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Skin Failure: Use of an evidence-based tool to identify it at end of life


Avoidable and unavoidable skin breakdown may occur in patients at end of life (EOL) across care settings, such as the following:

  • Inpatient or outpatient (home) hospice
  • Intensive care units
  • Long-term care facilities
  • Skilled nursing facilities
  • Medical surgical units

Avoidable skin breakdown includes preventable pressure injuries, whereas unavoidable breakdown includes Kennedy Terminal Ulcers (KTUs), Trombley-Brennan terminal tissue injury (TB-TTI), skin failure, and Skin Changes at Life’s End (SCALE).1

Unavoidable Skin Breakdown: What’s the Etiology?

There has been much discussion surrounding unavoidable skin breakdown; however, the exact etiology remains unknown. Experts have discussed hypoperfusion and multiorgan system failure as contributing factors.1 Unavoidable pressure injuries typically have clinical features that distinguish them from true pressure injuries. These features include butterfly, pear, or horseshoe-shaped discoloration (maroon, red, purple, black), which quickly develop on the sacrum, buttock, spine, and extremities in the absence of external pressure. These areas of breakdown can evolve in hours, from intact skin to a deep wound exposing muscle, bone, or tendon, and they often develop in months, weeks, days, or hours prior to death.1

Pressure Injuries: Misclassifications

Recent studies have revealed that many terminal ulcers (TUs) are misclassified and reported as pressure injuries (PIs). This misclassification poses significant complications for clinicians, patients, family members, and organizations.1 TU care planning and treatment modalities should focus on comfort care rather than aggressive wound healing. Additionally, organizations may face regulatory and/or financial penalties if a quality indicator, such as a PI, is thought to be preventable.1 Given that there is no specific tool to classify TUs, clinicians often use a standardized PI classification and assessment tool that is often not specific to unavoidable pressure injuries, comfort care, and EOL symptom management. This usage further highlights the need for a TU-specific assessment tool that would contribute to the accurate collection of prevalence and incidence data, along with improved and patient-specific care at EOL.1

Possible Solutions

A study that uses a Delphi technique aggregates the professional opinions of experts on a research question, usually without meeting in person. One study1 looked at a modified online reactive Delphi technique and a draft assessment tool for TUs. The research team developed the assessment tool, guided by the literature and evidence-based practices. It included 5 sections and 20 items focused on assessment descriptors, including location, appearance, intact skin, shape and color, speed of wound change, and wound healing.1 In this study, the wound specialist or occupational therapist completed the final management section, confirmed the presence of a TU, and developed a subsequent care plan.1 The End-of-Life Wound Assessment Tool was helpful in breaking down the sections in an easy-to-follow algorithm with concise instructions to differentiate TU versus PI.1


There is more research that needs to be done. Related to this vital topic, research has been ongoing. Unavoidable wounds develop in some patients and differ from true PIs in cause, appearance, development patterns, and management.1 The development of the EOL tool used in the study referenced in this article required the input of many subject matter experts (SME), along with continued discussion and research. The use of this tool in clinical settings may increase the accurate identification of EOL wounds versus PIs and confirm the significance of this clinical issue.1 Long-term implications of correctly differentiating EOL, unavoidable skin breakdown from true PIs will better guide the appropriate approach and specialized wound care provided to patients and accurately identify and track quality and performance data within facilities.


  1. Latimer, S., Harbeck, E, Walker, R, Ray-Barruel, G, Shaw, J, Hunt, T, Gillespie, B. Development of a Wound Assessment Tool for Use in Adults at End of Life: A Modified Delphi Study. Adv Skin Wound Care. March 2023;36(3):142-150. doi: 10.1097/01.ASW.0000911992.83362.eb

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse specialist at VA Northeast Ohio Healthcare System in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately ten years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.