Unavoidable Pressure Injuries, Terminal Ulceration, and Skin Failure: In Search of a Unifying Classification System

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Recent publications have accelerated the discussion of skin failure and its relationship to unavoidable pressure injuries and terminal ulceration.1–3 These articles underscore the confusion in nomenclature and lack of agreement on critical points, including the definition of skin failure, the relationship of skin failure to unavoidable pressure injury, and the classification of skin injuries when patients are dying. Over the years, a variety of authorities have entertained a growing array of names for terminal ulceration, including decubitus ominosus, Kennedy Terminal Ulcer, Trombley-Brennan Terminal Tissue Injury, and Skin Changes at Life’s End (SCALE), leaving many caregivers deservedly confused when discussing these lesions.4–7 There is a need for a unified classification system that brings together these concepts in a consistent, easily understandable fashion.
Given the scarcity of research regarding skin failure, terminal ulceration, and pressure ulcer unavoidability, the wound care community relies on thought leaders to generate clinical opinion, including consensus and “white papers.” A recent review reiterates the variety of classifications related to end-of-life wounds and unavoidability of certain pressure ulcers and concludes that proper characterization of terminal and unavoidable skin injuries has not been achieved.3 This article, however, does not offer solutions to consolidate or unify overlapping concepts and definitions.3 There is an urgent need to address classification of these entities and simplify nomenclature, which will require agreement from a broad interprofessional group of wound care professionals on critical points including definition of skin failure and its relationship to unavoidable pressure injury and terminal ulceration. This commentary offers suggestions for simplification of taxonomy and directions for evidence-based research.
Multiple pathophysiologic factors are at play with unavoidable pressure injuries, including the dying process itself.8 However, the literature is unclear as to whether “terminal ulcers” are different from pressure-related injuries, even though they commonly appear over bony prominences. In addition, there are other skin changes such as blistering, mottling, and gangrene that occur concomitant to the dying process, advanced chronic illness, vascular disease, and severe physiologic stress.6 Some authorities opine that pressure injuries are a form of skin failure, whereas others claim that pressure injuries and skin failure are separate entities.9–12 The solution I propose is recognition that skin failure is the common denominator for wounds occurring close to death, unavoidable pressure injuries, and skin impairment related to tissue ischemia.13 Simplification of nomenclature will facilitate coding, solve issues related to quality measurement, and set a path on the search for common mechanisms of organ failure.
The most distinctive diagnostic criterion for a terminal ulcer is the acknowledgment that a patient is dying. However, not all practitioners possess the ability to accurately prognosticate death.14,15 According to the hospice community, there are 2 phases prior to death: the “preactive phase of dying” and the “active phase of dying.”16 On average, the preactive phase of dying may last approximately 2 weeks, whereas the active phase lasts approximately 3 days. If a pressure injury occurs during the preactive or active phase of dying, most wound care specialists would agree that this could be classified as a terminal ulcer.7 But what if a pressure injury occurs before the active or preactive phase of dying—is this still a terminal ulcer? And what if a patient develops a pressure injury, and his/her life is prolonged by medical interventions, or he/she recovers from the brink of death?
Life support technologies have evolved in sophistication, increasing survivability of patients with acute catastrophic illness, including those with advanced age living with multiple chronic, debilitating illnesses.17 In this setting, the designation of “terminal ulcer” when death is months or years away is both inaccurate and inappropriate.
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