Actions and recommendations from NHS improvement 2019 state that a pressure ulcer at end of life often termed as a Kennedy ulcer or SCALE will no longer be reported as such in NHS trusts. A pressure ulcer will remain a pressure ulcer regardless of underlying pathophysiological status.
This does still leave an abyss on what these rapid skin failures atypically look like. With a lack of guidance on how we inform staff, patients and relatives if this occurs in practice.
Organ failure is inevitable in the dying phase and with the skin being the most outwardly and largest of these organs in may not come as a surprise if clinical indicators are observed.
Although we must follow our process on reporting the depth of Pressure ulcer as category not aetiology type, there is more up to date risk assessments such as Purpose T tool which can be used to determine risk factors. Many hospices are starting to implement this tool in replacement to the more dated Hunters Hill tool.
Pressure ulcers & palliative care challenges
At present there is no consensus as to what clinical indicators constitutes skin failure at life end, with a clear gap in research. Although there is plenty of health providers that have discussed these rapid skin failures seen at the end of life, we can not determine definitely that this is a result of pathophysiological organ failure.
Algorithm taken from the EPUAP in 2009 on SCALE guidance below:
This is a question I get asked frequently and it can be a grey area. Particularly around the end of life or cases of rapid skin failure where balancing up regular repositioning to the quality of life of the patient is paramount. Involving Multi-Disciplinary teams into this decision is important to help come up with a individualised and enhanced moving and handling plans and repositioning plan.
As providers we must adhere to our Nice pressure ulcer prevention and management guidelines which currently say 2,4,6 hourly repositions need to be prompted and documented. Clinical this is done mostly on the repositioning chart either at the bedside of through electronic care plan system.
For a resident with rapid skin failure in bed is this enough? Quite often we will recommend more regular repositions through the day and sometimes night. The reason being that from what we know from the research there is a 20 min ‘window of prevention’ for tissue hypoxia to occur on a local vascular supply. Waiting 2,4, and especially 6 at night may be too long and increase the risk of tissue decline. However will your patient want to be repositioned every 20 minutes??
Although the single most effective prevention method from tissue hypoxia leading to a cat 1 pressure ulcer is to remove the pressure forces on the affected area, this may not always be possible. Not just with compliance but due to physical factors sucks as contractures, MND, MS or palliative care.
What can you do:
- Working with your multi disciplinary team, either Physiotherapists, Occupational Therapist, Tissue viability nurse, District nurse, you may come up with some alternative plans. This can be documented as the home have explored all alternatives and worked for active solution. This is important as just saying the resident cannot be moved is not enough, we must be clear as to why and that alternatives have been explored.
- Lateral tilt mattresses – Although a AIR mattress may be placed but there will still be a point of contact whereas the same with most pumped devices the cells will offer temporary offloaded alternately. The use of lateral tilts have been around for a while and vary in comfort. With OSKA offering inbuilt lateral technology. No lateral device can replace a manual turn, so these still need to be prompted as per NICE guidelines. If you’re not sure seek advice from your local TVN.
- Micro-Movements- Where the recommendations are to gain a 30 degree angle tilt on turns, its may not always be possible. Any movement is better than none, so if you are able to encourage micro-movements this may offer a degree of offloading. This may be achieved with the use of wedges, beanbags (decubitus cushions).
With the above in mind, It is therefore prudent to stick to our pressure ulcer prevention and management policy and treat any pressure ulcer at any stage within this remit. This can be done inline with gold standard care plan tools such as the SSKIN bundle. However where there are disrepevcys within a care plan or compliance with care recommendations is compromised such as in ability to offer full 30% degree turn or compliance with using pumped mattress then a Multi- Disciplinary Team meeting is recommended to explore alternatives and offer an enhanced prevention care plan. Where this is not always possible an internal team decision involving the patient or next of kin should be established as part of your risk assessment with supported documentation in the care plan on actions, rationale and review date.
Elizabeth A. Ayello,Jeffrey M. Levine, Diane Langemo, Karen Lou Kennedy-Evans, RN, FNP, Arizona Mary R. Brennan, R. Gary Sibbald. ‘Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure injuries’. Advances in skin & wound care. March 2019 – Volume 32 – Issue 3 – p 109–121.
UnderstandingtheKennedyterminalulcer.www.kennedyterminalulcer.com.Lastaccessed December 11, 2018.
Skin Changes At Life’s End (SCALE) Expert Panel (2009).