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Unavoidable Skin Breakdown Versus Pressure Injury: Continued Discussions


Pressure injuries (PIs) typically are the result of unrelieved pressure, shear, or force. In an inpatient or hospital setting, interventions are put into place to prevent pressure injuries based on evidence and patient risk. However, PIs still develop in some patients despite interventions. Experts agree that most PIs are in fact avoidable; however, some patients may experience unavoidable skin breakdown at end of life (EoL).1Kennedy terminal ulcers (KTUs), skin changes at life’s end (SCALE), and Trombley-Brennan terminal tissue injuries (TB-TTIs) are some of the common terms used to describe unavoidable skin changes at EoL.1

A notable feature of these terminal ulcers is their sudden and rapid development on body locations that may be free from pressure, shear, or trauma and in the presence of PI prevention interventions. In contrast to terminal PIs, standard PIs typically develop as a result of sustained pressure, friction, and shear over a prolonged time (versus rapidly and sometimes without a causative factor).1

Kennedy Terminal Ulcers

KTUs typically develop rapidly on the buttocks, spine, sacrum, or limbs of patients at EoL. These wounds may progress from intact, red, blanchable skin to bone or muscle exposure within hours.1 KTUs have been debated in literature for many years as being a result of the dying process versus the nursing care provided. Kennedy described the occurrence of KTUs as the 3:30 syndrome; when the patient is up in the morning, skin is intact, followed by deterioration to black eschar in a period of six to eight hours (when the patient returns to bed to rest at 3:30 pm), with death occurring in hours, days, weeks, or months.1

In 2010, the National Pressure Injury Advisory Panel (NPIAP) acknowledged KTUs as unavoidable, and this position was subsequently adopted by the Centers for Medicare & Medicaid Services (CMS) in 2013.1 In practice, KTUs are often identified by the bedside caregiver during turning and positioning or routine care. Typically, these wounds develop even with all routine PI prevention measures in place. Literature states these wounds should be assessed using the standard PI staging system.1

Trombley-Brennan Terminal Tissue Injuries

TB-TTIs usually manifest as deep purple bruising that is nonblanchable, although skin remains intact. The exact etiology is unknown, but hypoperfusion and multiorgan failure are thought to be contributing factors.1 TB-TTIs were initially discussed in 2012, following KTUs, which were described by Kennedy in 1989.1 In 2017, the NPIAP recognized TB-TTIs as EoL wounds.1 Literature states these wounds should not be assessed using the standard PI staging system.1

Skin Changes at Life’s End

Unavoidable physiological changes result in skin changes at EoL in some dying patients. SCALE may be caused or precipitated by several factors, including medical devices, pressure, or skin irritants.1

Skin Failure

More recently, the term “skin failure” has been introduced to reflect the skin changes at EoL more accurately. Hypoperfusion, together with multisystem organ failure or dysfunction, reflects the clinical physiology behind skin failure.1

Global Problem and Conclusions

Acknowledgment of unavoidable skin injuries varies. In the United States, the NPIAP and CMS consider terminal ulcers to be unavoidable EoL wounds that comprise a subset of PIs. In contrast, health policy in the United Kingdom has determined that all PIs are avoidable and should be reported.1

Interprofessional assessment tools are available for clinical staff to determine whether EoL is approaching; however, assessment requires specialized knowledge, skill, and experience, with the understanding that it is difficult to predict prognosis and life expectancy with precision.1 Commentaries and new literature have shown an increase in discussions on unavoidable PIs and/or terminal ulcers since 2019, but more research is needed on this topic for multiple reasons, including the need to develop an assessment tool and classification system for terminal ulcers.1


  1. Latimer S, Walker R, Ray-Barruel, G, et al. Defining and describing terminal ulcers in adults at end of life: an integrative review. Adv Skin Wound Care. 2022;35(4):225-233. doi: 10.1097/01.ASW.0000798032.98853.95

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.