Terminal Wounds: When Complete Healing is Not an Option (FL INITIAL Autonomous Practice - Differential Diagnosis)

Laboratory values: Hemoglobin (Hgb) 11.1 / Hematocrit (Hct) 42.0; White blood cells (WBC) 9.8; Electrolytes were all within normal ranges. Hemoglobin A1c (HgbA1c) 6.9; Fasting blood sugar 135.

Mr. Smith's medications: Metformin 500 mg (milligrams) orally twice a day, a baby aspirin (81 mg) orally once daily, atenolol 50 mg orally once daily, and a multivitamin once daily. He reports taking acetaminophen 500 mg orally every 4 to 6 hours as needed.

Pertinent social information: Mr. Smith had a girlfriend he lived with for more than ten years, but she left him after his cancer diagnosis, saying she "could not stay around to watch him die." He lives at home alone and is a Veteran with a history of having served two tours of combat duty. He also reports having several guns at home. Nothing is known about any history of post-traumatic stress disorder (PTSD), and the patient states he has not received care at his local VA, saying only that he "has closed that chapter of his life." He currently has home care nurses who visit him daily for wound care; otherwise, he cares for his wound himself. Home care is recommending hospice.  It is estimated that approximately 30% of patients admitted to hospice have a cancer diagnosis. The life expectancy of patients with fungating cancerous wounds is reported to be 6-12 months (Furka et al., 2022; Vardham et al., 2019). Mr. Smith has had only one social visitor from his local church, but the patient asked them not to come back. When asked, "Why?" he said he was embarrassed by the wound odor, appearance, and amount of drainage he had to deal with during the visit. He has not left his house except for doctor's office visits and grocery shopping at a 24-hour grocery after midnight to minimize how many people see him.

Other clinical information and wound description: Mr. Smith weighs 175 lbs (he has lost 45 pounds over the past six months). His height is 5' 10"; his vital signs (blood pressure or BP, pulse, respiration, and temperature) are unremarkable. The patient complains of pain at the tumor site and inside of their mouth near the tumor site. He reports his pain level is an "8" on a scale of 1 to 10, which is constant and "achy" most of the time, but occasionally he experiences a sharp jabbing sensation.

The physical exam also demonstrated that Mr. Smith would not often make eye contact and was holding a folded towel against his right cheek near the tumor for exudate control. The tumor is protruding from his right cheek, approximately 3.0cm at the apex of the tumor. The size of the overall tumor/lesion is 6.0cm at the longest axis x 4.0cm at the broadest axis and is irregularly shaped with periwound redness, irritation, and erosion at the inferior border around the 4 o'clock position (using the body as a clock, think of the head always at 12 o'clock and the feet at 6 o'clock). This area now has a small open wound, which has been defined as a fistula tracking to and involving the mucous membrane of the mouth, currently draining copious amounts of clear to brownish liquid (slight sour odor from exudate). Mr. Smith also complains that it feels "raw" (very painful to touch) at the inferior border. Chewing on that side increases pain sharply ("up to a 10" on a pain scale of 1 to 10), and cold compresses seem to provide minimal and temporary relief (pain level is "3 or 4" on a scale of 1 to 10 when he has the most relief).

In some patients with advanced cancer, a tumor may protrude through the skin, which may or may not be operable. Some studies suggest that 5 to 19% of all patients diagnosed with malignant neoplasm will develop a metastatic cancerous skin lesion (Bauer, 2022; Emmons & Dale, 2022). Many metastatic breast cancers may result in cutaneous wounds on the breast/chest. Metastatic cutaneous lesions may be ulcerous (tend to look like craters) or fungating.

Fungating lesions result from infiltrating malignant cells into the skin, surrounding lymph vessels, and supporting blood vessels. They tend to have a nodular or cauliflower-like appearance above the surrounding skin level. Approximately 66-70% of all fungating wounds will be found in the breast/chest, 24% of all fungating wounds will be related to head and neck cancers, and approximately 11% of metastatic fungating wounds are observed in other sites of the body including the groin, genitals, extremities, and back (Bauer, 2022; Vardhan et al. 2019). Pain, bleeding, persistent exudates, and odor are the most common complaints reported with malignant cutaneous lesions (Bauer, 2022; Emmons & Dale, 2022; Vardhan et al., 2019). These wounds also produce a great deal of emotional stress for patients and their caregivers due to the appearance of the wound (Emmons & Dale, 2022). These cancerous lesions may bleed easily (friable) because of the vascular involvement in the tumor, impairment of the coagulation cascade, erosion of the capillaries by the tumor, and possibly effects from cancer treatments themselves (Bauer, 2022).

• Minimize wound enlargement if possible:
  • While minimizing wound enlargement is a typical goal for non-cancerous wounds, this may be an unrealistic expectation with some cancerous skin lesions. However, minimizing skin erosion due to exudate-related skin breakdown to the surrounding skin IS a reasonable management goal, as well as addressing pain, bleeding, and odor (Bauer, 2022; Beers, 2019; Bryant & Nalls, 2023; Emmons & Dale, 2022; Furka et al., 2022; Vardhan et al., 2019).
• Protect periwound skin (prevent or reduce periwound skin breakdown if possible):
  • Protecting the periwound skin may be accomplished by a variety of options, including the selection of wound dressings appropriate to absorb the anticipated amount of wound exudate, applying a liquid moisture protective barrier (skin barrier wipe or spray) or moisture barrier cream or ointment (such as a petrolatum-based ointment, silicone polymer, dimethicone, or zinc oxide cream). Applying a hydrocolloid may be an option to "window the wound" (apply to all of the periwound skin up to the skin edges), forming a protective barrier on which to secure other dressings (Bryant & Nalls, 2023; Woo et al., 2015).
  • If hydrocolloid is used to window the wound, applying a protective skin barrier (wipe or spray) and allowing it to dry first before applying it can help protect the skin from damage when removing the hydrocolloid. Regarding fistulas within the wound, hydrocolloids may also help protect the periwound skin and provide a base for applying fistula management systems or ostomy pouching appliances.  This depends on the location of the wound and fistula and if the moisture could be contained in some way, such as isolating the fistula with ostomy management supplies and applying ostomy seals (waxy strips, paste, or rings to seal edges of appliances and preventing leaking) to the edge of the hydrocolloid near the source of drainage. Controlling exudate from these cancerous lesions is often challenging, especially if it drains from a diffuse area (the whole lesion) (Bauer, 2022; Bryant & Borchert, 2023; Emmons & Dale, 2022).
• Manage wound-related moisture/exudates:
  • Managing wound moisture for Mr. Smith could include using a liquid skin barrier to the surrounding skin (or other moisture barrier cream or ointment as mentioned above if the liquid skin barrier is unavailable). Following that, apply a super absorbent layered primary dressing held in place with a non-traumatic securing device such as a silicone (gentle adherent) border dressing as a secondary dressing (making sure the skin liquid protectant is applied to the skin, which the dressing's adhesive border will be adhering to).
  • In this case, the primary dressing could be changed as needed, as often as every 2 hours during the day, while re-using the secondary silicone securing dressing as warranted or at least daily. This could allow the patient more mobility. During the evening (or if the patient's drainage amount warrants it during the day), the wound drainage, especially fistula exudate, could be contained in an ostomy or fistula pouch (using an opaque pouch instead of a clear pouch to address the patient's aesthetic concerns). This drainage may be emptied by the patient or caregiver during the night if needed. It could help prevent soiling of bed sheets and maceration of periwound skin, as well as help prevent a secondary fungal infection from excessive moisture in the area (Woo et al., 2015).
  • If bleeding is a problem, calcium alginate should be considered a component of the primary dressing with direct contact with the wound, as this may help reduce any blood oozing from the wound. However, care should be taken to prevent dressings from adhering to the wound, potentially increasing the bleeding of these friable tumors when removed (Cornish, 2019). If frank bleeding occurs, Monsel’s solution (ferric subsulfate) could be considered in conjunction with a bandage while compression is administered to the site. Alternatively, a clinician could consider applying a silver nitrate stick or other topical coagulant agents, which rapidly coagulate blood like gelling hemostatic foams. In emergent situations, a qualified clinician may also consider a topical time-limited application of 1:1000 liquid epinephrine (adrenaline) on a gauze or a cotton swab directly to the bleeding fungating wound. Still, caution is warranted to evaluate the appropriateness of the wound location and monitor the patient for potential systemic absorption of the medication (Bryant & Nalls, 2023).
• Minimize secondary infection (bacterial and fungal):
  • Minimizing secondary infection and reducing exudate odor could both be addressed by several approaches. First, ensure potential bacterial sources are minimized or eradicated (external contaminants, poor hygiene, poor technique with wound care, inadequate clean storage of dressing supplies, expired materials, etc.). Treating infection is often not considered an option for patients in palliative care. Still, if the infection causes pain, further skin/wound breakdown, or decreased quality of life, it is appropriate to address it(Cornish, 2019).
  • Bacteria often cause unpleasant odors, so removing bacteria and necrotic tissue that bacteria may attach to as much as possible is beneficial. When appropriate, these approaches could be considered: enzymatic ointments such as collagenase, surfactant gels, larval debridement therapy, and careful surgical removal by a qualified clinician. Also, cleansing the bacteria away regularly by washing or irrigating the wound with clean water, wound cleansers, saline, or an antimicrobial solution (such as <10% povidone-iodine solution or weak <0.025% sodium hypochlorite solution) and changing soiled linens, clothing, and wound dressings promptly should be considered (Cornish, 2019).

• Decrease unpleasant odors associated with the wound:
  • Using dressings that contain activated charcoal can reduce odor, as can applying topical metronidazole ointment directly to the fungating wound. Some studies report limited success with topical silver and manuka honey-coated wound products (Emmons & Dale, 2022). Additional ways to minimize odor in the room are to place a pan of odor-absorbing or neutralizing kitty litter on the floor or shelf near the bed and change the litter regularly. Additional options include baking soda on a windowsill or odor-absorbing/neutralizing electronic air fresheners. Note: Many patients with cancer or odor sensitivities may not appreciate air fresheners that cover the unpleasant odor with a stronger odor (so look for odor-neutralizing ones, not just fragranced air fresheners).
• Address wound pain:
  • Wound pain is a concern for this patient because he reports his pain to be an "8 to 10" on a scale of 1 to 10. He reports only taking acetaminophen and reports, "It does not do much, but I do not want to get hooked on pain meds." When asking about pain medication, do not forget to ask the patient if there is anything else he does or takes (eats, drinks, smokes, or alternative medicine) that helps relieve his pain. His understanding of his medical condition, prognosis, expectations of care, and pain treatment goals are important to explore with the patient (and family if appropriate) and discuss with his team (Cornish, 2019).
  • Self-medicating with alcohol, marijuana, or other street drugs is something people may be more apt to try if individuals are terminal or have previously tried it. You would need to know for several reasons.
    • Does it work?
    • How much is being used, and how often?
    • Does he drive or operate machinery while under the influence?
    • Could it pose a risk of more significant harm to himself or others?
    • Would it potentially interact with any other pain treatments/medications?
    • Is a referral to a Pain Management specialist warranted, desired by the patient, or feasible in this situation?
  • The healthcare provider may also ask if the patient has or would like to consider adding alternative treatments such as massage therapy, art in medicine, acupuncture, or acupressure. Some evidence suggests they may help reduce self-reported pain and increase the sense of well-being of cancer patients (Vickers et al., 2018). Additionally, mounting scientific evidence seems to support using certain plant-based essential oils and phytotherapy (treatments considered for many years to be “herbal remedies”) (Beitz, 2023).
• Psychosocial concerns (including aesthetic considerations to minimize feelings of social isolation):
  • There is a need for special considerations when managing the care of this individual. When addressing the most common issues with these types of wounds, it is critical to consider the patient's (and family member's, if appropriate) preferences, physical abilities, and emotional needs. It is also important to consider their functional abilities and care environment, ask the patient about their perceptions of the wound/wound care, allow discussion of their feelings, and offer choices based on this input during management planning (Cornish, 2019). A multidisciplinary approach is recommended (Cornish, 2019). Furthermore, this patient portrayed in the case scenario is at high risk of depression and possible suicide, which his multidisciplinary health care team should address.
  • The patient's Veteran status, presence of guns in the house, recent social isolation, possible feelings of helplessness or hopelessness, and terminal diagnosis make this case a particularly dangerous situation for the patient. At the first possible opportunity, the patient should be asked by a qualified individual (suicide prevention trained social worker, mental health professional, nurse, physician, therapist, etc.) about any suicide ideations and be encouraged to let a trusted friend take possession of any guns or weapons in the house, speak to a mental health professional to formulate a plan to help strengthen his coping skills and post the Veteran Crisis line on or near his phone. (Carroll et al., 2020; Ramos et al., 2024). The VA provides a free 25-minute course for anyone in the medical community to help them know about “the importance of including conversations about lethal means accessibility – specifically firearms – during safety planning in all types of clinical encounters.” See here.
  • The National Suicide Prevention Lifeline is 1-800-273-8255 (Veterans should press 1 for the Veterans Health Administration hotline) (Tsai et al., 2020).
  • Interventions for Veteran suicide prevention from the VA Office of Mental Health and Suicide Prevention (VA, 2023) can be found here.

Mr. Smith should also be encouraged to participate in regular phone follow-up calls with a healthcare provider team at his local VA and perhaps consider getting involved in a support group for terminal cancer patients near him. His local church or some Veteran's groups may be a potential support source if the patient allows them. If his clinical wound treatment plan included measures to help him feel less uncomfortable about his wound/tumor with visitors, this might help increase social support for this Veteran. If the patient does express any suicide ideations, it should be considered a medical emergency, with prompt intervention as warranted (e.g., call 911, do not leave the patient alone, and remove any means of self-harm such as guns or pills if at all possible) (Carroll et al., 2020). 

Mr. Simpson's left lower leg amputation stump is well-matured with no skin breakdown. He does have a prosthesis but has not used it since he spends most of his time in a chair or wheelchair. Mr. Simpson's skin is very dry, with only fair skin turgor. His right great toe amputation site still has a linear 3cm long x 0.5cm wide wound at the old incision site with pink, slightly hypergranulating tissue noted and some slight maceration to the inferior border up to 0.5cm away from wound edges. Only scant yellow/serous exudate is noted on the dry gauze dressing over this area. A small 0.7cm round dry, the scabbed area is noted to the inside aspect of his 2nd toe proximal to the foot. The interdigit spaces appear dry and intact, but the tip of the 4th toe is black and shriveled with dry gangrene. No exudate is noted from the 2nd toe nor the 4th toe. He has some moist callous noted to the lateral aspect of the right foot just below the 5th toe. He denies any wound pain or pain in the foot.

Image of dry gangrene
Photo Source: wikimedia.org

Pathophysiology of non-healing arterial ulcers and dry gangrene:

As could be surmised from the term "arterial insufficiency" or "arterial ulcer," these skin lesions result from a lack of adequate blood flow to intact or injured skin. Small blood clots in the microvasculature (small blood vessels), narrowing of these vessels due to plaque or factors that constrict blood vessels, and lack of power behind the "pumping" action of the heart (as in CHF or with very low cardiac ejection fractions) impairs blood flow and oxygenation to distal extremities such as feet and toes. This not only impairs the ability of these areas to heal but also may cause skin injury, causing the skin and tissue to die due to lack of oxygen and adequate nutrient and waste transport to/from cells. The initial damage may be reversible in many cases with revascularization surgery or procedures to restore adequate blood flow. However, if not corrected, skin and tissue damage may become irreversible in time (WOCN, 2019).

Due to significantly reduced blood supply, gangrene is the term for tissue necrosis (irreversible death). Gangrene may occur due to injury, complications of diabetes, arterial insufficiency, infection, or other health conditions. Gangrene is classified as dry, wet, and gas gangrene. In dry gangrene, it is desirable to keep it dry (not to ever apply moist dressings over this), as it may progress to wet and then gas gangrene (so noted due to gases typically produced by Clostridium bacteria in the tissue), which indicates a serious infection and is a surgical emergency. Diabetic patients are susceptible to wet gangrene because of peripheral neuropathy, vascular insufficiency, and hyperglycemia (Al Wahbi, 2018).

In wet and gas gangrene, surgical amputation is usually performed to prevent the progression and spread of infection to other tissues or sepsis. Sometimes, in dry gangrene (as in a distal toe), if there is a clear demarcation of the dry, necrotic tissues, autoamputation may occur (the dry, dead part of the toe may fall off). Autoamputation is desirable in certain parts of the globe, while some evidence suggests surgical amputation of dry gangrene may also improve patient outcomes (Al Wahbi, 2018).

• Minimize wound enlargement if possible:
  • Taking aggressive steps to prevent further amputation of Mr. Simpson's right lower leg is imperative to decrease his mortality risk and improve his quality of life (WOCN, 2019).  The right lower leg is likely the one he uses for most transfers if his mobility is limited to a chair/wheelchair. With arterial ulcers, some of the main ways the wound could enlarge are through infection, increasing ischemia, repetitive trauma, or deterioration of the patient's overall health or nutritional status. While enlargement of the wound may be prevented due to some of these factors, and others may not, each of these factors should be considered.
  • Mr. Simpson's recent great toe amputation of the right foot for osteomyelitis is of concern if that surgical wound does not heal or if there is any exposed bone in that toe or the proximal portion of the gangrenous toe. Exposed bone or the ability to probe to the bone through a wound opening is predictive of osteomyelitis, even without acute signs of deep infection (WOCN, 2019). Who is following up on Mr. Simpson's surgical site wound? Whether vascular surgery, orthopedic surgery, or podiatry performed the amputation, it is recommended to keep them appraised of the current condition and see if they will make an outpatient appointment for regular follow-up until the gangrenous toe and the right great toe amputation site are resolved.
  • Mr. Simpson's smoking is one factor impacting his tissue perfusion and ischemia that could be modified(WOCN, 2019).  Notably, he can only smoke one cigarette daily due to his residency in a long-term care facility. Exploring barriers to help Mr. Simpson stop smoking altogether is important. The 2014 WOCN Guidelines for the Management of Wounds in Patients with Lower-extremity Arterial Disease (LEAD) recommends, "Smoking cessation should be encouraged for patients with lower extremity arterial disease/arterial ulcers." Smoking cessation "slows the progression of atherosclerosis and decreases the risk of cardiovascular events/death" (Level of evidence = B).
    • Does the facility have on-site programs to help Mr. Simpson quit completely?
    • What are the reasons he still smokes?
    • Does he feel it is useless to stop?
    • Has he given up so much already that he feels he must retain this one last act of independence?
    • Exploring these questions can help you address the barriers and facilitators to quitting smoking.

• Minimize wound enlargement if possible (continued):
  • Mr. Simpson's left lower leg amputation is of concern because it increases his immobility, and he may be using his other leg for all transfers; therefore, he may be unable to stay off the leg/foot with the wounds. Is there a way for him to transfer that does not create repetitive injuries to any areas of the existing wounds or the rest of the foot? Assessing the arterial perfusion and sensation in the rest of the foot and taking measures to protect the foot from further trauma is vital for this patient (Schaper et al., 2020). Also important for wound healing and minimizing the progression of the existing wounds is to monitor his laboratory values, nutritional intake, and medications (WOCN, 2014). It is good that his labs and medications have remained stable and unremarkable for the last six months, but any change (addition of steroids or non-steroid anti-inflammatory medications, for instance, could negatively impact his wound healing) (Schaper et al., 2020).
  • His medications include daily oral Warfarin, with bi-weekly to monthly PT/INR blood tests being drawn, which remained in a therapeutic range for the past four months. Monitoring this is also important, especially if there is any consideration of surgically removing the gangrenous toe. He would have to be placed on another anti-coagulant for the surgery and possibly after surgery. His bleeding risk increases with any dressing or securing device that adheres to the wound or surrounding skin.
  • One of the biggest concerns with dry gangrene is to prevent it from evolving into a wet or "gas" gangrene (Al Wahbi, 2018; Simman, 2023). One non-surgical way clinicians may attempt to do this is to lightly “paint” (not soak) the gangrenous tissue with a drying/antimicrobial agent such as 10% povidone-iodine (if the patient is not allergic to iodine) or use a light application of a spray product such as one with balsam of Peru and trypsin, or skin protective barrier wipes/spray (typically containing alcohol, butenedioic acid, monobutyl ester, or polymer(s)). These products may be applied lightly daily and let air dry, kept uncovered, open, or covered only with a light cotton dry non-occlusive gauze (Emmons & Dale, 2022; Simman, 2023).
• Protect periwound skin (prevent or reduce periwound skin breakdown if possible):
  • Mr. Simpson's skin is very dry, with only fair skin turgor. Working with a multidisciplinary team to approach the issue of adequate hydration for Mr. Simpson is essential. With his history of CHF, he may be on fluid restrictions. Assessing the patient's knowledge and understanding of these factors is important to managing his care. His right great toe amputation site has some slight maceration at the inferior border up to 0.5cm away from the wound edges. Only scant yellow/serous exudate is noted on the dry gauze dressing over this area.
  • Applying a skin protection barrier wipe to his periwound skin with each dressing change and using a gentle, non-abrasive dressing securing device (surgical netting, silicone tape, etc.) would be recommended to avoid any damage to the periwound skin due to maceration or with dressing changes. Caution is warranted with any wrap gauze or netting/sleeve securing device so that care is taken so as not to impair circulation to the area further. Ensuring you are using an evidence-based wound dressing that meets the needs of his current surgical wound is essential, as well as evaluating the tissue perfusion to these other wounds besides the dry gangrenous toe (WOCN, 2019).  Is there adequate tissue perfusion for healing these other wounds?
• Manage wound-related moisture/exudates:
  • Mr. Simpson's wounds are not draining a large amount, so managing wound-related moisture can be addressed, keeping these three things in mind:
    • Care of an open wound includes maintaining a moist wound bed.
    • Area(s) affected by gangrene should be kept as dry as possible.
    • Closed surgical wounds (closed incision sites with no openings in the surgical incision site) should also have a dry protective dressing if one is warranted (WOCN, 2019). Mr. Simpson's open granulating wound is at the incision site, but it has been 12 weeks since surgery, so this is no longer a fresh post-op closed surgical incision. Instead, it is a chronic open wound (0.5 cm wide) that has some scant exudate. This open wound's inner bed should be moist without harming the surrounding skin. A silicone-interfaced wound dressing, petrolatum-based wound ointment, or impregnated dressing may meet that need (Woo et al., 2015).
• Minimize secondary infection (bacterial and fungal):
  • What is the temperature of the extremity? Literature suggests that colder temperatures that keep the affected extremity below normal body temperature may impair wound healing and promote bacterial growth in diabetic foot ulcers. Mr. Simpson's interdigit spaces (space between toes) appear dry and intact, which is good news. You will want to monitor these areas to ensure they remain moisture-free (which promotes fungal growth). Look at the patient's toenails – is there evidence of onychomycosis (toenail fungal infection)? If so, this is common in diabetics and has been associated with an increased risk of fungal infection in the wound and between the toes, so good skincare of the foot and especially between the toes, is important (Bryant, 2023; Schaper et al., 2020).
• Decrease unpleasant odors associated with the wound:
  • Mr. Simpson has no odor associated with his wound or exudate (drainage).
• Address wound pain:
  • Mr. Simpson denies any wound pain. Does he have pain elsewhere? Is he currently taking any medications (prescribed, over-the-counter, or other drugs) for pain elsewhere in his body? Assessing this is important. Evaluating the sensation in the foot and taking measures to protect the foot from further trauma is also vital for this patient (Schaper et al., 2020).
• Psychosocial concerns (including aesthetic considerations to minimize feelings of social isolation):
  • Mr. Simpson has been living in a long-term care facility for eight months, with no plans to return to independent living. How is he coping with this? He has no living family (a widower of 20 years and no children) and has had no visitors in the past eight months. This indicates a serious risk of social isolation (Cornish, 2019). His affect is rather flat when you talk with him, although he brightens up when he talks about his wife and some of their trips abroad. Asking the patient what his goals are can be critical at this point.
    • What are his goals for wound healing?
    • Are they realistic?
    • Is it feasible to attempt to reach any of these goals?
    • What are his goals for his care where he is at now?
    • Does he have any short-term goals (3 to 6 months) or one-year or five-year goals?
  • A multidisciplinary team approach to Mr. Simpson may include some steps to address his goals, come up with a treatment plan that is acceptable to him/considers his preferences and values, and decrease his social isolation (examples: arrange for volunteer visitors to come and talk to him about his travels, display some of his photos or personal effects related to happy memories around his room, encouraging a recreational therapist to meet with him regularly, explore ways to get him more involved in activities/hobbies, perhaps a short field trip to a location that interests him for a few hours).

Mrs. Jones does not like to be turned (as evidenced by her groaning whenever she is repositioned), and her family members do not want to see her pain increase by turning her. Her organs are failing (CHF and ESRD), and her skin is also failing (Cornish, 2019). The skin is the largest organ in the body, and at the end of life, when other systems or organs fail, the skin is likely to fail as well (Emmons & Dale, 2022).

Laboratory values:

Her hemoglobin and hematocrit are 8.5 g/dl and 32%; albumin is 2.0 g/dl; pre-albumin was not drawn in the past six months. Her BUN, creatinine, and serum glucose are all slightly elevated, as well as her sodium, indicating her serum osmolality is higher than normal. This indicates some poor nutritional values as well as potential dehydration.

Medications:

Levothyroxine 50 micrograms orally per day in the morning; Atenolol 25 mg orally daily in the morning; Furosemide 20mg orally daily in the morning.

Other clinical assessments and wound description:

Mrs. Jones has a large (6cm Long x 8cm Wide) butterfly-shaped area of deep purple discoloration to the intact skin over the sacral region (documented by the nurses as a suspected deep tissue injury or sDTI, likely related to pressure). Her skin turgor is poor, and the mucous membranes in her mouth are somewhat dry.

Pathophysiology of Kennedy terminal ulcers:

While pressure ulcers at the end of life may still be preventable and may be precipitated by shearing and friction forces, unrelieved pressure, and excessive moisture or incontinence (which could be avoidable/preventable), the type of skin discoloration that has been described in the scientific literature as a Kennedy Terminal Ulcer or, more recently, as Skin Changes at Life's End (SCALE) (Emmons & Dale, 2022) may be unavoidable. Kennedy Terminal Ulcers are typically located in the sacral region and initially may present as deep purple to maroon, deep tissue injury discoloration in a butterfly shape (see figure below). According to the National Pressure Ulcer Advisory Panel (NPUAP), an area of intact skin with deep purple or maroon skin discoloration over a bony prominence (related to pressure or shearing forces) is also known as a Deep Tissue Injury (DTI) (EPUAP, 2019). Kennedy Terminal Ulcer was first described by Kennedy (1989) and has also been described as Skin Changes at Life's End (SCALE).  These deep tissue injuries over the sacral area in terminal patients represent organ failure of the skin at the end of life when tissue perfusion is decreased and other organs, such as the heart, kidneys, and lungs, are failing (Emmons & Dale, 2022). The skin is the largest organ in the body, and even with optimal care, individuals at the end of life with multiple organs/system failure may experience this type of 'skin failure.’ The deep purple discoloration may slowly or quickly develop into a full-thickness pressure ulcer (Stage 3 or 4) even with optimal care (Emmons & Dale, 2022). Caregivers often feel guilt when Kennedy Terminal Ulcers occur, yet many experts believe these types of ulcers at the end of life are often unavoidable.

Example Image of Kennedy Terminal Ulcer

• Minimize wound enlargement if possible:
  • Management goals for this occurrence at the end of life commonly focus on comfort and pain control (and rightly so). Additional goals would be to prevent infection and further breakdown. However, for any pressure-related skin/tissue damage, offloading or minimizing pressure and reducing friction and shearing forces should always be considered. Addressing both pain and pressure/shear reduction is a challenge, yet just because a patient is terminal does not mean clinicians should stop providing good skincare. Attempts should be made to minimize friction/shearing/pressure and moisture insults to the skin as much as possible (Cornish, 2019).
  • In this case scenario, Mrs. Jones's skin is presently intact. However, deep tissue damage is evident, and measures can be taken within the patient's advanced directives to minimize the risk of further breakdown. For example, reducing friction/shear and moisture insults the skin (such as may occur with incontinence). In addition, taking measures to minimize the risk of secondary skin infection (bacterial and fungal) through good skin assessments and attentive skin care as tolerated by the patient is important. Applying a good skin moisturizing cream may help dry skin to be more supple and allows the skin to retain some suppleness, which can help skin resilience to external forces. Skin barrier creams (products) for the area of the DTI and skin exposed to urine or fecal matter may also be beneficial/protective.
  • Furthermore, her nutritional status and indicators of poor hydration put her skin at a higher risk of breakdown for this patient. The bottom line is that her organs are failing (CHF and ESRD), and now it appears her skin is starting to fail. It may or may not be possible to prevent the enlargement/progression of this DTI into an open wound, but steps can be taken to delay this progression as long as possible.
• Protect periwound skin (prevent or reduce periwound skin breakdown if possible):
  • To try and minimize wound enlargement/pressure ulcer evolution and protect the periwound skin: If the patient can tolerate it, a low air loss, alternating, or even foam/memory foam mattress may help redistribute some of the pressure in bed. Avoiding extended lengths of time sitting up in a chair or bed with the head of the bed elevated over 30 degrees would be an important consideration to reduce friction and shearing forces as well as concentrated pressure on the sacral/coccyx areas (Bryant & Nalls, 2023).
• Manage wound-related moisture/exudates:
  • Mrs. Jones does not currently have any wound drainage.
• Minimize secondary infection (bacterial and fungal):
  • Consideration for managing any incontinence or excess skin moisture may help minimize the risk of skin irritation, further skin deterioration, or fungal infection. Avoiding powders such as talc in skin folds (which trap moisture) may also help reduce the risk of fungal infection (Romanelli et al., 2023).
• Decrease unpleasant odors associated with the wound:
  • There are no unpleasant odors related to Mrs. Jones's skin discoloration or suspected Kennedy ulcer.
• Address wound pain:
  • Some of the newer mattresses or mattress overlays have turn assist features that accomplish slight position changes in very small increments so as not to cause pain but to be enough of a change in position to relieve some pressure. While the patient's comfort is paramount in palliative care, repositioning and offloading can be an important pain relief measure since a body that remains immobile for an extended period tends to get still/sore. Timing all repositioning for 30 minutes AFTER pain medication is administered (to allow the medication to work) – instead of immediately before or within only a few minutes after administering the medication would be an important pain relief measure. In non-verbal patients, assessing grimacing and moaning during movement may indicate discomfort (Bryant & Nalls, 2023).
• Psychosocial and other concerns:
  • Documentation is an important part of the palliative care for these terminal individuals. Skin and wound care are important but are only one part of a total care plan for the whole patient. Improving the hydration status in a slightly dehydrated individual may improve their overall well-being. However, in a "no-code" individual or someone with an advanced directive indicating they do not wish to have any life-extending measures, offering more fluid and nourishment is limited to what the patient wants (Woo et al., 2015).
  • This is very challenging for family members and health caregivers in a person with altered mental status. Therefore, the palliative care plan must be patient-centered (it is extremely valuable to have detailed advance directives drawn up while the patient is completely lucid before such documentation may be needed). At the same time, documentation must meet the facility, state, and organizational requirements. Ideally, when a patient enters into palliative care, a meeting with the patient, the patient's caregiver (CG) and family members are documented with the education provided to the patient and family about what palliative care is and what the care goals are for the patient under palliative care and what can be expected at the end of life (including skincare and potential skin changes at the end of life) (Woo et al., 2015; Bryant & Nalls, 2023; Bryant & Nix, 2023).
  • The medical record should document the patient's clinical condition, comorbid conditions, pressure ulcer risk factors, skin assessment(s), and interventions (consistent with the patient's/family/CG wishes as appropriate per state laws and evidence-based guidelines). The documentation should also report the patient's response to interventions(Bryant & Nix, 2023).
  • Controlling wound-related pain is a high priority, and using foam wedges and positioning pillows that can minimize pressure to bony prominences, including at the heels and knees, hips, elbows, shoulders, scapula, spinal vertebra, and occiput as well as sacrum and coccyx helps to reposition as well as provide comfort. Using silicone sheeting, silicone border wound dressings, or silicone creams over vulnerable areas (such as sacrum) to prevent pressure or friction/shear-related injuries has some supporting evidence (Woo et al., 2019). Still, more research is warranted on their potential to prevent SCALE lesions (especially if most SCALE lesions are unavoidable due to skin failure). There is currently no strong evidence to support or refute that they may be helpful, so clinicians are urged to review the literature and make decisions based on their clinical judgment.
  • Some silicone protective border dressings are large, butterfly-shaped, and self-adherent with a silicone interface and foam padding. Some experts feel they may help provide extra protection and reduce shearing forces over sacral areas and may be left in place for several days (5-7 days) if unsoiled. Still, the silicone interface allows the clinician to lift and assess the skin underneath the dressing daily and replace it in place easily (Bryant & Nix, 2023). Once moist or soiled, it should be removed/replaced (see below for one example of this type of dressing).

Example of silicone dressing
Photo source: molnlycke.co.uk