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

A survey of skin failure perceptions amongst pressure injury management staff in China: A cross-sectional study

This study sought to evaluate the perceptions of pressure injury (PI) management staff regarding skin failure (SF). Additionally, an analysis of influencing factors based on the collected data was conducted to establish a foundation for targeted SF training. A descriptive, cross-sectional survey was undertaken in October-November 2023, utilising a convenience sampling method involving selected management staff of PI from 16 provinces in China. A total of 501 nursing participants were included, exhibiting an overall perception level that was moderately low. Although the majority were aware of the possibility of SF (n = 417, 83.23%), only 60% reported an understanding of the fundamentals of SF, with the lowest level of comprehension observed in differentiating between SF and PI (n = 212, 42.31%). Overall attitudes were generally positive. Regarding behaviour, active learning was more prevalent (n = 340, 67.86%), but training is less (n = 287, 57.29%). Family education (n = 401, 80.04%) and nursing record monitoring (n = 426, 85.03%) demonstrated better behaviour. Further analysis revealed that training (t = 13.937, p < 0.001) and professional title (F = 4.681, p = 0.010) had a significant effect on participants' perceptions. These findings underscore that there remains a substantial lack of perception about SF amongst participants. Overall, participants exhibited a positive attitude towards SF, highlighting the need for future improvements in SF training.

Development of a Wound Assessment Tool for Use in Adults at End of Life: A Modified Delphi Study

BACKGROUND

Some patients at end of life (EOL) develop wounds known as Kennedy terminal ulcers, terminal ulcers, and Skin Changes At Life's End. However, there is ambiguity around the defining wound characteristics of these conditions and a lack of validated clinical assessment tools available to identify them.

OBJECTIVE

To gain consensus on the definition and characteristics of EOL wounds and establish the face and content validity of a wound assessment tool for use in adults at EOL.

METHODS

Using a reactive online Delphi technique, international wound experts reviewed the 20 items in the tool. Over two iterative rounds, experts assessed item clarity, relevance, and importance using a four-point content validity index. The content validity index scores were calculated for each item, with a level of 0.78 or higher signifying panel consensus.

RESULTS

Round 1 included 16 panelists (100.0%). The agreement for item relevance and importance ranged from 0.54% to 0.94%, and item clarity scored between 0.25% and 0.94%. Following round 1, four items were removed, and seven others reworded. Other suggestions included changing the tool name and including Kennedy terminal ulcer, terminal ulcer, and Skin Changes At Life's End in the EOL wound definition. In round 2, the now 13 panel members agreed with the final 16 items included and suggested minor wording changes.

CONCLUSIONS

This tool could provide clinicians with an initially validated tool to accurately assess EOL wounds and gather much needed empirical prevalence data. Further research is needed to underpin accurate assessment and the development of evidence-based management strategies.

Results of the 2022 Wound Survey on Skin Failure/End-of-Life Terminology and Pressure Injuries

OBJECTIVE

To summarize the major findings of a survey first conducted in 2019 and repeated in 2022 and review new concepts (angiosomes and pressure injuries) and challenges due to the COVID-19 pandemic.

METHODS

This survey captures participants' ranking of agreement or disagreement with 10 statements on Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, skin failure, and unavoidable/avoidable pressure injuries. The survey was hosted online by SurveyMonkey from February 2022 until June 2022. All interested persons were able to participate in this voluntary, anonymous survey.

RESULTS

Overall, 145 respondents participated. The same nine statements achieved at least 80% agreement (somewhat agree or strongly agree) as in the previous survey. The one statement that did not reach consensus also failed to reach consensus in the 2019 survey: "The concept of skin failure does not include pressure injuries."

CONCLUSIONS

It is the authors' hope that this will stimulate more research into terminology and etiology of skin changes in persons at end of life and encourage more research regarding terminology and criteria to define which skin lesions are unavoidable or avoidable.

Incidence of and Risk Factors for Self-load-related and Medical Device-related Pressure Injuries in Critically Ill Patients: A Prospective Observational Cohort Study

There are two types of pressure injuries: self-load-related pressure injuries (PIs) and medical device-related pressure injuries (MDRPIs), but the differences in risk factors between PIs and MDRPIs have not yet been clarified. If risk factors for PIs and MDRPIs differ, preventive interventions should take this into account. This is a prospective cohort study aimed to determine the cumulative incidence of PIs and MDRPIs in critically ill patients and to identify corresponding risk factors. The study included 1418 patients who were admitted to the critical care medical center of a single university hospital in Tokyo, Japan, between December 1, 2019, and August 31, 2020. The Kaplan-Meier method was used to calculate the cumulative incidence of PIs and MDRPIs. Furthermore, the Cox proportional hazards model was used to analyze the predictors in both the PI and MDRPI incidence and non-incidence groups. Predictors were based on data from the 0th disease day. The cumulative incidence of PIs and MDRPIs was 4.6/1000 person-days and 3.6/1000 person-days, respectively. Multivariate analysis using the Cox proportional hazards model showed that common risk factors for the occurrence of PIs and MDRPIs were possession of PI on admission, higher blood lactate, blood purification therapy, and positional restriction. The risk factors for PIs only were diabetes mellitus, septic shock, and a lower serum albumin level, while the risk factors for MDRPIs only were the D-dimer level and extracorporeal membranous oxygenation treatment. Therefore, prophylactic interventions need to consider these different risk factors. This article is protected by copyright. All rights reserved.

Defining and Describing Terminal Ulcers in Adults at End of Life: An Integrative Review

OBJECTIVE

The authors identify and synthesize the published primary literature on unavoidable skin breakdown and end-of-life wounds known as terminal ulcers.

DATA SOURCES

Sources were identified through a systematic search of the Cochrane Library, Medline, ProQuest, EMBASE, CINAHL complete, and PubMed databases.

STUDY SELECTION

The date limiters were set between 1984 and 2020 to locate primary qualitative, quantitative, and/or mixed-methods studies on terminal ulcers.

DATA EXTRACTION

Investigators examined 180 sources and ultimately included four quantitative studies in this review. All were conducted in the US and published between 1989 and 2019. Retrospective chart audits of deceased patients' medical files were undertaken in three of the studies, and prospective observations were used in the fourth.

DATA SYNTHESIS

Descriptive and inductive content analyses were conducted. Three categories emerged: (1) distinguishing the ulcer development patterns, (2) identifying the ulcer characteristics, and (3) delivering specialized and individualized end-of-life care.

CONCLUSIONS

Limited primary evidence has been published on terminal ulcers. Pressure injuries and terminal ulcers have similar appearances, but their development differs significantly. The lack of a specific terminal ulcer assessment tool and staging system increases the risk of these unavoidable end-of-life wounds being incorrectly assessed and managed as pressure injuries. Further research on terminal ulcers is needed to inform clinical practice and ensure specialized care is delivered to patients who develop these wounds.

Skin injuries associated with severe life-threatening situations: A new conceptual framework

PURPOSE

To create a conceptual framework for skin injuries developing in patients whose lives are severely compromised or who are expected to die within a short period of time. To name and classify these types of skin injuries. To describe the clinical features of the different types of skin injuries that may occur in terminally ill and/or dying patients.

DESIGN

A sequential design with several different phases (a literature review, a nominal group, and a consensus conference) was used.

METHODS

Six experts with extensive knowledge of these types of injuries were selected for the nominal group. The traditional eight-phase nominal group technique was followed. The consensus conference consisted of participants voting on different options based on the statements elaborated with the expert panel summarizing the best scientific evidence available.

FINDINGS

Using all these elements, a conceptual framework was constructed to identify skin injuries associated with severe life-threatening situations (SI-SLTSs), defined as unpredictable and therefore unpreventable injuries indicating a serious threat to life or even imminent death. These injuries can occur in two forms: (a) as skin injuries associated with multiple organ dysfunction syndrome (SI-MODSs) or (b) as skin injuries associated with severe vasoconstriction (SI-ESVs). SI-MODSs develop very quickly and suddenly. They progress from superficial to deep stages abruptly, even within hours. The severity of the injuries does not reflect the care provided to the patient. Individuals suffering from these injuries have an irreversible clinical condition. SI-ESVs also appear in individuals who are in a very critical, even terminal, clinical condition. They are frequently treated in the ICU and may exhibit severe vasoconstriction due to their disease process (e.g., shock), sometimes exacerbated by vasoconstriction caused by various drugs (e.g., noradrenaline).

CONCLUSIONS

We have developed a conceptual framework for skin injuries developing in patients whose lives are severely compromised or who are expected to die within a short period of time and have named them SI-SLTSs, distinguishing between SI-MODSs and SI-ESVs.

CLINICAL RELEVANCE

This new conceptual framework may help clinicians understand the mechanisms and the pathophysiology of skin injuries that develop in terminally ill and/or dying patients associated with multi-organ failure. Through this new framework these injuries can be identified and differentiated from pressure injuries or other dependence-related skin lesions.

Is it time to re-evaluate the inevitability of ulcers at the end of life?

BACKGROUND

The prevention of pressure injuries/ulcers (PI/PUs) in patients at the end of life is achievable, albeit challenging. Objective diagnostic tools, such as sub-epidermal moisture (SEM) scanning, support healthcare practitioners' clinical judgment in preventing PI/PUs.

AIM

A pragmatic study was conducted to assess the feasibility of preventing PI/PUs using SEM technology as an adjunct to routine care in a 22-bed inpatient hospice.

METHODS

Daily SEM scanning was introduced to support the device-trained practitioners' clinical judgment in detecting developing, non-visible PI/PUs. Preventive interventions were initiated by clinical judgment informed by Waterlow scores, visible, tactile skin and tissue assessments and scanner readings.

RESULTS

Prior to the study, the incidence of PI/PUs was 9%. The 6 month study period reported a 4.8% PI/PU incidence, 7/146 consenting patients developed a PI/PU, resulting in a 47% reduction in incidence rates.

CONCLUSION

Preventing the development of PI/PUs is possible with clinical judgment aided by SEM data.

Understanding Skin Failure: A Scoping Review

OBJECTIVE

To map the use of the term "skin failure" in the literature over time and enhance understanding of this term as it is used in clinical practice.

DATA SOURCES

The databases searched for published literature included PubMed, Embase, the Cumulative Index for Nursing and Allied Health Literature, and Google Scholar. The search for unpublished literature encompassed two databases, Open Gray and ProQuest Dissertation and Theses.

STUDY SELECTION

Search terms included "skin failure," "acute skin failure," "chronic skin failure," and "end stage skin." All qualitative and quantitative research designs, editorial, opinion pieces, and case studies were included, as well as relevant gray literature.

DATA EXTRACTION

Data collected included author, title, year of publication, journal name, whether the term "skin failure" was mentioned in the publication and/or in conjunction with other skin injury, study design, study setting, study population, sample size, main focus of the publication, what causes skin failure, skin failure definition, primary study aim, and primary outcome.

DATA SYNTHESIS

Two main themes of skin failure were identified through this scoping review: the etiology of skin failure and the interchangeable use of definitions.

CONCLUSIONS

Use of the term "skin failure" has increased significantly over the past 30 years. However, there remains a significant lack of empirical evidence related to skin failure across all healthcare settings. The lack of quality research has resulted in multiple lines of thinking on the cause of skin failure, as well as divergent definitions of the concept. These results illustrate substantial gaps in the current literature and an urgent need to develop a globally agreed-upon definition of skin failure, as well as a better understanding of skin failure etiology.

ACUTE SKIN FAILURE E LESÃO POR PRESSÃO EM PACIENTE COM COVID-19

Objetivo:relatar o caso de um paciente crítico com COVID-19 e mostrar os principais achados relacionados à lesão considerada Acute skin failure (ASF), bem como realizar seu diagnóstico diferencial com lesão por pressão (LP) evitável. Método: estudo observacional do tipo relato de caso, desenvolvido em um hospital de São Paulo, na unidade de terapia intensiva (UTI) exclusiva a pessoas diagnosticadas com COVID-19. Os dados foram coletados de um único paciente, entre os meses de março e setembro de 2020. Resultados: paciente com complicações da COVID-19 evoluiu com lesão de pele, inicialmente definida como LP e posteriormente reclassificada como ASF. Os seguintes achados corroboraram o diagnóstico: ventilação mecânica invasiva prolongada, insuficiências respiratória, renal e cardíaca e sepse de foco respiratório. Além disso, outros fatores agravantes, como o uso de droga vasoativa, instabilidade hemodinâmica com intolerância ao mínimo reposicionamento, jejum prolongado e coagulopatia intravascular disseminada associada à infecção pelo coronavírus. Conclusão: o relato mostra que existem dificuldades para o diagnóstico diferencial entre ASF e LP na prática clínica. Trata-se de conceito novo, sendo fundamental que o profissional de saúde reconheça os principais fatores associados ao aparecimento da ASF, muitos dos quais também estão relacionados ao desenvolvimento das LP, ressaltando a necessidade de análise individualizada dessas lesões, e garantia da implementação de intervenções adequadas para prevenção e tratamento.

ACUTE SKIN FAILURE AND PRESSURE INJURY IN THE PATIENT WITH COVID-19

Objective:report the case of a critical patient with COVID-19 and show the main findings related to the injury considered acute skin failure (ASF), as well as perform his differential diagnosis with preventable pressure injury (PI). Method: observational, longitudinal, case report type study, developed in a hospital in São Paulo, in the intensive care unit (ICU) exclusively for people diagnosed with COVID-19. Data were collected from a single patient between March and September 2020. Results: A patient with complications from COVID-19 developed a skin lesion, initially defined as PI and later reclassified as ASF. The following findings corroborated the diagnosis: prolonged invasive mechanical ventilation, respiratory, renal and cardiac insufficiency and sepsis of respiratory focus. In addition, other aggravating factors, such as the use of vasoactive drugs, hemodynamic instability with intolerance to minimal repositioning, prolonged fasting and disseminated intravascular coagulopathy associated with coronavirus infection. Conclusion: the report shows that there are difficulties for the differential diagnosis between ASF and PI in clinical practice. This is a new concept, and it is essential that health professionals recognize the main factors associated with the appearance of ASF, many of which are also related to the development of PI, highlighting the need for individualized analysis of these injuries, and ensuring the implementation of interventions for prevention and treatment.

Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review

AIMS

To undertake an integrative literature review to identify, analyse and synthesize current literature on the Kennedy terminal ulcer (KTU) and other unavoidable skin injuries that appear at the end of life regardless of the healthcare context in which they occur.

METHODS

Integrative review following the Whittemore and Knafl methodology. The search was carried out in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus. It was limited to articles in English, French, Portuguese and Spanish. As there is little scientific production on the subject, no restrictions were applied regarding publication date.

RESULTS

Only 17 articles met the inclusion criteria. These articles were reviewed and analysed. Four relevant issues emerged: Skin failure, SCALE, Kennedy Terminal Ulcer, Trombley-Brennan: different names for the same problem; the defining characteristics and physiopathology of KTU; the differences between KTU and other injuries; and the care approach for KTU and other unavoidable injuries at the end of life.

CONCLUSIONS

We identified gaps regarding the physiopathology of KTU since the current knowledge is based only on hypotheses. There is also a large gap in the knowledge about care approaches, perhaps because care plans are not recorded. Despite this, it is clear that the main objective in this situation at the end of life would be to prioritize patient comfort and quality of life.

Hospital-Acquired Pressure Injuries and Acute Skin Failure in Critical Care: A Case-Control Study

PURPOSE

The purpose of this study was to examine clinical characteristics and risk factors for critically ill patients who develop pressure injuries and identify the proportion of validated unavoidable pressure injuries associated with the proposed risk factors for acute skin failure (ASF).

DESIGN

Retrospective case-control comparative study.

SUBJECTS AND SETTING

The sample comprised adult critically ill participants hospitalized in critical care units such as surgical, trauma, cardiovascular surgical, cardiac, neuro, and medical intensive care and corresponding progressive care units in 5 acute care hospitals within a large Midwestern academic/teaching healthcare system. Participants who developed hospital-acquired pressure injuries (HAPIs) and patients without HAPIs (controls) were included.

METHODS

A secondary analysis of data from a previous study with HAPIs and matching data for the control sample without HAPIs were obtained from the electronic health record. Descriptive and multivariate logistic regression analyses were conducted.

RESULTS

The sample comprised 475 participants; 165 experienced a HAPI and acted as cases, whereas the remaining 310 acted as controls. Acute Physiology and Chronic Health Evaluation (APACHE II) mean score (23.8, 8.7%; P < .001), mortality (n = 45, 27.3%; P = .002), history of liver disease (n = 28, 17%; P < .001), and unintentional loss of 10 lb or more in 1 month (n = 20, 12%; P = .002) were higher in the HAPI group. Multivariate logistic regression analysis identified participants with respiratory failure (odds ratio [OR] = 3.00; 95% confidence interval [CI], 1.27-7.08; P = .012), renal failure (OR = 7.48; 95% CI, 3.49-16.01; P < .001), cardiac failure (OR = 4.50; 95% CI, 1.76-11.51; P = .002), severe anemia (OR = 10.89; 95% CI, 3.59-33.00; P < .001), any type of sepsis (OR = 3.15; 95% CI, 1.44-6.90; P = .004), and moisture documentation (OR = 11.89; 95% CI, 5.27-26.81; P <.001) were more likely to develop a HAPI. No differences between unavoidable HAPI, avoidable HAPI, or the control group were identified based on the proposed ASF risk factors.

CONCLUSION

This study provides important information regarding avoidable and unavoidable HAPIs and ASF. Key clinical characteristics and risk factors, such as patient acuity, organ failure, tissue perfusion, sepsis, and history of prior pressure injury, are associated with avoidable and unavoidable HAPI development. In addition, we were unable to support a relationship between unavoidable HAPIs and the proposed risk factors for ASF. Unavoidability of HAPIs rests with the documentation of appropriate interventions and not necessarily with the identification of clinical risk factors.

Acute Skin Failure in the Critically Ill Adult Population: A Systematic Review

GENERAL PURPOSE

To present a systematic review of the literature conducted to define and extend knowledge of the risk factors, causes, and antecedent conditions of acute skin failure (ASF) in adult intensive care patients.

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 participating in this educational activity, the participant should be better able to:1. Outline the background information helpful for understanding the authors' systematic review of ASF in adult intensive care patients.2. Summarize the results of the authors' review of the risk factors, causes, and antecedent conditions of ASF in adult intensive care patients.

ABSTRACT

To define and extend knowledge of the risk factors, causes, and antecedent conditions of acute skin failure (ASF) in the adult intensive care patient cohort.The Cochrane Library, Joanna Briggs Institute Evidence-Based Practice Database, PubMed, Medical Literature Analysis and Retrieval System, Cumulative Index of Nursing and Allied Health Literature, and Google Scholar.Studies were selected if they were qualitative or quantitative research that reported ASF in adult human patients in an ICU setting. The preliminary search yielded 991 records and 22 full texts were assessed for eligibility. A total of three records were included. Studies were appraised using the Mixed Methods Appraisal Tool.Data from the included studies were extracted by one reviewer and summarized in data collection tables that were checked and verified by a second reviewer.Study authors identified five independent predictors of ASF: peripheral vascular disease, mechanical ventilation longer than 72 hours, respiratory failure, liver failure, and sepsis. However, the term ASF was applied to retrospective cohorts of patients who developed severe pressure injuries. This, combined with the absence of evidence surrounding the assessment, clinical criteria, and diagnosis of ASF, could impact these variables' predictability relative to the condition.These results highlight a substantial evidence gap regarding the etiology, diagnostic biomarkers, and predictors of ASF. Further research focused on these gaps may contribute to an accurate and agreed-upon definition for ASF, as well as improved skin integrity outcomes.

Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries: Results of the 2019 Terminology Survey

GENERAL PURPOSE

To present the results of the 2019 study of healthcare professionals' consensus and opinions regarding terminology for terminal ulcers, Skin Changes At Life's End, skin failure, and unavoidable pressure injuries to improve clinical care and to foster research into current criteria for unavoidable skin changes at the end of life.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, NPs, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, the participant should be better able to:1. Explain the survey methodology and identify the consensus statements.2. Synthesize the open-ended questions and respondent comments and their implications for clinical care and research.

ABSTRACT

This article reports the results of a global wound care community survey on Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, skin failure, and unavoidable pressure injury terminology. The survey consisted of 10 respondent-ranked statements to determine their level of agreement. There were 505 respondents documented. Each statement required 80% of respondents to agree (either "strongly agree" or "somewhat agree") for the statement to reach consensus. Nine of the 10 statements reached consensus. Comments from two additional open-ended questions were grouped by theme. Conclusions and suggested recommendations for next steps are discussed. This summary is designed to improve clinical care and foster research into current criteria for unavoidable skin changes at the end of life.

Kennedy Terminal Ulcers: A Scoping Review

Kennedy terminal ulcers, a subset of pressure injuries, are associated with the dying process. This scoping review aimed to identify and map the published literature on Kennedy terminal ulcers in terms of its definition, prevalence, assessment, treatment, management, health care costs, and quality of life for patients in all health care settings. Using the Arksey and O'Malley scoping review framework, we systematically searched the Cochrane Library, CINAHL, EMBASE, MEDLINE, and ProQuest databases and 5 guideline repositories between 1983 and 2018. The following search terms were used: Kennedy ulcers, Kennedy terminal ulcers, terminal ulcer, skin failure, and Skin Changes at Life's End. Data were extracted using a purposely developed data collection tool. Initial searches yielded 2997 sources, with 32 included in this review. Most Kennedy terminal ulcer literature was published by nurses in the United States. Kennedy terminal ulcer prevalence data are limited, with no validated assessment tools available. Kennedy terminal ulcers may be misclassified as pressure injuries, potentially resulting in financial penalties to the institution. This scoping review revealed significant knowledge and clinical practice gaps in patient assessment, management, and treatment of Kennedy terminal ulcers. Timely patient education may help them to make informed care and quality end-of-life decisions. Further research is needed to inform clinical practice to improve patient care.

Pressure ulcers in patients receiving palliative care: A systematic review

BACKGROUND

Pressure ulcers are associated with significant morbidity and mortality as well as high cost to the health service. Although often linked with inadequate care, in some patients, they may be unavoidable.

AIM

This systematic review aims to quantify the prevalence and incidence of pressure ulcers in patients receiving palliative care and identify the risk factors for pressure ulcer development in these patients as well as the temporal relationship between pressure ulcer development and death.

DESIGN

The systematic review is registered in the PROSPERO database (CRD42017078211) and conducted in accordance with the 'PRISMA' pro forma. Articles were reviewed by two independent authors.

DATA SOURCES

MEDLINE (1946-22 September 2017), EMBASE (1996-22 September 2017), CINAHL (1937-22 September 2017) and Cochrane Library databases were searched. In all, 1037 articles were identified and 12 selected for analysis based on pre-defined inclusion and exclusion criteria.

RESULTS

Overall pressure ulcer prevalence and incidence were found to be 12.4% and 11.7%, respectively. The most frequently identified risk factors were decreased mobility, increased age, high Waterlow score and long duration of stay.

CONCLUSION

The prevalence of pressure ulcers is higher in patients receiving palliative care than the general population. While this should not be an excuse for poor care, it does not necessarily mean that inadequate care has been provided. Skin failure, as with other organ failures, may be an inevitable part of the dying process for some patients.

An Introduction to Skin as an Interface: Implications for Interprofessional Collaboration and Whole-Person Care

GENERAL PURPOSE

To increase health care professionals' awareness and perceptions of the skin as one of the largest body organs with multidimensional aspects and significant implications for interprofessional collaboration in whole-person care.

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 participating in this educational activity, the participant should be better able to:1. Apply physiologic and integumentary knowledge to assessing common skin variations and problems.2. Summarize the results of the authors' literature review of the evidence regarding the emotional, psychosocial, cultural, and spiritual aspects of skin health and disorders.

ABSTRACT

The skin reflects not only a person's physical state of health, but also the dynamic interplay of emotional and cultural influences. This article will increase health practitioner understanding of the skin and skin assessment by highlighting its multidimensional aspects and significant implications for interprofessional collaboration in whole-person care. Through a multidimensional assessment of the skin, practitioners can better understand the health story of each patient and intervene holistically to improve overall well-being and quality of life.

Prelude to Death or Practice Failure? Trombley-Brennan Terminal Tissue Injury Update

In 2012, we published a study in this journal exploring the emergence of unique skin changes in end-of-life patients admitted to a palliative care unit. The purpose of the study was to describe the skin changes and identify the relationship between these changes and time of death. In the above study of 80 patients, the skin changes were found to be unique and different from Kennedy terminal ulcers and deep tissue injuries. Median time from identification of skin changes and death was 36 hours. The phenomenon was named as Trombley-Brennan terminal tissue injury. The current article presents findings that include the study of additional 86 patients. The results further validate the phenomenon and its relationship with time of death.