Skin Changes At Life's End (SCALE)

This article reviews SCALE, a topic that is just beginning to be researched. A common manifestation of SCALE is the Kennedy Terminal Ulcer. Not all pressure ulcers are avoidable at end-of-life, especially the Kennedy Terminal Ulcer. Specialties Hospice Article

Skin Changes At Life's End (SCALE)

The skin is the largest organ of the body and can become dysfunctional at life's end, with loss of integrity, just like any other vital body system, with reduced ability to utilize nutrients and other factors necessary to sustain normal skin function.

The manifestations of this dysfunctional state are called skin changes at life's end (scale).

These end-of-life skin changes stem from ineffective skin and underlying soft tissue perfusion, increased vulnerability to external insults (such as minimal pressure), build up of metabolic wastes, and local tissue factors. At end-of-life, a person may develop skin breakdown, despite multiple appropriate interventions and optimal care, as it may be impossible to shield the skin from insult and injury in its compromised state.

The acronym scale describes clinical phenomena in skin and soft tissues that occur when the dying process compromises homeostasis, resulting in skin failure. Skin failure is defined as the localized death of skin and its underlying tissues due to decreased blood flow secondary to dysfunction of other body systems, often multiple system organ failure. This failure of the largest organ can be classified as acute, chronic, or end-stage. Clinicians need to have a realistic understanding of what can be achieved, in terms of prevention and treatment of wounds, due to the declining health status of individuals with multiple comorbid conditions and/or terminal illness, as they approach end of life.

As stated earlier, not all pressure ulcers at end-of-life are avoidable. A common manifestation of scale is a phenomenon known as the kennedy terminal ulcer (ktu), which is a special type of pressure ulcer that forms suddenly in dying individuals. A pressure ulcer, also termed a bedsore or a decubitis ulcer, is a lesion that develops as a result of unrelieved pressure, shearing force, or friction or a combination of these factors. It usually develops over bony prominences.

The damage consists of areas of tissue ischemic hypoxia, necrosis and ulceration. Pressure ulcers are most often seen in elderly, immobilized, or emaciated patients. The sores are graded by stages of severity, from stage i through stage iv.

Research is limited, but the ktu is an unavoidable pressure ulcer that develops in some individuals as they are dying, usually within 2 weeks of death and in conjunction with impaired skin perfusion. This unique type of skin failure or skin breakdown is typically found on the sacrum or coccyx, occurs suddenly (usually within hours), and is shaped like a pear, butterfly, or horseshoe. The ulcers may be red, yellow, black, or purple in color, and tend to progress rapidly to stage iii/ iv. The treatment for the ktu is the same as for any other pressure ulcer of the same stage.

This has been an overview of scale, a topic that is just beginning to be researched. Not all pressure ulcers are avoidable at end-of-life, especially the kennedy terminal ulcer.

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VickyRN

About VickyRN, MSN, DNP, RN

VickyRN, PhD, RN, is a certified nurse educator (NLN) and certified gerontology nurse (ANCC). Her research interests include: the special health and social needs of the vulnerable older adult population; registered nurse staffing and resident outcomes in intermediate care nursing facilities; and, innovations in avoiding institutionalization of frail elderly clients by providing long-term care services and supports in the community. She is a Professor in a large baccalaureate nursing program in North Carolina.

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Very informative, Vicky. I am old enough to recall being told that ALL ulcers were signs of poor nursing care. We knew that was not true and even back then had knowledge of cellular nutrition. I have seen many really bad decub. coming out of ICUs. Some I know could have been prevented, others never could have been prevented.

This helps to explain the differences and speed of onset. That is always amazing; the assessment of 2-4 hours a go might just as well be from last week when things start to change.

2 Votes
Specializes in Gerontological, cardiac, med-surg, peds.
aknottedyarn said:
Very informative, Vicky. I am old enough to recall being told that ALL ulcers were signs of poor nursing care. We knew that was not true and even back then had knowledge of cellular nutrition. I have seen many really bad decub. coming out of ICUs. Some I know could have been prevented, others never could have been prevented.

This helps to explain the differences and speed of onset. That is always amazing; the assessment of 2-4 hours a go might just as well be from last week when things start to change.

Very true - we're witnessing a much-needed shift in paradigm that is backed by emerging research - not all pressure ulcers are avoidable, especially in dying individuals. The KTU is also known as the "3:30 PM ulcer" - in that the patient/resident is inspected in the AM with morning care and the skin is intact, and then at 3:30, when the patient is inspected again, this rapidly progressing terminal ulcer is noted. Little can be done to stop its almost cankerous advance to Stage III/ IV. The KTU is a sign of impending death, usually within 2 weeks. Why it forms in some dying individuals and not others, is not well understood.

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Specializes in NICU, Infection Control.

My mother had this. I never knew this had a name. It developed ~ 10 days before she died. The ulcer was painful, but I could not get her to lie in any position but supine, if I tried to turn her to massage it, she resisted strongly. Until 5 days before she died, she insisted on getting up and dressed every day and moving (w/a lot of help) into another room. Very, very cachectic. About all I could do was give her MS. I felt very bad, but I don't think there was much more I could do about that.

1 Votes
Specializes in Gerontological, cardiac, med-surg, peds.
prmenrs said:
My mother had this. I never knew this had a name. It developed ~ 10 days before she died. The ulcer was painful, but I could not get her to lie in any position but supine, if I tried to turn her to massage it, she resisted strongly. Until 5 days before she died, she insisted on getting up and dressed every day and moving (w/a lot of help) into another room. Very, very cachectic. About all I could do was give her MS. I felt very bad, but I don't think there was much more I could do about that.

Thank you for sharing this very personal account concerning your dear mother. ((((Hugs)))) to you :redbeathe Seeing such a horrific wound form so suddenly in a dying individual can be immensely traumatic for caregivers. Caregivers can feel enormous guilt and stress about wounds in their loved ones at end-of-life, and need to be told that there was nothing that really could be done to stop this awful ulcer from occurring and that it was not their fault.

1 Votes
Specializes in IMC.

If I had known this type of would existed. My job may have been salvaged. I was working with a resident that had end stage Huntington's Chorea and he developed a wound exactly like you described. He stopped eating, drinking and was having a hard time swallowing. Lungs were not clear; we suspected Aspiration pneumonia. This resident's wound developed so fast. In the morning he was fine and by afternoon his sacrum and coccyx was black and looked like a pear. I ended up getting terminated from my job for not preventing the wound. If I had this knowledge about the Kennedy terminal Ulcer. My job may have been salvaged.

I would like to know is this a new founded type of wound. I would love to get more information about this and pass this bit of knowledge on to my former DON.

Thank you.

This resident was also on Hospice status. I am just wondering are Hospice nurses educated on wound care at all. Everyone assumed I was not taking care of this resident. It just crushed me to know that I failed as a nurse.

2 Votes
Specializes in LTC, assisted living, med-surg, psych.

I just went through a similar experience with a resident who went on hospice after he suddenly lost his ability to eat and drink due to esophageal stricture. The hospice RN explained the "skin failure" to me, as I felt awful about the butterfly-shaped Stage III on his coccyx that had seemed to open up literally overnight. I thought she was simply trying to make my staff and me feel better, and now I see that there really is a phenomenon in the dying that causes their skin to break down and is not caused by poor care. Thank you for sharing this!:bow:

2 Votes
Specializes in Hospice / Ambulatory Clinic.

Even in younger and newer nurses there seems to be the consensus that uclers = neglect. I come across a Kennedy ulcer once it awhile that seems to be accompanied by the gossip that so and so wasn't turning the patient. (Family or nurse) Unfortunately my knowledge of Kennedy ulcers is limited only that I know they exist and its not anyones "fault" so I can't always change people's minds.

2 Votes

i've seen a few of them, and never cease to amaze me.

no matter how much you know (or think you know), the guilt always continued to plague me. :)

here's an interesting blurb about the ktu (kennedy terminal ulcer).

www.o-wm.com/content/kennedy-terminal-ulcer-"ah-ha"-moment-and-diagnosis

leslie

2 Votes
Specializes in IMC.
tothepointeLVN said:
Even in younger and newer nurses there seems to be the consensus that uclers = neglect. I come across a Kennedy ulcer once it awhile that seems to be accompanied by the gossip that so and so wasn't turning the patient. (Family or nurse) Unfortunately my knowledge of Kennedy ulcers is limited only that I know they exist and its not anyones "fault" so I can't always change people's minds.

The fear also comes from states surveyors who will give G tags for pressure ulcers. Like the article stated no matter how much preventive care you do these KTU's are going to happen. I feel so bad for this resident. He suffered so long with his terminal illness. He passed away two days after I was terminated. :scrying:

This termination is really hurting me getting a LPN position because they see on my application a termination, and I tell them what happened. I can just sense them thinking "you are never going to work here, you caused a PU and you are unsafe"....

2 Votes
Specializes in Corrections, Cardiac, Hospice.

I have seen many Kennedy Ulcers form, usually just hours before death. It was a big indicator for me to inform families. Almost always the shape of a butterfly.

2 Votes
Specializes in Oncology.

Had a patient one time who was actively dying. She did have previous skin breakdown from before I worked there. It was healing though, after I came and took over her wound care. But the night she died, she went from not a mark on her hip to a full scale stage 4, all the way to the bone: Overnight! I knew this would be her last day of life and she didn't want to be turned anymore after I looked at it so I let her be comfortable. There was no point preventing the ulcer from worsening, she was gone that afternoon. The PU was shaped kinda like a bow/butterfly, same description you describe here. She had no previous issues in that area and had a low air loss mattress and lots of positioning, I religiously turned her every 2 hours when she was not actively dying, and her one skin breakdown area was improving. Until 2 days before, when it started to deteriorate (I was told) then the night I came back to work she was actively dying. I wanted to turn her off that spot as soon as I saw it was red, but she said it hurt to lay on the other side (she had always preferred one side) so I didn't force her. I could see in her eyes her mind was slowing and then her breathing changed, then she was in and out of consciousness and then the terminal secretions started, I did oral care, swabbed with a few drops of water, used the atropine, everything. Oxygen for comfort, morphine for pain and to slow respirations when she seemed to start getting uncomfortable. I felt guilty as could be that when they released her body that she would go off to the funeral home with that horrible wound. I am glad to know that it was something that is expected and not just a mistake on my part. I prayed with her and her family. My first patient death.

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