Kennedy Terminal Ulcer

By the WoundSource Editors

As the body's largest organ, skin has multiple functions, causes, and manifestations of failure at end of life. The concept of skin failure was first proposed in 1991 and continues to impact how injuries at end of life are understood. Skin failure is often discussed alongside mention of unavoidable pressure injuries, which develop despite implementation of prevention measures, best practices, and monitoring. For patients who are critically ill, these pressure injuries may be categorized as acute skin failure depending on the pathophysiological factors that led to their development.

The National Quality Forum (NQF) introduced the term never event in the early 2000s, and it refers to a preventable error that may represent fundamental issues with the quality or safety of care within a medical setting. This wording was initially selected because these events are situations that should never happen to any patient, such as surgery to the wrong leg or leaving a sponge in a patient after surgery. In recent years, the NQF has adopted the term serious reportable events (SREs), but in many instances, the term never event is still used.

Jeffrey M. Levine, MD, AGSF

I was asked to perform a wound consult on a newly admitted resident to a post-acute unit of a nursing home. She rested quietly with a barely touched breakfast on her bedside table. Her aide had tried to feed her, but she accepted only small spoonfuls of oatmeal and a sip of orange juice. She came to our facility after a long hospitalization for COVID-19–related complications, including pneumonia, kidney failure, and septic shock that required pressor agents. While in the ICU on a ventilator, she developed a pressure injury. At 86 years old, her transfer papers revealed feeding tube refusal and a do-not-resuscitate (DNR) order.

By Holly Hovan, MSN, GERO-BC, APRN, CWOCN-AP

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).¹ Kennedy 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

By Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN

Many questions arise and confusion develops when wound care providers mention Kennedy terminal ulcers (KTUs). Because these wounds are not frequently seen, and because they develop rapidly and observation ends abruptly with the death of the patient, wound care providers may have never observed a KTU, even in a long career in wound care. Although the literature reveals that there is a lack of knowledge regarding the exact cause of a KTU, let’s look at the facts currently known from published resources.

By: Mary Brennan, RN, MBA, CWON, Karen Lou Kennedy-Evans, RN, FNP, APRN-BC, and Diane Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN

What is the best way to differentiate between a Trombley-Brennan terminal tissue injury (TB-TTI) and deep tissue injury (DTI)?

Mary: This is the most challenging because these injuries resemble one another. The difference is that a TB-TTI does not evolve as a DTI does. There may be an increase in surface area but no change in the appearance or type of tissue. A TB-TTI will look the same in color and appearance on day 3 or 5 as it does on day 1.

by Heidi H. Cross, MSN, RN, FNP-BC, CWON

According to the Agency for Healthcare Research and Quality, more than 17,000 lawsuits related to pressure ulcers (PUs) are filed annually in the United States, second only to wrongful death lawsuits. One of the greatest gifts to defense attorneys was when the Centers for Medicare & Medicaid Services (CMS) published F-Tag 314, finally acknowledging that some ulcers can occur despite best care. The facility essentially can maintain, “Hey, we did everything we were supposed to, and despite that, the patient developed that pressure ulcer”—that is, the ulcer was unavoidable. To prove unavoidability, proper documentation (proof) of best care needs to be in place, as well as documentation that all proper prevention and treatment measures were implemented.

by Heidi H. Cross, MSN, RN, FNP-BC, CWON

"If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed sore, it is generally the fault not of the disease, but of the nursing." —Florence Nightingale

Ouch! What an indictment of nursing and, by extension, the facility in which the nurse works. We have a lot to thank Florence Nightingale for—a brilliant woman considered to be the founder of nursing and nursing standards and the first to ever put statistics to health care, among other valuable contributions.

by the WoundSource Editors

Palliative care and hospice care are not the same, but they both share one goal. They both focus on a patient's physical, mental, social, and spiritual needs. Palliative care can begin at diagnosis and treatment or for patients at any stage of their illness. Patients may not want to receive aggressive treatment of non-healing wounds because of underlying diseases, pain, and/or cost.

By Jeffrey Levine MD

Please join me Thursday, November 16 from 3:00-4:00pm EST for a free webinar presented by myself and Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWOCN, ETN, MAPWCA, FAAN sponsored by the National Pressure Ulcer Advisory Panel (NPUAP), entitled, Unavoidable Pressure Injuries, Terminal Ulceration, and Skin Failure: Where Are We and Where Are We Going?