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Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries

Ayello, Elizabeth A., PhD, RN, CWON, ETN, MAPWCA, FAAN; Levine, Jeffrey M., MD, AGSF, CMD; Langemo, Diane, PhD, RN, FAAN; Kennedy-Evans, Karen Lou, RN, FNP, APRN-BC; Brennan, Mary R., MBA, RN, CWON; Gary Sibbald, R., MD, DSc (Hons), MEd, FRCPC (Med Derm), ABIM, FAAD, MAPWCA

Advances in Skin & Wound Care: March 2019 - Volume 32 - Issue 3 - p 109–121
doi: 10.1097/01.ASW.0000553112.55505.5f

GENERAL PURPOSE: To synthesize the literature regarding skin injuries that are found in patients at the end of life and to clarify the terms used to describe these conditions.

TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to:1. Define the terms used to describe pressure injuries and skin changes at the end of life.2. Discuss the concept of skin failure as applied to end-of-life skin injuries and implications for practice.

ABSTRACT This article synthesizes the literature regarding the concepts of “terminal” skin injuries that are found in patients at the end of life, including Kennedy terminal ulcers, Skin Changes At Life’s End, Trombley-Brennan terminal tissue injuries, and skin failure. Also included is a discussion of avoidable and unavoidable pressure injuries as defined and differentiated by the Centers for Medicare & Medicaid Services and the National Pressure Ulcer Advisory Panel. To help clarify the controversy among these terms, a unifying concept of “skin failure” that may occur with an acute illness, chronic illness, or as part of the dying process is proposed. This proposed concept of skin failure is etiologically different than a pressure injury, although pressure injury and skin failure can occur concomitantly. These proposed concepts require further research and validated diagnostic criteria. Consensus around appropriate terminology is essential to reduce confusion among stakeholders and ensure appropriate patient care.

Elizabeth A. Ayello, PhD, RN, CWON, ETN, MAPWCA, FAAN • Faculty • Excelsior College School of Nursing • Albany, New York • President • Ayello Harris & Associates, Inc • Copake, New York • President • World Council of Enterostomal Therapists • Co-Editor-in-Chief • Advances in Skin & Wound Care • Philadelphia, Pennsylvania

Jeffrey M. Levine, MD, AGSF, CMD • Associate Clinical Professor of Geriatrics and Palliative Care • Icahn School of Medicine at Mount Sinai • New York, New York

Diane Langemo, PhD, RN, FAAN • President • Langemo & Associates • Professor Emeritus and Adjunct Professor • University of North Dakota College of Nursing • Grand Forks, North Dakota

Karen Lou Kennedy-Evans, RN, FNP, APRN-BC • Wound Consultant • Foothills Rehabilitation Center • Tucson, Arizona

Mary R. Brennan, MBA, RN, CWON • Assistant Director for Wound and Ostomy Care • North Shore University Hospital • Manhasset, New York

R. Gary Sibbald, MD, DSc (Hons), MEd, FRCPC (Med Derm), ABIM, FAAD, MAPWCA • Professor • Medicine and Public Health • University of Toronto • Toronto, Ontario, Canada • Director • International Interprofessional Wound Care Course and Masters of Science in Community Health (Prevention and Wound Care) • Dalla Lana School of Public Health • University of Toronto • Project Lead • ECHO Ontario, Wound & Skin Care • Previous President • World Union of Wound Healing Societies • co-Editor-in-Chief • Advances in Skin and Wound Care • Philadelphia, Pennsylvania

Acknowledgments: This manuscript reflects the authors’ interpretation/opinions of the literature/evidence and not of any professional organization or group. Consult the Centers for Medicare & Medicaid Services (CMS) website for official language regarding guidance, Resident Assessment Instrument manuals, the Minimum Data Set (MDS) for different care settings, and related documents. Parts of this manuscript were presented at the National Pressure Ulcer Advisory Panel (NPUAP) conference in March 2017 in New Orleans, Louisiana. Dr Ayello was an original member of the Skin Changes At Life’s End (SCALE) panel; is a past president, past vice president, past secretary, and past member of the Board of Directors for the NPUAP; and consultant to CMS for F-Tag 314 and MDS 3.0. Dr Levine has published several historical manuscripts and papers on skin failure and is a consultant to Advantage Surgical & Wound Care. Dr Langemo has proposed a definition for “skin failure;” was an original member of the SCALE panel; is a past president, past secretary, and member of the Board of Directors for the NPUAP; was cochair of the 2014 NPUAP Unavoidable Pressure Injury Consensus Conference; and is a coauthor of the related 2014 Unavoidable paper. Ms Kennedy-Evans was an original member of the SCALE panel and original member of the For the Recognition of the Adult Immobilized Life panel that defined and published data on the Kennedy terminal ulcer in 1999. Ms Brennan has previously defined and published data on the Trombley-Brennan terminal ulcer. Dr Sibbald was the cochair and first author of the SCALE panel consensus documents, is a previous author of the Canadian Association of Wound Care best practices for Pressure Ulcers & Managing Pain in Pressure Ulcers, and is cochair of the current Registered Nurses Association of Ontario pressure injury guideline & Health Quality Ontario Pressure Injury Standards.

The authors, faculty, staff, and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies relevant to this educational activity.

To earn CME credit, you must read the CME article and complete the quiz online, answering at least 13 of the 18 questions correctly.

This continuing educational activity will expire for physicians on February 28, 2021, and for nurses on March 5, 2021.

All tests are now online only; take the test at for physicians and for nurses. Complete CE/CME information is on the last page of this article.

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