Prelude to Death or Practice Failure

Purpose:
To describe alterations in the integrity of the skin in patients at the end of life. We propose these wounds differ significantly from Kennedy Terminal Ulcers and Suspected Deep Tissue Injuries and as such propose labeling them as Trombley-Brennan Terminal Tissue Injuries.

Background/Significance:
The phenomenon of Terminal Ulcers is not well understood even though Kennedy Terminal Ulcers were originally reported over 25 years ago. A literature search revealed little to no validation of the skin changes being seen in the Palliative Care Unit. The staff began to question the occurrence of these ulcers in spite of rigorous preventive efforts. Our concern with reporting these skin injuries as suspected deep tissue injuries led to this research study.

Methods:
After completing a literature review, an IRB approved retrospective chart review was undertaken with sixty three medical records of patients who had developed a suspected deep tissue injury. The injuries never progressed to eschar or slough and the skin remained intact. Time period for study was January 1, 2009 to June 30, 2011. We developed a data collection tool encompassing twenty data points ranging from age/gender,co-morbidities,location of wound, wound size and shape, to date and time of presentation of ulcer as well as time of death. Sixty three patients were enrolled in the study, and upon study completion, data analysis and results were tabulated by a Biostatistician.

Results:
Our database demonstrated a distinct correlation between development of lesion and time of death. The median time in hours from when the ulcer was first identified until death was 29 hours ( 2 hours to 93 hours) and the median number of days from the identification of the ulcer to death was 1.21. Of the sixty three patients with documented TTI's in the study, sixty one patients remained intact to time of death, and 50% of the wounds occurred in areas of devoid of pressure. Mean age was 73 (range from 35 to 95). We came to realize that these skin changes were proving to be a invaluable indicator of impending demise and began to use them as a prognostic tool in communication with families.

Conclusions and Implications for Practice:
It is our hope that the results of this study will serve to encourage further exploration into this phenomenon. We were able to identify that the development of Terminal Tissue Injuries did not indicate a practice failure, but rather an indication of skin failure preceeding demise.