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JOURNAL OF WOUND CARE VOL 22, NO 5, MAY 2013 265
Review of patients’ experiences
with fungating wounds
and associated quality of life
l Objective: To investigate the evidence exploring the experiences of patients with fungating wounds
and associated quality of life, and to subsequently provide recommendations to how these implications
may be addressed in practice.
lMethod: Using a systematic approach, a comprehensive literature search was conducted to investigate
the most appropriate and relevant evidence regarding the experiences of patients with fungating wounds.
lResults: Studies unveiled the enormity of the unrelenting, unique and devastating consequences that
these wounds have on an individual’s life and that every domain of their life is negatively affected.
lConclusion: These ndings must galvanise nurses to become aware of the extent of the devastation
experienced and aspects of life affected by these wounds. The issues raised have multifaceted and challenging
implications for practice; however, all aspects need to be addressed and satised in an attempt to improve
the quality of life of individuals with fungating wounds.
lDeclaration of interest: There were no external sources of funding for this study. The authors have
no conicts of interest to declare.
fungating wounds; patient experience; quality of life
F
ungating wounds can develop anywhere
on the body1 and, although they may arise
from malignant cell transformation from
chronic wounds, they are commonly asso-
ciated with breast cancer (62%), head and
neck cancer (24%), genital and back cancer (6%),
and others (8%).1 Tumour permeation disrupts
surrounding blood and lymphatic vessels causing
haemorrhage, tissue hypoxia, necrosis and infec-
tion, while proliferating cells cause the wounds to
possess ‘cauliower-like’ nodules.2
Literature suggests that fungating wounds devel-
op in the last 6months of life and, for the cancer
patient, have a devastating impact on quality of life
(QoL).3–5 Although therapies such as chemotherapy,
radiotherapy or hormone therapy may be used in an
attempt to delay progression, fungating wounds are
usually non-healing and prognosis is poor; care is
therefore palliative, with an emphasis on patient
comfort and QoL.5
The exact prevalence of fungating wounds is
unknown, as they are not recorded on any popula-
tion-based cancer registers.6 The current estimation
for the prevalence of fungating wounds in cancer
patients is considered to be 5–10%,7 a gure sup-
ported by Alvarez et al.8 and Probst et al.9 However,
DolBeault et al.10 suggest that some fungating
wounds may never be brought to the attention of
health professionals, due to embarrassment.
Early detection through patient education and
screening (such as breast screening) may result in a
reduction of such wounds,11 while some argue that
with an ageing society and advances in health care,
the number of people with these wounds is set to
increase.12 Irrespective of the precise incidence of
fungating wounds, they have a devastating impact
on a patient’s life.
While there is a raft of literature and guidance
around various aspects of wound care, fungating
wounds appear to be overlooked.7 Information
regarding fungating wounds appears to be based on
anecdotal evidence, case studies or expert opinion.
Therefore, perhaps unsurprisingly, studies relating to
patient experience and QoL are even more limited.
Goode13 infers that this gap in knowledge may be
based around the ethical dilemma and challenge of
gaining approval to research this client group; how-
ever, limited knowledge of patient experience in
relation to fungating wounds restricts the delivery of
care for the person as a whole. As Alexander7 points
out, psychological aspects of an illness frequently
create more suffering than physical ones.
Method
A literature search was conducted, using a systematic
approach, to investigate the evidence regarding the
experiences of patients with fungating wounds. This
ensured that all pertinent literature was included.
Multiple databases were explored. CINAHL Plus,
MEDLINE, EMBASE and PsycINFO were investigated
using the key words [‘fungating’ OR ‘malignant’]
AND [‘wound*’], [‘quality of life’ OR ‘experience*’]
AND [‘psychosocial’]. Internurse, Web of Knowl-
edge, Google SCHOLAR, Scirus and Cochrane
S. Gibson,1 BSc(Hons);
J. Green,2 MSc, Lecturer
and PhD Research Fellow;
1 Staff Nurse, Critical
Care Unit, University
Hospital of North
Staffordshire,
Stoke-on-Trent, UK;
2 School of Nursing
and Midwifery, Keele
University,
Staffordshire, UK.
Email: sarah.gibson@
uhns.nhs.uk
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JOURNAL OF WOUND CARE VOL 22, NO 5, MAY 2013266
Library were also searched, using the key words
[‘fungating’], [‘wounds’], [‘quality of life’], [‘experi-
ence’] and [‘psychosocial’].
The period covered was 2000–2012. The inclusion
criteria were adult patients, primary studies published
in English after 1999 and QoL focused. Excluded
articles consisted of those associated with paediatric
patients, studies published before 2000 and literature
evaluating wound management (Table1).
Results
The search was considered complete when repeti-
tion of literature emerged and, following these
search criteria, 158articles were identied. A hand
search discovered a further paper and the search was
then rened. The nal number of articles was
reduced to10 (Fig1).
A thorough, critical analysis of the literature to
ensure robustness, credibility and relevance of arti-
cle was performed via implementation of the Criti-
cal Appraisal Skills Programme method,14 and each
article was given a quality assessment score.15
From the 10 articles included in the review, a
number of themes emerged, which have been
combined into four primary themes: physical,
social, psychological and spiritual.
Theme one: physical impact
Physical implications emerged from a number of
articles. The most frequently reported physical
impact was malodour, with nine articles nding this
to have a prevailing negative impact on patient
quality of life;3,16–23 some of these studies revealed
malodour as the symptom causing most
anguish.3,17,18,21,22 Lo et al.17 constructed ve compre-
hensive themes from their study, all of which
revealed malodour as a key characteristic of physical
duress experienced by patients. Patient attempts to
disguise the odour from the wound by using
perfume or towels to mask or dampen the smell,
without success, and descriptions ranging from ‘a
smell that never goes away’ to being compared with
‘rotten meat’ were common in several articles.3,19,21,22
Uncontrollable exudate was also experienced and
found to have a profound impact on QoL.16,18,19,22,23
Grocott16 highlighted irrepressible exudate as the
principle problem for patients with fungating
wounds, subsequently leading to skin irritation and
maceration. Inadequate dressing t also featured
strongly, the consequences of which were further
leakage, soiled clothing and recurrent dressing
changes. These problems with wound management
created lifestyle constraints in terms of frequent
dressing changes and additional laundry. These nd-
ings are corroborated by other studies.18,19,22,23 Evi-
dence further suggests that haemorrhage is a factor in
the physical wellbeing of these patients.17,19,20,22,23
Some patients resorted to taking spare clothes when
they went out, or limiting their activities.22
The literature identied pain as a consequence of
living with a fungating wound,10,17,19,20,22,23 which
was described by patients as ‘stabbing’, ‘break-
through’ and ‘constant’,17,19,22 and in some cases
restricted nutritional intake to a soft diet.3 Other
Table 1. Databases, search terms and number of hits (22/02/12)
Database Search terms No. of hits
CINAHL Plus [‘fungating’], [‘malignant’], [‘wound*’], 79
[‘quality of life’], [‘experience*’], [‘psychosocial’]
MEDLINE [‘fungating’], [‘malignant’], [‘wound*’], 35
[‘quality of life’], [‘experience*’], [‘psychosocial’]
EMBASE [‘fungating’], [‘malignant’], [‘wound*’], 14
[‘quality of life’], [‘experience*’], [‘psychosocial’]
PsycINFO [‘fungating’], [‘malignant’], [‘wound*’], 4
[‘quality of life’], [‘experience*’], [‘psychosocial’]
Internurse [‘fungating’], [‘wounds’], [‘quality of life’], 5
[‘experience’], [‘psychosocial’]
Web of Knowledge [‘fungating’], [‘wounds’], [‘quality of life’], 8
[‘experience’], [‘psychosocial’]
Google Scholar [‘fungating’], [‘wounds’], [‘quality of life’], 12
[‘experience’], [‘psychosocial’]
Scirus [‘fungating’], [‘wound’], [‘quality of life’], 1
[‘experience’], [‘psychosocial’]
Cochrane Library [‘fungating’], [‘wounds’], [‘quality of life’], 0
[‘experience’], [‘psychosocial’]
Fig 1. Selection of articles
Excluded at abstract stage (n=65)
Reasons:
Review articles
Evaluation of dressing/management
Not patient focused
Excluded at electronic stage (n=84)
Reasons:
Duplicate reference
Non-English language
Complete text unavailable
Articles included in review (n=10)
Possibly-relevant article identied by
search and screen (n=159)
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JOURNAL OF WOUND CARE VOL 22, NO 5, MAY 2013268
functional restrictions in various activities of daily
living were unearthed, such as reduced mobility as
a result of the location of the wound, inability to
sleep, fatigue, breathlessness, drooling, swallowing
and speech problems, incontinence, depleted
nutrition and hydration, and vision and hearing
impairments.23 Functional compromise and phy-
sical deformity proved problematic with the tting
of clothing and individuals reported that cumber-
some wound dressings emphasised their bodily
disproportion due to the awkward anatomical
locations of the wounds.19,23
The study conducted by Maida et al.19 was of a
more substantial sample size and investigated
various anatomical sites of fungating wounds, thus
enabling a deeper, and more comprehensive and
diverse analysis of patient experience and QoL;
this study stated that many of those with visible
fungating wounds, such as head or neck wounds,
reported increased aesthetic anguish. In addition,
Schultz et al.23 also discovered physical restraints
affected the ability to self care, which consequently
reduced independence.
These ndings suggest that numerous physical
problems are associated with living with a fungating
wound. The studies further imply that these phy-
sical problems and functional limitations are also
directly associated with social problems.3,16–23
Theme two: social impact
Social relationships were found to have suffered as a
direct result of malodour, exudate, altered body
image, embarrassment, low self esteem, dressing
regimes, the unpredictable nature of the wound and
social stigma.10,16–23 Although Schultz et al.23 did not
address nancial implications of living with a fun-
gating wound, this was the only study to acknow-
ledge the need to investigate this aspect, as nancial
problems and inability to work are also associated
with loss of social pastimes and networks.24
Self withdrawal from family and society was
expressed because, as a result of the wound, patients
could not wear their preferred choice of clothing.
Bulky dressings and inability to wear underwear
caused women to reject others and left them feeling
socially isolated.18 Patient fears regarding accept-
ance in society were evident as feelings and fears of
social stigma, negative public response and subse-
quent self alienation from society were reported in a
number of articles.16,19,21,23 An in-depth study by Pig-
gin and Jones21 revealed that a lady described how
her loss of self left her feeling poles apart from
everyone else yet she endeavoured to ‘be normal’.
Others spoke of their decision not to inform their
social circle of the wound and how they declined
social invitations due to anxiety caused by the
unpredictable nature of the wound, in turn dimin-
ishing social support.21 The literature search also
identied two previous studies investigating fung-
ating wounds from the viewpoint of the patient,
albeit in varying depths.16,18
One study similarly discovered that some people
decided to conceal their wound from family mem-
bers, believing that, if they saw the wound, they
would be appalled at it.17 Individuals felt that expo-
sure of the wound would damage how their family
perceived them. Moreover, ndings describe how
stigma resulted in social withdrawal, as one indi-
vidual gave an account of how people are unable to
accept the wound.17 Altered relationships were evi-
dent;3,10,16,18,20–22 inability to full the role of mother
was expressed—not only due to the aforementioned
physical restrictions caused by the wound, but also
as a result of how people with fungating wounds
perceive themselves and act.21
Participants found that they were suddenly pro-
pelled into different relationships with themselves
and others, as they described how their existence
had been brutally altered as they became almost
unrecognisable to their former self.3 Loss of
identity and disgurement were linked to self
disgrace and blame, and were found to affect femi-
ninity and sexuality; one woman reported how she
was no longer the person her husband once loved
and how she felt that she had to cover her body
because of the possible traumatic effects it would
bestow on her husband.21
Loss of femininity and sexuality were familiar
themes in other studies.10,16,18,20,22 Research by Lund-
Nielson et al.18 focused on and explored the
feminine and sexual perspectives of 12women with
breast cancer and fungating wounds. Similar to
Grocott,16 this study formed part of an evaluation of
dressing interventions, which may have affected
impartiality.25 Lund-Nielson et al.18 revealed that
wound dressings affected their choice of underwear,
which subsequently affected their self esteem and
femininity. Moreover, altered body image and exu-
date also affected choice of clothing (such as bras)
and consequently further impacted on femininity.
Women described how intimacy and sexuality were
also found to be affected by the appearance of the
wound, often due to malodour and uncontrolled
exudates, with one woman disclosing how she and
her husband never discussed the wound.18 These
ndings were echoed by Probst et al.22 where the
wound was found to be considered a ‘taboo’ for
some couples.22 Difculty in patients and their
partners touching the wound were equally
discussed, often due to wound progression.10,22
Literature suggests that people living with a fun-
gating wound experience a range of detrimental
implications in relation to their social lives, which
has a negative impact on their QoL. Common views
comprise attempts to conceal the wound, self with-
drawal from family, friends and society, lack of social
education
JOURNAL OF WOUND CARE VOL 22, NO 5, MAY 2013270
acceptance and stigma, inability to full roles, altered
relationships, reduced femininity and sexuality.
Evidence demonstrates that fungating wounds have
a profound impact and, of signicant, consequence
is that all of the literature reviewed also refer to
psychological concerns.
Theme three: psychological impact
The psychological impacts of fungating wounds
were found to be far-reaching and Alexander3 even
went so far as to say that the emotional effects of
fungating wounds were the most devastating. Exten-
sive feelings of embarrassment and shame due to the
physical issues were reported by patients,3,10,16,17,19,22,23
and it was these feelings that compelled some
patients to self care.10,22 For some, these psycho-
logical consequences prevented them from seeking
professional care and meant neglecting their wound
and only reporting to health professionals when the
wound became unmanageable, which resulted in
difculties conversing about the wound, when it
had been previously concealed.10 It should be noted
that a number of patients in this study displayed
personality or anxiety disorders and, as such, it may
prove difcult to establish the extent that these
issues accounted for their responses.3 With the lack
of a control group these ndings cannot be transfer-
able to patients without neglected fungating wounds
or those without these disorders; therefore, more
research is required into this aspect.
Grocott16 and Schultz23 disclosed how the uncon-
trollable nature of fungating wounds strained cop-
ing abilities. The challenges posed by an unreliable
body and loss of control were described as a feeling
of susceptibility,21,22 in addition to reports of altered
personalities and attrition of one’s self with bouts
of anger and aggression.3,22 A sense of loss ranged
from a loss of everyday living, as participants
described how their existence had been brutally
altered as their lives were ruled by the wound,3 to
not being able to nurture their children to maturity.
Guilt also featured in relation to letting people
down, the impact on children, failure to full roles
and of becoming a burden.17,21
Feelings of being dirty and bodily decay were
expressed as people described themselves as ‘fester-
ing’ and ‘rotting meat’.3,17,21,22 Reports of the wound
acting as an indication of either the response to
treatment or advancement of cancer were evi-
dent,10,17,21,22 and the effects of fungating wounds
were considered to be the worst aspect of cancer.21
This direct reminder of cancer was related to disease
progression and death,10,22 which, in addition to the
above implications and a fear of life threatening
haemorrhage,16,23 often caused depression, distress,
anxiety and anguish.3,17,19,22,23
Alexander3 is the only author to provide an
insight into the lasting intensity of the memories
fungating wounds leave carers. The distressing
details and images engraved on their minds
appeared to be unforgettable, even years after the
death of the patient.3
On analysis, the literature suggests that the psy-
chological impacts of living with fungating wounds
are the most devastating. A multitude of emotions
were expressed with several common feelings
featuring strongly. Among these were an unwil-
lingness to seek help and difculty talking about
the wound, a sense of loss, embarrassment and
shame, lack of self esteem, guilt, fear, distress, anger,
anxiety and depression. Feelings of being dirty,
bodily decay and living with an untrustworthy
body were present, in conjunction with accounts of
how the wound acts as a constant reminder of
cancer, progression of the disease, an association
with death and a lasting impact on carers.
Theme four: spiritual impact
In spite of spirituality having scarcely been explored
with people with fungating wounds,3 studies touch
on this aspect. Piggin and Jones21 imply that hope is
difcult to achieve when faced with a visual repre-
sentation of the internally progressing cancer; yet,
according to Alexander,3 reports of hope of a peace-
ful death or preserving hope of discovery of a cure
were revealed. Conversely, it was disclosed how hope
for a cure also caused distress and conict between
family and health professionals, as they appreciated
the importance of rendering hope but were also
mindful of the need to foster realism.3 Revelations of
patient existence were portrayed as a ‘new mode of
being-in-the-world’ and, despite patient efforts to
accept this, time is often in short supply for people
with a fungating wound trying to adapt or to truly
come to terms with this new way of life.3
The only research to directly address spirituality
was supported by an independent grant-giving
charity.20 The researcher claims to be the rst to
examine palliative care concerns in Kenya and
focused on QoL in patients with fungating wounds.
With this in mind, the ndings may not be transfer-
able due to different health systems and lifestyles;
however, this study provides an insight into patient
experience. Employing the Functional Assessment
of Chronic Illness Therapy (FACIT) measurement
system (a series of questionnaires which assessed
QoL for patients with chronic illness), Marete20 sug-
gested that individuals found comfort and strength
from faith or spiritual beliefs. These ndings were
reiterated in one of the two case studies included in
the paper, where a lady revealed a lack of content-
ment and gratication in life, but although she
occasionally felt that her faith had deserted her, she
also found reassurance from it.
Reecting on these results, future research is
required in this area. It would appear that the spiritual
education
s
JOURNAL OF WOUND CARE VOL 22, NO 5, MAY 2013 271
impact of fungating wounds is extremely individual;
for some, spirituality may be difcult given the
anguish the wound may cause, while others cling to
hope for varying reasons. Equally, where one person
may nd peace this may cause another distress.
Implications for practice
The literature provides a compelling argument that
patients with fungating wounds experience multi-
faceted challenges, which have an immense, unique
and devastating impact on QoL, creating enormous
exigent implications for practice. Although these
wounds may appear to affect a relatively small
number of individuals, the consequences are huge.
Despite a lack of clinical guidance for fungating
wounds, nurses are the predominant professionals
involved in holistic care of patients and their fami-
lies; therefore, these aspects need to be addressed to
improve patient QoL.
Recommendations
The patient
Lack of patient information was identied, which
inuenced the ability to self care and increased anx-
iety and pain.18 Provision of information regarding
aetiology, symptoms, care, management, emotions,
coping mechanisms and how to access support
(practical and psychosocial) should be promoted.
This facilitates patient understanding of their condi-
tion, simultaneously encouraging self care, empow-
erment and partnership, and enabling patients to
make informed decisions about their care, further
allowing a sense of control over their life.26
Information is linked with reducing anxiety and
stress.27 This should be endorsed through informa-
tion leaets/booklets written in an appropriate way
for the patient,28 or by recording consultations, as
literature suggests that patients’ ability to under-
stand and remember information—particularly dur-
ing times of high levels of stress—is often dimin-
ished.29 This is supported by research that explored
patients’ capabilities to recall information following
a standardised theoretical clinical situation.30 With
a generous sample size (n=755), less than half of the
participants were able to correctly recall some
aspects of the scenario. It could be argued that this
recorded hypothetical setting may not reect true
experience, yet another study reinforces this
notion.31 Demir et al.31 interviewed women under-
going breast biopsies, which were recorded to ensure
authenticity,32 and ndings revealed that many
participants lacked comprehension or failed to
remember verbal information.
A simple, specic self assessment tool, which incor-
porates all aspects of QoL from the patient experi-
ence and perspective, could be completed in private
by the patient prior to consultations. Although this
structured approach may not represent all individual
experiences, it may provide the opening for the pro-
fessional to discuss sensitive information, inviting
the patient to discuss areas of concern. This may
prove benecial if the patient feels unable to verbally
initiate such issues.33 The Wound and Symptoms
Self-Assessment Chart was designed with the intent
that patients could portray how fungating wounds
affected their lives,34 and an adaptation of such a
tool may also be utilised to identify the effects and
needs of family/carers. Advantages of such practice
have been demonstrated via the ‘distress thermo-
meter’ for patients in oncology and palliative care.35,36
Despite the potential benets to this approach,
anecdotal evidence suggests that practitioners often
overlook such tools.
Literature suggests that a designated section in
multidisciplinary care plans for patients with com-
plex wounds to document information they wish
professionals to be aware of promotes empower-
ment.37 This may be particularly problematic for
patients with fungating wounds, as psychological
implications dominate QoL,3 and as these people
experience shame and embarrassment, often
attempting to conceal the wound,18,22 the ability to
share sensitive or distressing information with a range
of professionals may be compromised. In these
circumstances, a patient diary may not only evaluate
effectiveness of treatment but also encourage oppor-
tunities to convey unlimited and extensive feelings,
which the patient and nurse can address together.38
The impact of fungating wounds on QoL can be
immense, diverse, personal and unique. Informa-
tion may enable the patient to take greater control
over their life and relieve anxiety, while patient par-
ticipation in their own care allows this to be shaped
around any aspect of life that is affected or consid-
ered important to the individual.
The nurse
The literature repeatedly comments that nurses are
poorly prepared to care for patients with fungating
wounds and recognises the need for professional
education and support.22,39,40 There does appear to
be some progress in this area, as the European
Oncology Nursing Society hopes to devise an ‘edu-
cational toolkit’, which aims to support best
practice by providing nurses with clinical guidelines
and information regarding the pathophysiology
and assessment of fungating wounds.41 These
toolkits should be available to all nurses who are
likely to care for those with a fungating wound, or
at the very least specialist nurses, such as tissue
viability, oncology or palliative care nurses.
Support should be offered by community nurses
by allocating sufcient time for home visits. Com-
munity nurses frequently provide the only source of
social contact for some patients with chronic
wounds,42 yet the level of social support provided by
education
JOURNAL OF WOUND CARE VOL 22, NO 5, MAY 2013272
community nurses is deemed insufcient for these
patients.43 Wound-care clinics have been found to
increase social contact for patients with complex
wounds;44 however, with the various anatomical
locations of fungating wounds people may be reluc-
tant to attend these appointments. In addition,
adequately timed visits may encourage therapeutic
relationships and allow patients to express their
concerns; the nurse must be attentive to patient
feelings of anguish, as opposed to primarily
focusing on caring for the wound.45,46
Therapeutic relationships are considered vital to
people with fungating wounds;47 involving a consist-
ent and minimal number of staff in care may allow
this relationship to ourish, providing efcient
symptom management and enabling patients to
express their innermost or personal problems.48 Evi-
dence further demonstrates how rapport positively
inuences how patients with non-healing wounds
approach everyday activities and encouraged
empowerment and self care, providing patient
autonomy, dignity and psychological wellbeing in
palliative care.49–54 When encouraging patients to
express their concerns, the nurse must be equipped
to address and act on issues raised; offering counsel-
ling to patients may be one way to achieve this,
simultaneously improving psychological support.
Professional opinions must not hinder this valuable
aspect of care and an awareness of the potential ben-
ets must be recognised, as nurse education regard-
ing counselling prociencies results in improvements
in psychological care for patients with wounds.45
Therapeutic relationships may enhance spiritual
care and, as growing evidence demonstrates the
effects of spirituality on health, wellbeing and
QoL,55–59 this should be considered in an attempt to
deliver holistic care, yet this aspect is often neglected
by nurses.57 Nurses highlight a gap in knowledge in
this area,60 which may account for this omission of
care; therefore, education must be rolled out to nurs-
es in order for them to deliver this effectively.61
Self assessments/patient diaries could be used in
conjunction with specic wound assessments to
establish individual care and effective dressing selec-
tion.7 Literature recognises the role of wound assess-
ment in this process and the benets to QoL34,39,62 and
two tools have been designed with this in mind:
l TELER (Treatment Evaluation by A Le Roux)63
focuses on the evaluation of dressings
l The malignant wound assessment tool64 claims to
consider clinical aspects of the wound and patient
issues surrounding practical, social and psycho-
logical aspects.
However although tools such as these may assist
practice, studies reveal that they are rarely utilised.65
Studies demonstrate how effective dressings can
improve patient QoL.16,21 Thomas66 states neither the
‘ideal wound’ nor the ‘ideal dressing’ exist, but
provides several considerations in an attempt to
select a suitable dressing. Fungating wounds are far
from an ‘ideal wound’ and rarely heal;5 therefore, the
selection of dressing must conform to patient choice
and improve QoL. Types of dressings and topical
applications are too substantial for the scope of this
article; however, various practical measures can be
undertaken by nurses to improve patient QoL. The
awkward positions of fungating wounds pose
frequent problems for nurses67 and Fletcher68 offers a
useful guide on dressing adaptation by re-designing
and re-shaping dressings to suit the wound. Some
patients may also be suitable for chemotherapy,
radiotherapy or hormone therapy, which may reduce
the wound and associated symptoms.5
Pain should be continually assessed, addressed
and evaluated.69 The World Health Organization
pain ladder69 focuses on these aspects using chemi-
cal analgesia, while the involvement of pain special-
ists may be of further benet. Dressing changes
should be done in a suitable time frame to maximise
therapeutic analgesic effects, and nitrous oxide and
oxygen (such as Entonox) may also prove useful to
tackle pain during procedures. The nurse needs to
be imaginative in practice and the benets of com-
plementary therapies must not be forgotten or
underestimated during dressing changes.70 Relaxa-
tion may be advantageous to some patients, while
distraction techniques, such as music therapy or
conversation, may reduce anxiety and pain.
Various other complementary therapies can also be
employed, if the practitioner has completed relevant
training and is competent.71 Fenton72 describes the
potential for these therapies, revealing how massage
provided comfort for a lady with a fungating wound,
simultaneously improving her overall health and
wellbeing, while aromatherapy could be used to
mask odours. There is diminutive evidence to sup-
port the outcomes of these approaches;73 however, a
recent pilot study by Lim et al.74 examining
the effects of acupuncture suggested symptom
improvement with palliative cancer patients.
Pre-emptive measures, such as the creation of an
‘emergency box’ with suitable dressings, medication
and dark coloured towels (to disguise haemorrhage),
could be left in the home of the patient. The box
could be separated into two sections—one for the
patient/carer (with relevant advice and instructions)
and one for the professional—and would be con-
stantly available and may be useful for emergency
situations to relieve patient/family distress. The
potential benets of such boxes are supported by the
successful implementation in areas such as end-of-
life care and end-stage motor neurone disease.75–77
Delivering holistic care for a patient with a fun-
gating wound can be complex, and nurses must
acknowledge their limitations and seek advice from
experts, when appropriate. The central role and
References
1 Naylor, W. Part 1: symptom
control in the management
of fungating wounds.
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education
JOURNAL OF WOUND CARE VOL 22, NO 5, MAY 2013274
special relationship with the patient enables the
nurse to act as the connection between patient and
other professionals.78 Multidisciplinary involve-
ment for these patients is important,18,79 but as
highlighted previously, this approach should be
assessed on an individual basis, as patients often
experience embarrassment18,22 and may not feel
comfortable sharing personal problems or inner-
most feelings with a multitude of people. Despite
these considerations, patients conrm how they
value the contribution of expert help, and how this
enables them to live more optimistically.18
Nurses report how they often struggle to restrain
their own emotions when caring for patients with
offensive wounds,80 and studies expose how nurses
caring for people with fungating wounds experi-
ence profound anguish in relation to numerous
aspects of patient care.3,80,81 Examination into how
nurses should address their emotions reveals con-
icting advice. Hawthorn82 afrms that nurses
should conceal their reactions and emotions when
delivering care to patients with a fungating wound,
whereas Aranda83 argues that suppression of feel-
ings by professionals not only connes the patient
to silence, as they feel unable to discuss obvious
symptoms, but may also have detrimental effects
on the nurse. To combat these challenges faced by
nurses, Hawthorn82 suggests that practice reection
alleviated some distress, while recognition of these
stressors by senior professionals and subsequent
support should be offered to promote staff wellbe-
ing and high-quality patient care.82
To optimise and maximise patient QoL nurses
need to be educated regarding effective holistic care
for those with fungating wounds. Sufcient time
must be allocated to care for patients to address their
needs fully and allow therapeutic relationships to
develop, acknowledging patient/family needs and
acting on their concerns by being adaptable and crea-
tive in their approach to care, seeking support if
appropriate. To enable high quality care, support
should also be available for nurses, if they so desire.
Organisations
Increased public awareness and education are called
for regarding the detection of early signs and symp-
toms of cancer, in an attempt to minimise the devel-
opment or progression of the disease and conse-
quently the development of a fungating wound.
Increasing the frequency of screening programmes
may further reduce the development of fungating
wounds; however, for those who conceal these
wounds from health professionals, the uptake to par-
ticipate in these programmes may be limited. Dis-
parities of education and health-care systems in
developing countries should be addressed, as these
may be contributing factors in the signicant number
of people presenting with fungating wounds in such
countries.11,20 Allocating funding and resources into a
greater understanding of fungating wounds may
initiate interventions to inhibit their development.
A formal reporting process is required to establish
the true extent and prevalence of fungating wounds,
and simultaneously provide ofcial statistics and
highlight trends regarding where/why these wounds
proliferate (anatomically and geographically), and
enabling efcient focusing of resources. Moreover, in
today’s modern health-care system, where evidence-
based nursing is paramount,84 it appears astonishing
that nurses are delivering care without any formal
guidance. Therefore, information collation from the
reporting process and nancial investment would
provide a rationale for research towards comprehen-
sible recommendations and local, national and inter-
national evidence-based guidelines on which to base
nursing practice. Randomised controlled trials or
systematic reviews are deemed the pinnacle of the
evidence hierarchy;23 however, given the sensitive
nature and ethical considerations surrounding
fungating wounds, perhaps guidelines based on less
favourable methods, such as case studies or qualita-
tive or anecdotal evidence may be employed.
National guidance, research and training around
fungating wounds may also reduce nancial expendi-
ture on wound care.85 Increased awareness of the dev-
astating effects may stimulate funding into the tissue
viability industry to enhance the lives of people living
with a fungating wound through development of
innovative wound-care strategies. Examples of such
innovation may include exploration into ‘dry wound
management’,86 advancements into dressing systems
and the creation of more effective dressings and appli-
cations, where the emphasis of wound care moves
towards QoL rather than healing.87
Organisations must raise awareness of the signs and
symptoms of cancer and increase the regularity of
screening programmes to reduce the development of
fungating wounds. A formal reporting process and
guidance is required on which to anchor best prac-
tice, while funding and research into the prevention
and management of fungating wounds may reduce
the incidence of these wounds, alleviate the disturb-
ing experiences of patients and improve patient QoL.
Conclusion
Fungating wounds are a seldom-researched topic,
while the sensitive nature of fungating wounds adds
further complexities. This literature review provided
an insight into the experiences of patients living
with a fungating wound, which evidence suggests
are overwhelming, unrelenting and affect every
domain of life. These ndings must galvanise nurses
to become aware of the extent and devastation of
these wounds. With a paucity of evidence in all
areas relating to fungating wounds, the need for
further research is paramount. n
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