brain and spinal cord, whereas the CB2 receptors are mostly located in the periphery. More than a hundred cannabinoids have been identified in the marijuana plant. Of these, tetrahydrocannabinol (THC) and cannabidiol (CBD) have been studied most extensively. THC is thought to interact mostly with the CB1 receptor, whereas CBD seems to have an effect on both the CB1 and CB2 receptors. Furthermore, cannabis can be divided into two primary species: indica and sativa. Indica strains are more CBD dominant, so it binds to CB1 and CB2 receptors, causing increased mental and muscle relaxation. The sativa strain is more THC dominant and is more commonly used for recreational purposes. 







Medical Uses of Cannabis

When a state approves the use of cannabis for medicinal purposes, the patient must meet certain criteria in order to be able to use medical marijuana. One of these criteria is a qualifying condition. There are many qualifying conditions for which several states have approved the use of medical marijuana, but evidence that marijuana is actually effective for these conditions is limited. It’s thought that cannabis may play a role in symptom management in neurodegenerative diseases, including Parkinson’s and Huntington’s disease. Studies have found that cannabis helps improve patient-reported symptoms of spasticity and pain associated with multiple sclerosis.

Additionally, cannabis appears to have a role in treating chemotherapy-induced nausea/ vomiting. Marinol® (dronabinol) is a synthetic THC derivative that is FDA approved for the treatment of chemotherapy–induced nausea/vomiting. It also has indications to treat anorexia in AIDS patients. However, since it is a THC derivative, its most frequently reported adverse effect is euphoria.

It is also thought that cannabis may be effective for pain management. Interestingly, there is some evidence that shows cannabis may be effective for refractory neuropathic pain in cancer and in patients with multiple sclerosis. However, some recent studies have shown that the use of cannabis for cancer pain was no better than placebo, and not effective for this type of pain.

Cannabis also appears to have a role in seizure management. In 2018, Epidiolex®, the first US-approved drug made solely from plant-grown cannabis, was approved for specific, rare types of epilepsy.

Routes of Administration










Laws and Regulations Concerning Cannabis Use

Although many states have started to legalize marijuana for medical use, it is still classified as a Schedule I substance at the federal level. As a hospice organization, it is illegal to furnish patients with cannabis. If your patient is taking marijuana for medical purposes, it should be documented and the patient should be offered evidence-based information regarding medical marijuana, but it cannot be provided by the hospice. In those states where medical marijuana is legal, only physicians that are specially certified by the state are able to recommend this substance for their patients who meet certain criteria. Also, marijuana is a cash-only market, which makes payment difficult, and government reimbursement should not be used to reimburse the patient or family.

Within facilities, laws regarding medical marijuana use, storage and administration can depend on state laws and also individual facility policies – it may even depend on what type of facility it is. Many nursing homes, for example, are regulated and funded by the federal government, and are concerned that non-compliance with federal law by allowing cannabis, may result in loss of funding. The past several decades have shown an increase in the use of medical marijuana. As a growing number of states vote to legalize its medicinal use, there is hope that there will be more research done to show its evidence based use and to further define its role in hospice and palliative care.

 Written by Kiran Hamid, RPh


Aggarwal SK, “Use of cannabinoids in cancer care: palliative care”, Curr Oncol. 2016 Mar; 23(Suppl 2): S33–S36.

Bereseford L, “How should Hospices Handle Legalized Marijuana” The Lancet, 19 Oct 2016

Häuser W, Fitzcharles M, Radbruch L, Petzke F, “Cannabinoids in Pain Management and Palliative Medicine: An Overview of Systematic Reviews and Prospective Observational Studies, Dtsch Arztebl Int. 2017 Sep; 114(38): 627–634. 

Cannabinoids No Help for Cancer Pain, Concludes Meta-Analysis - Medscape - Jan 29, 2020.



Anxiety is one of the most common symptoms for hospice patients. It has been reported within 20% to 50% of patients with advanced cancer.  While the impact of anxiety is recognized, anxiety management in palliative care is a major challenge due to a variety of contributing factors.  Timely identification, support, and treatment of anxiety are essential in patients with limited life expectancy.  Anxiety management benefits from a multi-dimensional team approach.  From physicians to nurses to social workers and spiritual care – all disciplines can play a role in helping alleviate anxiety.  There are several etiologies behind anxiety in hospice patients – including metabolic causes, drug withdrawal, and adverse drug effects.  Anxiety has cognitive, emotional, behavioral, and physical manifestations ranging from mild/occasional to a severe/constant state of anxiousness.



Constipation is a common gastrointestinal complaint.  It consists of less than three bowel movements per week, and stools that may be hard, dry, lumpy, and difficult or painful to pass.  Some patients may feel that not all of the stool has passed after having a bowel movement.1  Dehydration, bowel motility, and lubrication can also affect bowel movements.4


Non-Pharmacological Treatments

Diet and lifestyle changes like increasing fiber, fluids, and activity are not appropriate for many hospice patients.  If a patient is on opioids, has minimal fluid intake or poor gut motility, fiber can actually worsen the situation, or even cause an obstruction.4.

If possible, educate patients to go to the bathroom as soon as they feel the need to defecate.  Optimal times are after waking and after meals.  The patient’s perception may also need to be altered.  As they decline, it may no longer be realistic or appropriate to have bowel movements with the same regularity that they had before.3


Pharmacological Treatments

For patient with hard stools, utilize osmotic agents which include magnesium salts, polyethylene glycol (PEG), sorbitol, and lactulose (reserve for patients with hyperammonemia, sorbitol is better tolerated and more cost effective than lactulose).

The stool softener docusate sodium (Colace®) is not included in the list above.  There is no evidence that docusate sodium is effective for constipation.  Multiple randomized controlled trials have failed to show any significant efficacy of docusate sodium over placebo.  These trials have included hospital, nursing home, hospice, and ambulatory patients.5.  Continuing docusate sodium, even though the drug itself doesn’t work, has many negative downstream effects, including, but not limited to, creating extra work for the nurse, caregiver, families and patients.  Along with increased pill burden and a delay in obtaining effective treatment of constipation, if a patient is having difficulty swallowing medications, they may take docusate sodium over an important comfort medication.6  Note, docusate liquid has been known to taste terrible.7  If a patient is on the combination product senna/docusate sodium 8.6-100 mg tablet, this can be replaced with plain senna 8.6 mg tablet.6   Let’s stop flushing good money down the toilet with habitual use of a laxative (docusate sodium) that doesn’t work. 

Stimulant laxatives are used when patients are having motility issues.  Oral senna is preferred and the tablets can be crushed.  It is also available in liquid and tea form.  Bisacodyl is another stimulant laxative available in tablets and suppositories.  The suppositories can be used daily or as needed (prn) for constipation.4

Lubricant laxatives can be used in patients having painful bowel movements.  Mineral oil is a lubricant and available as an enema.  It is not recommended to be given orally as pneumonitis can result if it is aspirated.  Glycerin suppositories are another lubricant laxative with the added benefit of drawing water into the rectum.4




Opioid Induced Constipation (OIC)

Opioid induced constipation (OIC) affects 45-90% of patients on opioids.  Patients do not develop tolerance to OIC like most other side effects.  Also, there is no evidence that physical activity, scheduled toileting, fiber, or adequate fluid intake are effective.  Opioids cause constipation using multiple mechanisms.  They affect GI motility, inhibit mucosal transport of electrolytes and fluids, and interfere with the defecation reflex.

Stimulant and osmotic laxatives are effective for opioid-induced constipation (OIC).  The preferred oral stimulant is senna.  Bisacodyl is also available orally.9  Rectal-based laxatives are often used when oral options fail. Warm tap water and milk of molasses enemas can also be used, and can be dosed more frequently (up to every 2 hours).8


Refractory Constipation

For refractory constipation, suppositories and enemas can be used.  As a last resort, manual evacuation can be done.8

If there is a high impaction that has failed to be relieved with other treatments, Vaseline balls can be used.  Freeze a dollop of Vaseline, roll/squeeze into pea-sized balls, roll in confectioners’ sugar or cocoa powder for taste.  Have the patient swallow 1-2 balls q3-4 hours until BM, may increase if no BM in 12 hours.9  


Newer Agents for Constipation

There are some newer agents for OIC as well as other types of constipation.  However, the first-line agents for constipation are the traditional laxatives. This includes OIC.  The traditional laxatives are proven safe and effective, and are also extremely cost effective when compared to the newer agents.   




In summary, identify patients who are at risk for constipation and initiate a bowel regimen.  All patients on opioids are at risk.  Target the cause, when possible.  Most elderly patients have complex constipation and OIC has multiple causes, so multiple agents may be needed.  Stimulants and osmotics are usually the best options.  When needed, utilize suppositories and enemas.  Make sure to titrate to maximum doses (senna 8.6 mg tab up to 12 tabs/day, 4 tabs po tid), and if needed, add on other routine (sorbitol) or prn laxatives (mom, suppositories etc.).  Newer agents should only be tried after an adequate trial (titrated to maximum doses) of the appropriate traditional laxatives.

Written by Karen Bruestle-Wallace, PharmD, BCGP, RPh


  1. Lacy, B. E. (Ed.). (2018, May). Constipation. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved October 21, 2021, from 
  2. 3 in PowerPoint. Sonnenberg, A., & Koch, T. R. (1989, January). Epidemiology of constipation in the United States. Diseases of the colon and rectum. Retrieved October 21, 2021, from 
  3. 4 in PowerPoint De Giorgio, R., Ruggeri, E., Stanghellini, V., Eusebi, L. H., Bazzoli, F., & Chiarioni, G. (2015). Chronic constipation in the elderly: A Primer for the Gastroenterologist. BMC Gastroenterology15(1). 
  4. 5 in PowerPoint Hallenbeck, J. (2015, May). Fast facts and concepts #15 constipation James Hallenbeck ... FAST FACTS AND CONCEPTS #15 CONSTIPATION. Retrieved October 21, 2021, from 
  5. 6 in PowerPoint Fakheri, R. J., & Volpicelli, F. M. (2019). Things we do for no reason: Prescribing docusate for constipation in hospitalized adults. Journal of Hospital Medicine14(2), 110–113. 
  6. 7 in PowerPoint Lee, T. C., McDonald, E. G., Bonnici, A., & Tamblyn, R. (2016). Pattern of inpatient laxative use. JAMA Internal Medicine176(8), 1216. 
  7. McKee, K. Y., & Widera, E. (2016). Habitual prescribing of laxatives—it’s time to flush outdated protocols down the drain. JAMA Internal Medicine176(8), 1217. 
  8. Badke, A., & Rosielle, D. A. (2015, April). FF and Concepts #294 Opioid Induced Constipation Part 1: Established Management Strategies. FF-294 Opioid Constipation. Retrieved October 21, 2021, from 
  9. Shah, S.; Madison, M.; Speer, K. ProCare HospiceCare, Hospice Medication Utilization Guidelines (HUGS). Gainesville, GA
  10. Lexicomp Online, Lexi-Drugs, Waltham, MA: UpToDate, Inc.; Oct. 18, 2021. Accessed Oct 20, 2021.
  11. Crockett, S. D., Greer, K. B., Heidelbaugh, J. J., Falck-Ytter, Y., Hanson, B. J., & Sultan, S. (2019). American Gastroenterological Association Institute guideline on the Medical Management of opioid-induced constipation. Gastroenterology156(1), 218–226. 


The use of antibiotics is an ongoing ethical debate in hospice care as it can be perceived to be less aggressive/invasive than other curative/life-prolonging interventions (e.g., intubation, dialysis, chemotherapy, etc.).  Hospice patients are especially vulnerable to infections and have high rates of resistant bacteria due to long-term chronic illness.  However, there are no guidelines directing appropriate antibiotic decision-making in hospice patients.  Therefore, hospice-related infectious disease studies seek to determine if antibiotics provide symptom relief and/or prolong survival in our patient population.



ANCC Accreditation

ProCare HospiceCare is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.