Malignant fungating wounds assessment in palliative care: a scoping review

Introduction: Malignant fungating wounds (MFWs) are secondary chronic wounds resulting from malignant cell proliferation and migration, compromising skin integrity in patients with cancer. These wounds present a range of signs and symptoms. Although several instruments are used in their assessment, it is still unclear which tool is most appropriate for comprehensive evaluation and wound healing.

Aim: To review the existing instruments for MFW assessment, highlighting their strengths and limitations.

Methods: A scoping review was conducted following the Arksey and O’Malley framework (2005), the Joanna Briggs Institute guidelines (2020, 2021), and the PRISMA-ScR checklist (2018). The search was performed on four databases: Web of Science, Scopus, PubMed, and EBSCO.

Results: Forty studies were included, describing 22 instruments. They described half targeted general symptoms, and half wound-related signs and symptoms. Four instruments were specifically designed for MFWs, all based on the Malignant Wound Assessment Tool (MWAT). These were: MWAT – Clinical; MWAT– wound bed status; MWAT– Perception; MWAT – Research. However, only the Clinical and Research versions were validated in English, but neither was subjected to psychometric validation, and lacked a comprehensive assessment, such as key symptoms.

Conclusion: Despite the existence of specific tools for MFW assessment, a comprehensive, validated, and standardized tool is still lacking. While the Clinical and the Research versions of the MWAT offer a broad assessment of MFWs, they require refinement to address overlooked symptoms and validation in other languages. Establishing standardized, multidimensional measures could enhance clinical decision-making and improve outcomes for patients living with MFWs.

Introduction

Malignant fungating wounds (MFWs) are complex, secondary chronic wounds arising from the uncontrolled proliferation and infiltration of malignant cells, compromising skin integrity in patients with cancer (1). They can present as an ulcerated wound, raised nodules with a cauliflower appearance, or a combination of these forms, explaining the term ‘fungating’ used to describe these ulcers (2). MFWs can develop due to primary skin malignancies, like melanoma, basal cell carcinoma, or squamous cell carcinoma, direct spread from an underlying cancer, or when the tumor metastasizes and breaks the skin (3).

The epidemiology of MFWs remains uncertain due to limited data (4), but estimates suggest that 5–10% of cancer patients may develop such wounds, typically in the last 6 months of life, with minimal prospects of wound healing (1). MFWs are most frequently located on the breast (62–66%), head and neck (22–24%), or chest (1%) (5). These wounds are characterized by rapid tumoral growth, excessive exudate, necrosis, pruritus, malodor, and bleeding (6). Excessive exudate can result from increased vascular permeability, infection, or devitalized tissue (7), while necrotic tissue fosters bacterial proliferation, leading to secondary infections and malodor (8). Such odor can induce nausea, reduce appetite, drive social withdrawal, and contribute to depression among both patients and caregivers (9). Patients with MFWs experience a significant symptom burden, and studies have shown that managing these symptoms not only improves patient outcomes and physical well-being but also enhances their self-esteem (10). Bleeding commonly occurs due to friable tissue and impaired homeostasis, compounded by cancer disease and treatment that influence coagulation (7). Rapid tumor growth can also compress nearby structures, such as nerves and lymphatic vessels, leading to pain, reduced mobility, and impaired drainage. These issues can be worsened by incorrect wound dressing techniques (1, 2).

The numerous and distressing symptoms associated with MFWs can significantly affect the quality of life of patients with advanced cancer (11). Low-performance status and the challenges of ongoing wound care may further compromise essential dimensions of health, such as functional status, social relationships, and mental well-being (12, 13). Moreover, the terminal prognosis of MFWs imposes a substantial emotional burden on patients and their families, which in turn often results in patients experiencing fear and uncertainty about the future (14, 15).

Given these challenges, developing pragmatic, patient, and family-centered palliative wound care strategies is essential, beginning with a comprehensive assessment of MFWs (12). Such assessment can enable appropriate symptom evaluation, prioritizing patient safety, comfort, and quality of life (16). For instance, managing exudate and bacterial colonization through proper wound cleaning can be transformative for patients, alleviating discomfort, pain, and social isolation triggered by leakage of malodor (17). Nurses play a central role in the assessment of wounds, leveraging their expertise to identify complications early, implement personalized pain management strategies, and provide education and support to patients and their families (18). Their ability to assess wounds within the broader context of advanced illness enables them to make meaningful contributions to patient comfort and dignity (19). Therefore, an adequate assessment could support the palliative care nurses in managing these wounds, which is currently challenging given the heightened risk of complications (20). Although the literature highlights the clinical relevance of these symptoms, there are still gaps in accurately documenting their prevalence, characteristics, and impacts on patients’ functional status, underscoring the need for comprehensive assessment (21). However, to the best of our knowledge, no reviews have systematically evaluated the tools available for assessing and managing MFWs.

To address this gap, a clinical tool that facilitates the evaluation of MFW signs and symptoms is urgently required (7), both to guide interventions (22) and to overcome the barriers to evidence-based care (23). Such interventions should reflect patient and family goals of care, especially in advanced disease where the symptom burden can be invalidating, with physical disfigurement and emotional debilitation (24). Given the complexity of MFWs, it is also relevant to inform both patients and families about the scenarios, reassure them, and ensure that the healthcare providers can assess, select, and deliver tailored and appropriate treatment to best manage the condition (25). In light of these considerations, the present study seeks to answer the following question: What instruments are currently available for the comprehensive assessment of MFWs?

Aims

The primary aim of this study is to review the existing research on the comprehensive instruments used to assess and manage malignant fungating wounds (MFWs). Specifically, we aim to (1) identify how current research addresses the assessment of MFWs’ signs and symptoms, and (2) highlight the strengths and limitations of available tools to guide clinical practice and future research.

Materials and methods

This scoping review followed the five-stage framework of Arksey and O’Malley (26) and the methodology outlined by the Joanna Briggs Institute (JBI) (27, 28). We also adhered to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist to ensure transparent reporting (29).

Eligibility criteria

In line with established scoping review methodologies (27–29), we formulated eligibility criteria and their justification. We included peer-reviewed quantitative and qualitative studies reporting on tools for MFW assessment, without limiting to specific symptoms or signs, to capture a broad range of characteristics. No temporal and language restrictions were applied, ensuring a comprehensive overview of the literature. Studies were excluded if they focused on other types of wounds (e.g., surgical), involved non-cancer populations, or lacked information on instruments relevant to MFW assessment. Gray literature and non-empirical research (e.g., editorial) were excluded to prioritize feasibility and ensure the inclusion of peer-reviewed tools, consistent with previous review (30). Eligibility criteria were refined iteratively, as recommended by Arksey and O’Malley (26), allowing for adjustment based on emerging insights from the literature.

Information sources

An extensive search was performed in four databases to identify potentially relevant studies.

Pub-Med, Web of Science, Scopus, and EBSCO were used. These databases were selected for their broad coverage of biomedical, nursing, and health sciences literature, ensuring a comprehensive and multidisciplinary retrieval of studies related to MFWs’ assessment. The initial search was conducted from 06th July 2024 to 11th February 2025.

Search strategy

Search strings were developed using a combination of controlled vocabulary (e.g., MeSH terms), free text keywords, and Boolean operators. Each search string was tailored to the specific databases consulted. Consistent with methodology, reference lists and citations of all retrieved full-text articles were screened to identify additional eligible studies. Zotero X8 software (Clarivate Analytics, Philadelphia, PA) was employed to organize records and ensure traceability. Duplicates were removed through the automated merging function of Zotero and manual checking. The final search strings used can be found in Table 1.

Table 1

Table 1. Queries with keywords, Boolean operators, and Mesh terms were utilized for each database.

Selection of sources of evidence

The study selection followed a two-stage process. In the first stage, two authors (DN, FG) independently screened the titles and abstracts of all identified records against the inclusion and exclusion criteria. Records deemed potentially eligible were advanced to the second stage, and the full texts were retrieved. In the second stage, two other authors (GA, RL) reviewed the full texts to confirm their eligibility. Any disagreements in study selection were resolved through discussion with a third reviewer (AP), ensuring consensus on final inclusions.

Data charting process

A data-charting form was created in Microsoft Excel following the JBI scoping review guidelines (27) to collect relevant data from the included studies. Two authors (DN, RL) independently extracted the data, and any discrepancies were resolved by consultation with another two authors (AP, SD) until an agreement was reached.

Data items

The following information was extracted from each included study: reference (author and year of publication), country, study objective, study design, instrument used for MFWs assessment, symptoms considered, the database from which the study was identified, and the language of publication.

Critical appraisal of individual sources of evidence

Considering that scoping reviews are generally undertaken to map existing evidence rather than evaluate methodological quality or risk of bias (29), we did not formally assess the quality of the included studies. Consequently, no study was excluded based on methodological limitations, ensuring a broad representation of the available literature. Nonetheless, every study included in this review was published in a peer-reviewed scientific journal.

Synthesis of results

A narrative approach was used to synthesize and present the findings of this scoping review, in line with the framework by Arksey and O’Malley (26). Studies were organized based on whether they employed instruments explicitly designed for wound assessment or instead targeted general symptoms without a wound-specific focus. We also searched the databases consulted for this review for validation studies related to each identified instrument. The key findings are described narratively in the results section and supplemented with tables, graphs, and visual representations when appropriate.

Results

Selection of sources of evidence

The search on the four databases returned 2,699 potentially relevant records. After the duplicates were removed, 1,358 records proceeded to the first stage of screening. After screening for relevance based on title and abstract, 116 records proceeded to the full-text screening phase. All identified full-text records were retrieved. Only 40 articles met the eligibility criteria and were included in the review. A PRISMA flow diagram (31) describing the screening process is displayed in Figure 1, with the number of included and excluded records for each phase and the justification for exclusion.

Figure 1

Figure 1. PRISMA flowchart illustrating the selection process and the number of sources included and excluded.

Characteristics of sources of evidence

The characteristics of the studies included in this review are presented in Tables 2, 3.

Table 2

Table 2. Characteristics of sources of evidence.

Table 3

Table 3. Instruments and signs and symptoms evaluated.

The publication period of the included studies ranges from 1997 to 2024. The distribution of studies over these years is heterogeneous, with a marked increase in research interest over the past decade (n = 21, 52.5%) (32–52). The highest number of eligible studies was published in 2019 (34, 43, 46, 50), as illustrated in Figure 2.

Figure 2

Figure 2. Number of included records per year of publication.

In terms of study design, most of the studies included were primary research (n = 27, 67.5%), comprising case studies (n = 8, 20%) (33, 48, 52–57), observational studies (n = 8, 20%) (34, 36, 37, 39, 41, 44, 47, 58), randomized controlled trials (n = 4, 10%) (38, 42, 43, 59), clinical trials (n = 3, 7.5%) (49, 60, 61), mixed-methods research (n = 2, 5%) (62, 63), and validation studies (n = 2, 5%) (46, 64). Secondary research was less common (n = 13, 32.5%), consisting primarily of systematic reviews (n = 5, 12.5%) (32, 40, 45, 50, 65) and other literature reviews (n = 8, 20%) (35, 51, 66–71).

Geographically, the included studies originated from 13 countries in six macro-regions: Europe (n = 16, 40%) (32, 39, 40, 45, 53–57, 59, 60, 62, 67–69, 71), East Asia (n = 9, 22.5%) (43, 47–49, 51, 52, 58, 61, 63), North America (n = 6, 15%) (36, 41, 46, 64, 66, 70), South America (n = 6, 15%) (33–35, 37, 38, 65), the Pacific (n = 2, 5%) (42, 50), and South Asia (n = 1, 2.5%) (44). As shown in Figure 3, the United Kingdom contributed the largest number of eligible studies (n = 12, 30%) (32, 45, 53–57, 60, 67–69, 71). Most of the included articles were published in English (n = 37, 92.5%) (32, 36–46, 53–62, 64–70), followed by Portuguese (n = 2, 5%) (33, 34), while one record (n = 1, 2.5%) (35) appeared in both languages.

Figure 3

Figure 3. Map of included records per country.

Finally, 22 distinct instruments were identified across the included studies (Tables 2, 3). Out of these, 13 studies (32.5%) reported on two or more tools concurrently, resulting in a total of 68 instances of tool reporting. The Visual Analogue Scale (n = 16, 23.5%) and the Treatment Evaluation by Le Roux (n = 12, 17.6%) emerged as the most cited. Half of the instruments (n = 11) were specifically developed to assess wounds and related signs and symptoms, whereas the other half (n = 11) targeted general symptoms such as pain or insomnia, without a wound-specific focus. Furthermore, considering their validity, most of the assessment tools identified were previously validated (n = 16, 72.7%), whereas a minority lacked formal validity testing (n = 6, 27.3%). Lastly, as illustrated in Figure 4, the most common signs and symptoms evaluated by validated instruments were pain (n = 12, 78.5%), exudate (n = 8, 57.1%), and odor (n = 7, 50%). The following sections discuss each tool and its investigated dimensions, signs, and symptoms in detail, distinguishing between wound-specific and non-specific instruments.

Figure 4

Figure 4. Overview of signs and symptoms assessed by the validated instruments, grouped by instrument and dimension evaluated. BWAT, Bates-Jensen Wound Assessment Tool; ESAS, Edmonton Symptom Assessment System; FLACC, Face Legs Cry and Consolability Scale; FRS, Faces Rating Scale; MPQ, McGill Pain Questionnaire; MWAT-C, Malignant Wound Assessment Tool – Clinical; MWAT-R, Malignant Wound Assessment Tool – Research; NRS, Numerical Rating Scale; PAINAD, Pain Assessment In Advanced Dementia; PUSH, Pressure Ulcer Scale for Healing; SF-MPQ, Short-form McGill Pain Questionnaire; TELER, Treatment Evaluation by Le Roux; TSAS-W, Toronto Symptom Assessment System for Wound; VAS, Visual Analogue Scale; VNS, Verbal Numeric Scale; VRS, Verbal Rating Scale.

Wound-specific instruments for sign and symptom assessment

Of the tools employed to assess MFWs’ signs and symptoms, most (n = 7, 66.6%) were originally developed for other wound types (e.g., pressure ulcers) and subsequently applied to MFWs. These include the Bates-Jensen Wound Assessment Tool (BWAT), the Hopkins Wound Assessment Tool (HWAT), the Pressure Ulcer Scale for Healing (PUSH), the Treatment Evaluation by Le Roux (TELER), the Toronto Symptom Assessment System for Wound (TSAS-W), the Wound Assessment Tool for hospices (WAT), and the Wound Symptoms Self-Assessment Chart (WoSSAC). A smaller subset (n = 4, 36.3%) was specifically designed for MFWs, comprising four versions of the Malignant Wound Assessment Tool (MWAT): Clinical (MWAT-C), Research (MWAT-R), Wound Bed Status (MWAT-N), and Perception (MWAT-P).

Figure 5 illustrates the dimensions covered by each validated wound-specific instrument, along with the percentage of items that address each dimension. Overall, the MWAT-R includes the broadest range of wound-related items (n = 24), capturing aspects such as pain and odor alongside their impacts on social interactions, physical activity, appetite, self-perception, and emotional well-being. MWAT-C also addresses various wound-related issues (n = 12), further detailing wound characteristics such as location, size, changes over time, exudate, bleeding, and edema.

Figure 5

Figure 5. Signs and symptoms assessed by the validated wound-specific instruments, grouped by instrument and dimension evaluated. BWAT, Bates-Jensen Wound Assessment Tool; MWAT-C, Malignant Wound Assessment Tool – Clinical; MWAT-R, Malignant Wound Assessment Tool – Research; PUSH, Pressure Ulcer Scale for Healing; TELER, Treatment Evaluation by Le Roux; TSAS-W, Toronto Symptom Assessment System for Wound.

Non-specific instruments for sign and symptom assessment

Most non-wound-specific tools identified (n = 6, 54.5%) focus on evaluating a single symptom. These include the Bleeding Intensity Scale (BIS); Face, Legs, Activity, Cry, and Consolability (FLACC) scale; Faces Rating Scale (FRS); McGill Pain Questionnaire (MPQ); Pain Assessment in Advanced Dementia (PAINAD); and Short-Form McGill Pain Questionnaire (SF-MPQ). The remaining instruments (n = 5, 45.5%) assess multiple symptoms, such as the Edmonton Symptom Assessment System (ESAS) and widely used, simple scales like the Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Verbal Numeric Scale (VNS), and Verbal Rating Scale (VRS). These tools are valued for their feasibility and Likert-like structure, making them adaptable for various clinical contexts. Almost all (n = 10, 90.9%) have been validated in English (72–77), except the BIS. As shown in Figure 6, none of these instruments address wound characteristics or tissue integrity, but all capture at least one wound-related symptom, such as pain. Only two were also employed to describe wound characteristics: the VAS for exudate amount and the VRS for both exudate and bleeding.

Figure 6

Figure 6. Signs and symptoms assessed by the validated non-specific instruments, grouped by instrument and dimension assessed. ESAS, Edmonton Symptom Assessment System; FLACC, Face Legs Cry and Consolability scale; FRS, Faces Rating Scale; MPQ, McGill Pain Questionnaire; NRS, Numerical Rating Scale; PAINAD, Pain Assessment In Advanced Dementia; SF-MPQ, Short-form McGill Pain Questionnaire; VAS, Visual Analogue Scale; VNS, Verbal Numeric Scale; VRS, Verbal Rating Scale.

Discussion

This scoping review identified the instruments used for MFWs’ assessment, which remain a significant clinical challenge in patients with advanced cancer. MFWs have a negative impact on psycho-social and emotional quality of life (78), affecting body image perception and contributing to worse distress (79), due to related symptoms, such as pain, excessive exudate, malodor, and bleeding (1). Malodor is particularly distressing, often contributing to stigma and social withdrawal, making patients reluctant to seek medical attention (10). The visible and odorous nature of MFWs can also act as a distressing reminder of disease progression and the imminence of death, exacerbating anxiety for both patients and their families (80). Stigma or fear, especially when wounds occur in sensitive areas such as the breast, face, or genitals, further discourages patients from seeking timely care (81). Given these challenges, a comprehensive and multidimensional assessment of MFWs is crucial (46), although these wounds do not have a good healing prognosis. Our results described multiple tools that have been used to assess MFWs, which most capture only a limited subset of wound-related signs and symptoms. Therefore, this review partially addresses the research question, as the available instruments, while some are specific to the assessment of MFWs, cannot achieve a comprehensive and multidimensional evaluation. Half of the instruments were specifically developed to assess wounds, and related signs and symptoms (i.e., bleeding, odor, exudate), and the other half targeted general symptoms such as pain, anxiety, and insomnia, without a wound-specific focus. Our research identified the MWAT in four different versions, but only the MWAT-C and MWAT-R (64) are specifically for assessing and managing MFWs. The MWAT-C addresses several wound-related issues, particularly wound characteristics such as location, size, changes over time, exudate, bleeding, and edema. Instead, the MWAT-R includes a broad range of wound-related items, capturing clinical characteristics of the wound and social interactions, physical activity, self-perception, and emotional well-being, and also focuses on nutritional and self-esteem. A systematic approach is optimal for the evaluation of patients presenting with MFWs, given the infrequent etiology of a singular underlying cause. A comprehensive assessment of both local and systemic contributing factors within each stage of the diagnostic work-up is critical. The principles guiding ongoing nursing and clinician assessment and monitoring of wounds generally exhibit considerable overlap (82). It is plausible that managing skin wounds with bad healing prognoses does not solicit standardized clinical and welfare responses, with careful funds to support research (83). All health professionals, and in particular nurses, are now part of the healthcare team as patient advocates. They must respond to health needs as a nursing imperative, supporting public health as a fundamental right (84).

A key insight of this review is the lack of standardized, multidimensional instruments capable of capturing both physical and psychosocial domains of MFWs with a single tool. The MWAT-C and MWAT-R strive toward such comprehensiveness by integrating wound characteristics, social impacts, and emotional dimensions. Moreover, they fail to address certain symptoms frequently reported in the literature, such as itching and the presence of maggots (22). Although these symptoms can be recorded under an open-ended other symptoms category, this approach relies on practitioners’ awareness and assessment skills, potentially introducing variability and inconsistency in evaluations. As our review indicates, healthcare professionals often use separate instruments to evaluate different aspects, such as pain intensity, exudate volume, or odor severity, leading to fragmented assessments and repeated measurements. This fragmentation not only places an additional burden on patients but can also reduce adherence to regular assessments (20). Reflecting best practice recommendations (grade B) and recognized as a quality indicator for the physical aspects of palliative care, nurses and other healthcare professionals should utilize evidence-based assessment tools for the initial and ongoing evaluation of symptoms in end-of-life care patients (84, 85). As highlighted by the guidelines generated by the European Oncology Nursing Society (EONS) only some scales assess psychosocial aspects and their impact on daily life; therefore having an integrated and comprehensive instrument for the assessment of MFWs is vital for guiding effective palliative strategies, particularly in situations where patients are facing profound physical, emotional, and social strains. A comprehensive assessment should take into account the physical and psychosocial aspects of both the patient and caregivers, treatment such as symptoms evaluation, supportive care, and preventative measures, and a focus on local wound management such as bleeding, odor, pain/pruritus, exudate, and superficial infection (86). The substantial metabolic demands of patients with MFWs, often due to significant wound exudate or fistula fluid, necessitate a higher energy intake. Standard guidelines recommend 25–35 kcal/kg body weight per day, so frequent meals and snacks may be indicated for individuals with MFWs to satisfy these elevated energy requirements (87). The National Health Service Forth Valley guidelines for the management of MFWs suggest the M: EMPHIS Pathway approach which is specific for guiding the management of local symptoms about malignant wound (M), exudate (E), malodour (M), pain (P), hemorrhage (H), infection (I) and skin tissue related problems (S) (88). This may be a good approach to manage the core symptoms related to MFWs, but it does not address the other symptoms that occur in patients with this lesion. Nurses report difficulties in applying wound dressings and concealing their disgust at the odor, often finding the care of these patients emotionally challenging due to the sometimes incurable nature of the wounds, while also facing the complexities of patient isolation, altered body image, and holistic interdisciplinary approach guided by specialist-level palliative wound care expertise (22). Effectively managing the complex needs of patients with MFWs demands a pragmatic approach. Implementing palliative care relies on a holistic approach that spans multiple levels of assistance, involving the collaborative input of various disciplines from the health, education, business, and labor sectors, all guided by a transdisciplinary framework to address these needs. It’s vital to consider the transdisciplinary nature of palliative care, enabling diverse professions to contribute their specific knowledge toward a common objective, which includes integrating family and community. Their experiences and inherited knowledge can significantly inform the goal of addressing the needs of the individual-family dyad (89). Interdisciplinary care involves assistance where knowledge is shared at the point of care delivery and where the goal of care is agreed upon. There is communication, collaboration, and coordination among the various care providers. The importance of each discipline and the contribution each can make is recognized to deliver integrated and individualized palliative care based on the needs of the patient-family dyad (90).

Comprehensive and easy-to-use tools, and an interdisciplinary team could facilitate the use of a standardized language, help nurses and healthcare professionals to effectively assessment the complexities of MFWs, reduce wound management times, ensure the assessment of all the symptoms, and provide well-being in the patient-family dyad (91). Therefore, it is imperative to investigate the adoption and implementation of efficient tools informed by scientific evidence, which support the transition toward more efficacious care paradigms, as exemplified by transdisciplinary palliative care.

Additionally, the MWAT-C and the MWAT-R have only been validated in English and lack comprehensive psychometric testing, raising concerns about their reliability and limiting their applicability in diverse cultural contexts (92). Validation in terms of both validity and reliability is essential to ensure that an instrument accurately measures the intended constructs and can be confidently applied across different clinical and research settings. Without such validation, the use of these instruments risks introducing measurement errors, leaving practices prone to error in contexts not oriented toward evidence-based practice (93).

Strengths and limitations

The findings of this review should be interpreted in light of a few limitations. First, the search was limited to four databases, which may have resulted in the omission of relevant studies indexed elsewhere. Additionally, to ensure a timely completion while upholding methodological rigor, gray literature was not included. This may have narrowed the scope of the findings and excluded potentially valuable insights. Furthermore, the limited validation of assessment tools across different languages and cultural contexts may hinder the global applicability of current approaches to the evaluation of MFWs. Finally, the sensitive nature of the topic, where patients may hide their wounds due to stigma or embarrassment, could lead to underreporting thereby affecting the generalizability of existing evidence, and could be a potential bias (10).

Conclusion

The assessment of MFWs continue to raise significant challenges due to the lack of standardized, comprehensive, and evidence-based evaluation tools. Although various instruments have been employed, most focus only on specific dimensions of MFWs, leading to fragmented assessments and potentially suboptimal care. Among the available measures, the MWAT-C and MWAT-R demonstrate the greatest potential, due to their relatively broad scope. However, both tools still require further refinement and validation, especially to incorporate underreported symptoms and enhance applicability across diverse clinical and cultural settings. There is an urgent need for the development of a validated, multidimensional instrument specifically designed to capture the complexity of MFWs within a broader biopsychosocial framework. In the interim, in the absence of such tools, nurses are encouraged to follow evidence-based and adapt clinical guidelines in different clinical context (94), such as those from the EONS and NHS (86, 88), to guide wound assessment in clinical practice. Future research should prioritize rigorous investigations that address existing gaps in knowledge and practice, moving beyond traditional, non-standardized approaches. This process will ultimately improve the assessment of MFWs in palliative care settings and provide better support to patients, their families, and healthcare professionals.

Author contributions

DN: Conceptualization, Writing – original draft, Writing – review & editing, Project administration, Formal analysis, Methodology, Supervision, Data curation. FG: Supervision, Writing – original draft, Formal analysis, Writing – review & editing, Data curation, Project administration, Methodology, Conceptualization. GA: Writing – original draft, Writing – review & editing, Project administration, Conceptualization, Methodology, Formal analysis, Supervision, Data curation. AP: Conceptualization, Project administration, Supervision, Writing – review & editing, Data curation, Methodology, Formal analysis, Writing – original draft. SD: Data curation, Writing – review & editing, Formal analysis. MG: Writing – review & editing, Formal analysis, Data curation. VB: Data curation, Formal analysis, Writing – original draft. SQ: Formal analysis, Data curation, Writing – review & editing. LI: Project administration, Data curation, Formal analysis, Supervision, Methodology, Conceptualization, Writing – review & editing. RL: Writing – review & editing, Conceptualization, Writing – original draft, Supervision, Data curation, Formal analysis, Methodology, Project administration.

Funding

The author(s) declare that financial support was received for the research and/or publication of this article. The work reported in this publication was funded by the Italian Ministry of Health, RC-2025-2796962 project.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The authors declare that no Gen AI was used in the creation of this manuscript.

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