Chuck Tilley MS, ANP-BC, ACHPN, CWOCN
Discuss the concept of skin failure in the chronically
ill and in terminally ill hospice patients and the
development of Kennedy Terminal Ulcers
 Describe various position statements regarding
avoidable vs. unavoidable pressure ulcers
 Discuss the use of some traditional pressure ulcer
prevention and treatment strategies: are they
evidence-based?
 Review a typical hospice patient’s course of
treatment and identify best practices used and/or
missed opportunities to utilize evidence-based
strategies


First used in the literature by La Puma 1991

“An event in which the skin and underlying
tissue die due to hypoperfusion that occurs
concurrent with severe dysfunction or failure
of other organ systems”.
(Langemo & Brown, 2005)
Pathophysiology:

“As a body shunts blood and nutrients to vital
organs such as the heart, lungs, and kidneys, it
shunts blood away from the periphery or the
skin”

“Damaged tissue loses its tolerance to pressure
and trauma and cannot assimilate nutrients
causing more tissue damage and, ultimately,
necrosis”
(Goode & Allman, 1989)



“Skin and underlying tissue die d/t
hypoperfusion concurrent with an
ongoing, chronic disease state”
Elderly, DM, HF, CKD, MS, ALS,
Paraplegics, Quadriplegics, AIDS
Combination of age-related declines and
chronic co-morbidities accelerate loss in
functioning
(Langemo & Brown, 2005)

“Skin and underlying tissue die d/t hypoperfusion
concurrent with end of life”
(Brown, 2003)

“62.5% of pressure ulcers in hospice patients
occurred in the 2 weeks before death”
(Brown, 2003)

Occurrence of skin failure, like any other organ
system failure, should be used to establish goals
of care and future treatment
(Langemo & Brown, 2005)
Characteristics:
 Pear, butterfly or horseshoe shaped
 Usually develops on the sacrum
 Color may be red, yellow, purple or black
 Skin is almost always intact and looks at times almost like a
black blood blister
 Borders of the ulcer are usually irregular
 Sudden onset. Starts out larger than other pressure ulcers,
usually more superficial initially, and develops rapidly in size
and depth
 Treatment for a Kennedy Terminal Ulcer is the same as if
would be for any other pressure ulcer
 Tends to be a geriatric phenomenon. Reported frequently in
hospice patients
 Patients have a history of dying within 8-24 hours of
development
(Schank, 2009)
(Schank, 2009)
Centers for Medicare and Medicaid (2004)
Avoidable
Unavoidable
….facility did not do one or more:
• evaluate the resident’s clinical
condition and pressure ulcer risk
factors
• define/implement interventions
consistent with resident needs, goals,
and recognized standards of practice
• monitor and evaluate the impact of
the interventions
• revise the interventions as appropriate
….even though the facility:
• had evaluated the resident’s clinical
condition and pressure ulcer risk
factors
• defined/implemented interventions
consistent with resident needs, goals,
and recognized standards of practice
• monitored and evaluated the impact
of the interventions
• revised the interventions as
appropriate
Wound, Ostomy, and Continence Nurses Society, 2009
• Published a position paper in 2009 ; “There are clinical circumstances in which a
pressure ulcer is unavoidable”
•The presence of pressure ulcers can suggest an overall deterioration in the medical
condition (included in hospice criteria)
(Langemo et al., 2006; Witkowski et al., 2000)
• In the case of palliative care, pressure ulcer prevention may be displaced by the
greater need for comfort and the family’s need for support. Many pressure ulcer
interventions may be inappropriate if the measures cause intractable pain or undue
family burden near end of life
(Brink, Smith, & Linkewich, 2006; Reifsnyder & Magee, 2005)
Skin Changes At Life’s End, 2008
• Some skin changes, including pressure ulcers, at end of life are
unpreventable
• SCALE is a reflection of compromised skin (reduced soft-tissue
perfusion, decreased tolerance to external insults, and impaired removal
of metabolic wastes
• Risk factors, symptoms, and signs associated with SCALE may include
suboptimal nutrition, including loss of appetite, weight loss, cachexia
and wasting, low serum albumin/prealbumin levels, and low
hemoglobin, as well as dehydration.
• Expectations around the patient’s end-of-life goals and concerns
should be communicated among members of the interprofessional team
and the patient’s circle of care
Case: 82yo female with a history of NIDDM, HTN, CKD Stage III,
HLD, Vascular Dementia and weight loss of 20lbs over 5
months admitted to a hospice residence with a L Trochanteric
Stage III pressure ulcer s/p 1 week stay at a local hospital for a
fall at home with surgical pinning of R hip
Advance Directives: DNR/DNI/DNH, HCA: husband, HCP states
she doesn’t want artificial nutrition/hydration:
no tube feeds, IV fluids/TPN
Functional: A & Ox1, bedbound, total care for all ADLs, incontinent
of B & B, eats 25-50% of most meals (NAS, NCS diet),
frequently spits out meds, egg crate mattress, uses adult
diapers and soap and water to manage incontinence
Pain: Moans and calls out with facial grimacing when
turned- especially onto R hip: turns self onto left
side where she appears comfortable
PE: Dry flaky skin, poor turgor, oral mucosa slightly
moist, cachectic, temporal wasting, observed
intermittently coughing after meals, incontinent
of urine Q2H, stools at
least twice daily
VS: 132/86 98-88-20
FS range: 244-288
BMI: 18. 1
Braden Score: 9
Labs: Albumin 2.0
Orders:
Advance Directive: DNR/DNI/DNH
Diet: NCS, NAS Pureed consistency
Aspiration precautions, Nutrition consult
Activity: Bedrest, T & P Q2H
VS: Routine
Weights: Weekly
Wound Care: Hydrocolloid L Hip Q72H
Meds: MVI 1 po daily, Zinc 220mg po daily, Vitamin
C 500mg po BID, Lisinopril 10mg po daily,
Metphormin 500mg po BID, Metoprolol 25mg
po BID, Tylenol 650mg po/PR Q6H PRN
Therapy: Swallow evaluation for diet recommendations



Course: Developed Aspiration PNA with deterioration in VS
(profound hypotension) and neurological function.
Developed a sacral Kennedy Terminal Ulcer which was found
on Day 19. L Trochanteric wound deteriorated to a Stage IV
pressure ulcer with periwound Incontinence Associated
Dermatitis (IAD). Day 21 patient expired.
BMI: 17
Functional: Despite being changed every two hours she is
frequently found wet (incontinence care with adult diapers
and soap and water), despite T & P she continued to migrate
to L Trochanter for comfort, egg crate mattress,
Orders (Day 19):
Wound Care: Hydrocolloid Q72H to both
wounds
Meds: Vitamin C 500mg po BID, MVI 1 po
daily, Zinc 225mg po daily, Augmentin
875mg po BID x10D, Roxanol 5mg
po/sl Q2H PRN pain/tachypnea/dyspnea
Diet: NPO except meds
Incontinence Care: Attends, soap and water
Oxygen: O2 2L NC humidified


WOCN developed a Guideline For
Prevention and Management of Pressure
Ulcers first published in 2003 then
updated in 2010
Examined the evidence surrounding
pressure ulcer prevention and
treatment with recommendations
based on an extensive literature review
with over 300 articles reviewed

Level A: Two or more supporting RCTs of at
least 10 humans with pressure ulcers, a metaanalysis of RTCs, or a Cochrane Systematic
Review of RCTs

Level B: One or more supporting controlled
trials of at least 10 humans with pressure ulcers
or two or miore supporting non-randomized
trials of at least 10 humans with pressure ulcers

Level C: Two supporting case series of at least
10 humans with pressure ulcers or expert
opinion
Risk Identification:
 Use of a valid and reliable risk assessment tool is
recommended (Level of Evidence = B)
 Risk assessment should be performed upon entry to a health
care setting, and repeated on a regularly scheduled basis, or
when there is a significant change in the individual’s
condition. (Level of Evidence = C)
(WOCN, 2010)
 The Braden, the Norton and Waterlow PU risk assessment
scales have been found valid for the prediction of PU risk in a
variety of health care settings and in multiple countries
 Hospice is identified as an appropriate unit to administer the
Braden Scale
(Bolton, 2007)
Nutrition: Routine Vitamin C & Zinc supplementation

Vitamin C: “The use of Vitamin C and Vitamin A
supplementation remains unproven”.
(Gray & Whitney, 2003; Gray, 2003)

Zinc: “There is no evidence to conclude that routine
administration of supplemental zinc will promote
healing of pressure ulcers. In fact, doses of zinc greater
than 40mg per day may effect copper levels with
possible anemia”
(NPUAP/EPUAP, 2009)
Turning and positioning: Q2H
 Repositioning and turn; regularly and
frequently (Level of Evidence C)
(WOCN, 2010)

The frequency of repositioning is unknown
and lacks scientific evidence
(Moore & Cowman, 2009; Pieper, 2007)
Dressing Selection: Hydrocolloids
 Studied more than any other dressing
 Recommended Stage II and IIIs with
minimal depth
(NPUAP/EPUAP, 2009)

May be undermined by urine or stool
and can aggravate wounds/IAD etc.
Support Surfaces: Egg Crate Mattress
 Pressure redistributing surfaces are recommended
for individuals with full thickness or ulcers that
involve multiple turning surfaces
(Nix, 2007)
 For patients with a large stage III or IV pressure
ulcers or ulcers on multiple turning surfaces; a lowair-loss or air-fluidized surface may be indicated.
(Level of Evidence B)
(WOCN, 2010)
Incontinence Care: Soap and Water/ Adult Diapers
Use of soap is discouraged as it is more alkaline and
causes skin irritation
 Consider using briefs when out of bed and underpads
when in bed to minimize moisture and heat trapping
 pH-balanced perineal skin cleanser and barrier
ointments are recommended for incontinence care
 Indwelling Foley: Indicated for stage III-IV pressure
ulcers
(WOCN, 2011)


Did we:
▪ Evaluate risk factors?
▪ Follow established standards of practice?
▪ Consider patient’s goals of care?
▪ Monitor, evaluate and revise interventions?

Was the deterioration of the L Trochanteric pressure
ulcer avoidable or unavoidable?

Was the Kennedy Terminal Ulcer avoidable or
unavoidable?
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scales are valid for use in the clinical setting? Journal of
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Brown, G. (2003). Long-term outcomes of full thickness
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M.pdf
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