An end-of-life wound assessment tool for dying hospitalised adults: A feasibility study.

An end-of-life wound assessment tool for dying hospitalised adults: A feasibility study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An end-of-life wound assessment tool for dying hospitalised adults: A feasibility study. Sharon Latimer, Rachel. M. Walker, Jayne Hewitt, Gillian Ray-Barruel, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6241301/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Jul, 2025 Read the published version in BMC Palliative Care → Version 1 posted 10 You are reading this latest preprint version Abstract Background: End-of-life (EOL) wounds, including unavoidable pressure injuries (PIs) and skin failure, are similar to PIs. Differentiating between these wounds is difficult, so we developed an EOL wound assessment tool for use in dying adults to aid clinicians. The study aim was to determine the feasibility of a larger multisite study by testing the study protocol and establishing the interrater reliability of a new EOL wound assessment tool. Methods: This feasibility study was conducted in medical and palliative care units at three hospitals across southeast Queensland, Australia. We gathered quantitative data on study screening, recruitment, consent, and data collection procedures in dying hospitalised adult patients with a new pressure injury (PI). We recruited and trained four research assistants (RAs) and an independent blinded outcome assessor. Following recruitment, clinical data and a deidentified wound photograph were collected. The RAs used the EOL wound assessment tool to determine if the PI was an EOL wound. An off-site independent blinded outcome assessor accessed the same research data and undertook the same assessment using the EOL wound assessment tool. Frequencies and percentages were computed for the feasibility outcomes. Cohen’s kappa statistic was calculated to determine the interrater reliability agreement. Results: Over 20 months, 140 patients with a new PI were screened, with 23 (16.4%) eligible for recruitment, exceeding our ≥10% target. Ten (43.5%) participants were recruited, which fell short of our ≥50% target, with study refusal and imminent death being the reasons for nonrecruitment. Among the 10 recruited study participants, 13 wounds were observed on the sacrum, coccyx, and lower extremities. The interrater reliability between the two assessors was moderate (n=8/13; 61.5%), with disagreement on five wounds, all located on the heels and toes. One participant with two wounds, was assessed by the independent outcome assessor as having an EOL wound and a PI. Conclusions: With minor study protocol adjustments, conducting a larger multisite study testing the inter- and intrarater reliability of the EOL wound assessment tool is feasible. Differentiating between PI and unavoidable EOL wounds in dying patients is a clinical imperative that will help clinicians make informed comfort-based clinical decisions. skin assessment end-of-life Kennedy terminal ulcer palliative care skin failure terminal ulcer pressure injury Figures Figure 1 Figure 2 BACKGROUND Pressure injuries (PIs) are avoidable local skin and tissue injuries caused by pressure in combination with shear and often develop over bony prominences such as the sacrum and heels ( 1 , 2 ). In contrast, some individuals develop unavoidable skin injuries, or end-of-life (EOL) wounds ( 2 , 3 ), within the hours, days, weeks and months before death ( 4 ). Once thought to develop due to poor nursing care ( 5 , 6 ), these wounds are now deemed unavoidable, as pressure is not the main causative factor ( 2 , 7 ). While the exact aetiology of EOL wounds is unknown, multiorgan failure, hypoperfusion, poor nutrition, and low serum albumin are thought to play a role ( 2 , 7 – 9 ). The estimated prevalence and incidence of EOL wounds in any healthcare setting is 2.0–56.0% ( 10 , 11 ). However, most of this data was based on retrospective chart audits of deceased patients ( 10 – 12 ) which has limitations relative to data accuracy. Since 1989, these EOL wounds have been named Kennedy terminal ulcer ( 13 ), Kennedy lesion, Trombley-Brennan terminal tissue injuries ( 14 ), Skin Changes at Life’s End (SCALE) ( 8 ), and end-stage skin failure ( 15 ). Visually, PIs and EOL wounds look similar, yet their aetiology and management differ significantly ( 12 , 16 , 17 ). PIs can range from non-blanching erythema with intact skin (stage I), to deep ulceration with exposed muscle, cartilage, and bone (stage IV), along with unstageable and suspected deep tissue injury ( 1 ). EOL wounds may appear red, black, or maroon coloured; have intact or deep open wounds; be pear, horseshoe, or butterfly shaped; and develop on the sacrum, buttocks, spine, and extremities ( 13 , 14 ). A distinguishing feature of EOL wounds is that they develop quickly and can progress from non-blanching erythema with intact skin to a deep ulcer within hours or days ( 18 ). Notably, individuals who are not dying cannot develop an EOL wound, yet those who are dying can concurrently develop PIs and EOL wounds ( 7 , 12 ). The goal of pressure injury (PI) treatment is aggressive wound healing, including surgery ( 1 ). Conversely, for EOL wounds, comfort care, pain relief, wound exudate management, and goal setting are the care aims ( 19 , 20 ). Accurate skin assessment is vital for the delivery of value-based and appropriate care ( 16 , 19 ), but differentiating between PIs and EOL wounds can be challenging for clinicians. The evidence suggests that many clinicians, especially novices, lack awareness of EOL wounds ( 20 ), highlighting the need for targeted education and training ( 17 , 19 , 21 ). Compounding this is the lack of an EOL wound classification system ( 22 ) and an ICD-10-CM code, meaning that these wounds are staged, reported, and treated as a PI ( 9 , 12 , 17 ) despite experienced clinicians knowing that these wounds were not PIs. This misclassification results in inaccurate and potentially inflated PI incidence data, unnecessary aggressive wound treatment and surgical procedures, reduced patient quality of life, increased healthcare costs, organisational fines, litigation ( 16 , 19 , 23 ) and incarceration for abuse ( 24 ). Demonstrating progress in the field of EOL wounds, in October 2023, the Centers for Medicare and Medicaid Services revised Section M-skin conditions in the Long Term Care Facility Resident Assessment Instrument (RAI) User’s Manual ( 25 ), recognising that EOL wounds were different from PIs. However, how EOL wounds should be coded remains unknown ( 9 ). Evidence from two systematic reviews revealed that an EOL wound assessment tool for clinicians was non-existent ( 12 , 17 ), prompting the development of one using a modified Delphi method ( 26 ). Our tool, described elsewhere ( 26 ), can be used by clinicians if they suspect a dying patient has developed an EOL wound. This tool has the potential to increase the accuracy of EOL wound identification and the subsequent delivery of multidisciplinary, comfort-based wound care, and reduce organisational penalties for wound misclassification ( 26 ). Testing the interrater reliability of the new tool was necessary to establish its credibility ( 27 , 28 ). Nonetheless, we anticipated several potential challenges. First, EOL wounds develop quickly and appear within the hours or days before death, which could make it difficult to recruit study participants. Second, evidence suggests conducting clinical research with dying individuals can result in high participant refusal rates and gatekeeping by clinicians and managers, impacting study recruitment ( 29 ). Therefore, this feasibility study aimed to test the recruitment procedures and to undertake interrater reliability of the EOL wound assessment tool in dying hospital patients ( 28 ). The study findings will inform the development of a study protocol and sensitive recruitment procedures, data collection, and staff training for a larger future observational study, testing the tool’s inter- and intrarater reliability. METHODS This feasibility study, conducted between March 2021 and November 2023, gathered quantitative data on study procedures in hospitalised dying adult patients with a newly reported PI. Feasibility studies are useful in testing aspects of the methodology, obtaining stakeholder support for a larger study, or determining the ability to collect data on study variables (30). The feasibility research aims were to: Test participant screening using the study inclusion and exclusion criteria. Test the recruitment procedure (i.e., how participants were identified, approached, and recruited). Test the feasibility of collecting photographs of EOL wounds for inter-rater reliability testing. Describe who provided study consent: dying patient, family member, legal guardian. Undertake interrater reliability testing of the EOL wound assessment tool. The study outcomes are outlined in Table 1. Table 1: Study feasibility outcomes Primary outcomes Secondary outcomes Eligibility: ≥10% of screened patients with a new reported PI Recruitment: ≥50% of eligible patients are recruited Digital photographs: ≥95% of recruited participants’ PI Number of eligible dying adult patients, family members, or legal guardians who provided study consent. Number of eligible dying adult patients who died/near death before study recruitment. Interrater reliability: ≥90% agreement between raters of wounds The study reporting followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (31). Ethical approvals were obtained from the relevant hospital and university Human Research Ethics Committees (hospital: HREC/2020/QGC/54403; university: 2020/379). Setting The study settings were acute adult medical and palliative care units at three Australian healthcare facilities (Gold Coast University Hospital, Robina Hospital and Queen Elizabeth II Hospital) located in Queensland’s southeastern region. We recruited seven clinical units (one palliative care unit; six medical units) at Gold Coast University Hospital, five clinical units (one palliative care unit; four medical units) at Robina Hospital, and one palliative care unit at Queen Elizabeth II Hospital. These clinical specialties were selected because of the higher reported PI incidence rates and the larger number of dying patients cared for in these units compared to surgical units. Collectively, these hospitals have about 1,500 beds and provide a range of acute healthcare services (emergency, medical, surgical, palliative, maternity and mental health) to a large and diverse population (32). Prior to data collection, Chief Investigators [SL, JH, G R-B, TH] and [JS] delivered study information sessions to the nurses in the recruited units. Sample and Recruitment Dying adult patients (aged ≥18 years) with a new PI (any stage) reported in the clinical incident management database (RiskMan) in the previous 24 hours were eligible to be invited to participate. Participants were excluded if written consent could not be obtained from the patient, family member or legal guardian. The nature of the study and the lack of hypothesis testing means that our sample size calculation used a pragmatic approach based on patient access and study resources (28). For feasibility studies, a sample size of between 10-50 participants is considered sufficient (28); therefore we aimed to recruit a consecutive sample of 30 dying adult hospital patients meeting the study criteria, or 10 participants per hospital site. Registered nurses with 1-3 years of clinical experience in palliative care were recruited and trained as Research Assistants (RAs). In addition, a registered nurse who was a palliative wound expert, and independent of the research team, was also recruited and trained as an off-site independent blinded outcome assessor. A four-hour training package was delivered by the Chief Investigator [SL] to the RAs and blinded outcome assessor and included the differences between PIs and EOL wounds, the study protocol, data collection including wound photography, and using the EOL wound assessment tool. After the training, interrater reliability of the RAs, blinded outcome assessor and Chief Investigator [SL] was established by assessing EOL wounds published in the literature (33) to achieve a 0.8 kappa coefficient (34). If this was not achieved, additional training and wound assessments were performed. Data collection commenced after training and a kappa of 0.8 or greater was achieved. Using the study criteria, the RAs identified eligible participants in one of two ways. The primary approach involved screening the RiskMan incident reporting database for new PI from the recruited units in the previous 24 hours. When potential participants were identified, the RA contacted the nurse unit manager and verbally confirmed that the identified patient was receiving EOL care. In the second approach, the nurse unit manager (or delegate) from the recruited units identified potential patients and directly contacted Chief Investigators [SL] while the clinical staff concurrently entered the RiskMan PI incident data. Obtaining study consent varied depending on the patient’s clinical condition. For conscious patients, the nurse unit manager introduced them to the RA who provided a plain language study overview. Patients were advised of the type of data that would be collected and how it would be used. The RA answered their questions and obtained a written consent from willing participants. For sedated or unconscious patients, the nurse unit manager introduced the RA to the next of kin or legal guardian at the bedside. In a private location, the RA provided them with a plain language study overview, including the type of data collected and how it would be used. All questions were answered and, if willing, a written consent was obtained on behalf of the participant. A ll participants and legal guardians were reminded of their right to withdraw from the study at any time. Data Collection Between March 2021 and November 2023, we undertook 20 months of data collection; March-August 2021 (6 months), June-September 2022 (4 months) and February-November 2023 (10 months funded period). During data collection, the RA collected anonymous, deidentified participant data and entered it directly into the Research Electronic Data Capture (REDCap®) platform (35) hosted at the university. Baseline data (age, sex, primary diagnosis, number of comorbidities) were gathered from participants’ electronic medical files. Using the EOL wound assessment tool (26), the RA confirmed the patient was in the EOL phase where death was likely in the following hours, days, weeks or months (36). They also confirmed the patient received regular PI prevention strategies, such as repositioning, before developing the new PI. The RA conducted a clinical bedside assessment of the reported PI including a visual inspection of the anatomical location and wound characteristics such as shape, colour, and degree of skin loss, if any. A three-second skin blanching test adjacent to the wound/injury was completed to assess for reperfusion. Finally, a de-identified colour digital photograph of the new PI was taken. Using the gathered data, the trained RA determined if the new PI was an EOL wound (Yes/No) and documented the outcome of their assessment in REDCap®. After data collection, the independent blinded outcome assessor reviewed the data and digital photographs and determined if the new PI was an EOL wound (Yes/No). The assessments of the RA and blinded outcome assessor were used to calculate the interrater reliability between the raters. Data Analysis Using IBM SPSS Statistics (Version 29.0) (37), the study data were cleaned and tested for accuracy, distribution, and missing values. Frequencies and percentages were computed for the primary and secondary feasibility outcomes. Demographic data were analysed using descriptive statistics. Normally distributed continuous variables were reported using mean and standard deviation (SD), while median and interquartile range (IQR) were used to report nonnormally distributed variables. Categorical variables were reported using frequencies and percentages. Cohen’s kappa statistic was computed to determine the inter-rater reliability agreement with the binary variable: EOL wound (Yes/No) and reported using 95% confidence intervals with a p-value of <0.05 indicating statistical significance. RESULTS Across the 13 recruited clinical units at the three hospitals, 140 adult inpatients with a new PI reported in the RiskMan clinical incident management database were screened, with 23 (16.4%) meeting the study selection criteria (Figure 1). Of these, four (17.4%) patients died before the RA could commence recruitment. In total, 18 (78.3%) eligible participants, including two others near death at the time, were approached for study recruitment. Eight (34.7%) patients declined to participate due to reasons such as refusing wound photography, not disrupting the patient’s comfort, and wanting to spend time with their loved ones. Therefore, 10 (43.5%) patients (Gold Coast University Hospital: n=0; 0.0%, Robina Hospital: n=3; 30.0%, Queen Elizabeth II Hospital: n=7; 70.0%) who consented were enrolled in the study. Feasibility We met two of our three feasibility criteria (Table 2). We exceeded our eligibility criterion target (n=23/140; 16.4%) and achieved 100.0% for digital photography data collection. We recruited fewer participants than our target (n=10/23; 43.5%), with the actual or imminent death of eligible patients (n=6; 26.1%) being the main reason for nonrecruitment. Table 2: Feasibility Results Criteria and target Result Target achieved Eligibility: ≥10% of screened patients with a new reported PI are eligible for recruitment 23/140 (16.4%) Yes Recruitment : ≥50% of eligible patients are recruited 10/23 (43.5%) No Digital photography: ≥95% of recruited participants’ PI were photographed 13/13 (100.0%) Yes The sample of 10 (43.5%) dying adults had 13 new wounds reported in RiskMan. Males (n=7; 70.0%) were mostly recruited, and metastatic cancer was the primary diagnosis for most participants (n=8; 80.0%). The median participant age was 74.0 years (IQR: 63;8; range 44–95 years). All but one participant (n=9; 90.0%) were in specialist palliative care units. Six (60%) patients provided written study consent with the remaining (n=4; 40.0%) obtained from a partner or adult child. The sample and wound characteristics are presented in Table 3. Most participants (n=7; 70.0%) presented with one new wound, while three (30.0%) participants each had two new wounds. Digital photographs were collected on the 13 (100.0%) wounds. EOL wound assessment tool inter-rater reliability We did not meet our interrater reliability target of ≥90% agreement. Using the EOL wound assessment tool, the RA assessed all 13 (100.0%) wounds as EOL wounds. Meanwhile, an independent blinded outcome assessor determined eight (61.5%) of the wounds were EOL wounds, with the remainder assessed as a PI (Table 3). One (10.0%) participant, with two wounds, was assessed by the independent outcome assessor as having an EOL wound on one anatomical site and a PI on another site. Disagreement between the raters occurred for five (38.5%) wounds, all located on the heels and toes. The interrater reliability (EOL wound Yes/No) between the RA and blinded outcome assessor using Cohen's Kappa coefficient could not be calculated because no variation was observed in the RA rating data (Yes=100.0%), resulting in this being handled as a constant in the SPSS analysis (38). As such, only a percentage agreement was calculated, with a 61.5% (n=8/13) interrater reliability level of agreement, which was considered moderate (38). Table 3: Sample and wound characteristics ( n = 10) Age (years) Sex (M/F) Study consent obtained from Primary diagnosis Number of observed wound/s Wound developed quickly in the absence of pressure (Yes/No) Received regular PI prevention care (Yes/No) Wound location Observed wound characteristics EOL wound or Pressure injury rating Inter-rater agreement (Yes/No) Research Assistant Outcome Assessor 44 M Patient Metastatic oesophageal cancer 1 Yes Yes Coccyx Non-blanchable Colour: pink, purple and maroon Shape: butterfly and pear Wound appearance: stage II PI (full thickness skin loss) EOL wound EOL wound Yes 65 F Patient Pyloric adenocarcinoma 1 Yes Yes Sacro-coccygeal-lumbar region (bilateral) Non-blanchable Colour: red, black, purple, and maroon Shape: horseshoe and striations Wound appearance: bruise like appearance (skin intact) and a stage II PI (full thickness skin loss) EOL wound EOL wound Yes 74 F Patient Metastatic lung cancer 1 Yes Yes Sacrum (bilateral) Non-blanchable Colour: pink, purple and maroon Shape: butterfly Wound appearance: bruise like appearance (skin intact) and a stage II PI (blister with partial-thickness skin loss) EOL wound EOL wound Yes 77 M Patient Metastatic prostate cancer 1 Yes Yes Buttock (bilateral) Non-blanchable Colour: red and pink Shape: three linear striations Wound appearance: bruise like appearance (skin intact) EOL wound EOL wound Yes 79 M Patient Bladder cancer 1 Yes Yes Lumbar spine Non-blanchable Colour: red Shape: linear striation Wound appearance: bruise like appearance (skin intact) EOL wound EOL wound Yes 95 F Adult child Sudden clinical deterioration 2 Yes Yes Right buttock (unilateral) Non-blanchable Colour: red Shape: one linear striation Wound appearance: bruise like appearance (skin intact) EOL wound EOL wound Yes Right posterior upper thigh Non-blanchable Colour: red Shape: two linear striations Wound appearance: bruise like appearance (skin intact) EOL wound EOL wound Yes 71 M Partner Metastatic pancreatic cancer 2 Yes Yes Sacrum (bilateral) Non-blanchable Colour: red, deep darkening skin with white center Shape: horseshoe Wound appearance: bruise like appearance (skin intact) EOL wound EOL wound Yes Yes Yes Lateral right foot and heel Non-blanchable Colour: pink, purple and maroon Shape: linear striations Wound appearance: bruise like appearance (skin intact) EOL wound Pressure injury No 59 M Partner Metastatic cancer 1 Yes Yes Left greater metatarsal joint Non-blanchable Colour: red, pink, purple and maroon Shape: circular Wound appearance: stage II PI (blister with partial-thickness skin loss) EOL wound Pressure injury No 74 F Patient Metastatic Colorectal Cancer 2 Yes Yes Left heel Non-blanchable Colour: pink, purple and maroon Shape: round Wound appearance: bruise like appearance (skin intact) EOL wound Pressure injury No Yes Yes Right heel Non-blanchable Colour: pink, purple and maroon with a white center Shape: pear Wound appearance: stage II PI (full thickness skin loss) EOL wound Pressure injury No 77 M Partner Sepsis 1 Yes Yes Right heel Non-blanchable Colour: pink, purple and maroon Shape: circular Wound appearance: bruise like appearance (skin intact) EOL wound Pressure injury No Abbreviations: EOL: end-of-life; F: female; M: male; PI: pressure injury EOL wound characteristics The eight EOL wounds developed quickly on patient’s sacrum (bilateral) (n=2; 25.0%), lumbar spine (n=2; 25.0%), coccyx (n=1; 12.5%), unilateral buttock (n=1; 12.5%), bilateral buttock (n=1; 12.5%) and upper thigh (n=1; 12.5%). Most (n=7; 87.5%) of the EOL wounds had a bruise-like appearance, and all (n=8; 100.0%) were nonblanchable. The skin was intact in five (67.5%) of the EOL wounds and their colour ranged from a single red colour or multiple colours including red, black, pink, purple and maroon and white in the centre of the wound. Various shapes were observed, with linear striations being the most common (n=5; 62.5%). Other shapes included butterfly (n=2; 25.0%), horseshoe (n=2; 25.0%), and pear (n=1; 12.5%) with and without striations (Figure 2 A-D). We did not collect participant data from time to death. DISCUSSION This feasibility study evaluated our study protocol in a sample of dying adult inpatients at three large Queensland hospitals. Although we did not reach our target sample size, we did meet the remaining primary study outcomes. During this study, we gained valuable insights regarding data collection, recruitment and research staff training, which will inform the development of a study protocol for a larger multisite observational study to test the inter- and intrarater reliability of our EOL wound assessment tool. Dying adult patients with a new PI were our target population. Using our study criteria, we achieved an eligibility rate of 16.3%, exceeding our ≥ 10% target. We based our study eligibility rate of ≥ 10% on the 2.7% Kennedy terminal ulcer incidence rate reported in cancer patients admitted to hospice care ( 10 ), a similar cohort and setting used in our study. Our findings support recent research that found 17.3–19.7% of dying patients developed a Kennedy terminal ulcer or unavoidable PI ( 10 , 11 ). Yet, there is limited reliable EOL wound prevalence and incidence data available in the published literature ( 16 ), with estimates varying from 2.0 to 56.0% ( 12 ) from a handful of observational studies across a range of clinical settings ( 10 , 11 , 13 , 14 , 21 , 39 , 40 ). Accurately identifying EOL wounds in dying adults will help to reduce the misclassification of PI, guide clinical care and resource allocation, and potentially save money for healthcare organisations ( 12 , 16 , 19 , 41 ). As such, further inter- and intrarater reliability testing of our EOL wound assessment tool is needed. Given our encouraging results, we will retain the study eligibility criteria in a larger research project. We successfully collected the digital photographs of the reported wounds including those located on the sacrum and buttocks. We attribute this success to our extensive experience of sacral photography in several randomised controlled trials and recruiting registered nurses to gather this data ( 42 – 45 ). This experience informed the RA training on recruitment, consent and photography including potential ethical and legal issues ( 46 ). During recruitment, the RA and potential participant/family member discussed the role of photography in data collection and analysis, who (i.e., the RA) and how the photographs would be taken (i.e., patient comfort, de-identified, minimal skin exposure, positioning) ( 47 , 48 ) and its intended use (i.e., manuscripts, conference presentations) ( 46 ). Patient clinical photography is used as standard practice to monitor conditions in dermatology ( 49 ), mental health ( 50 ), plastic surgery ( 51 ) and as a research data collection method ( 42 – 45 ). Evidence suggests most patients have a positive attitude toward photography for clinical and education purposes ( 49 , 52 ) yet, for a handful of our eligible study patients, privacy concerns regarding the photographs were one reason for recruitment refusal. A 2020 qualitative survey of 71 patients also found privacy and confidentiality concerns around photography informed study refusal ( 52 ). In a larger study, we will use photography to collect data in a larger study and train the RAs on its legal and ethical issues including a participant’s right to refuse. We did not achieve our recruitment target of ≥ 50% largely because seven eligible patients either died or were close to death at the time of recruitment. Conducting clinical research with dying individuals is challenging ( 29 ) and requires the timely identification of living participants and local clinician and manager support ( 12 , 17 ). In our study, screening the RiskMan database for potential participants was useful, but we experienced a delay of up to 24-hours between the time clinicians entered the data on the new PI, to when we conducted the daily screening. The fast-developing nature of EOL wounds in the hours or days prior to a person’s death was a major challenge in our study which likely contributed to our high rate of ‘near-miss’ recruitments. When conducting research with patients in palliative care units, barriers to recruitment include clinician gatekeeping and ethical concerns about burdening patients can result in high participant refusal rates ( 29 , 53 ). Yet, in our study, we received positive support from clinicians and managers in the recruited clinical units, which resulted in some staff directly contacting the researchers about potential participants. All our research team and the RAs were affiliated with the three study sites, either as direct employees or an adjunct position, and had collegial relationships with many of the staff in the recruited units, which likely contributed to our positive experience. In addition, many of the palliative care clinicians in our recruited units supported our research because they had extensive experience with EOL wounds including documenting them as a PI in the RiskMan database. In a future study, we will continue to foster collaborations with staff and clinical leaders at potential study sites ( 53 ) to build research cross-pollination and develop strategies to increase participant recruitment. In addition, we will invite consumers receiving palliative care and their families as members of our research team and to codesign a future study ( 54 ). We did not achieve our total target sample size of 30 participants. However, our experience of screening 140 patients and achieving a sample of 10 dying patients was considered sufficient to test the feasibility criteria for a larger study. A lack of research funding was the main reason for not achieving our goal, reducing our access to the resources needed to complete the project. This resulted in ad-hoc screening, missed recruitment opportunities and two data collection stoppages lasting 16 months. In 2022, we secured research funding, enabling us to train a team of RAs to collect daily data for 10 months resulting in increased participant identification and recruitment. It is well documented that EOL wound research is grossly underfunded, which limits research knowledge development and has clinical implications ( 17 ). Globally, the number of older people and those with chronic health conditions is rapidly growing, placing increased pressure on palliative care in community and healthcare settings ( 55 , 56 ). Recruiting dying patients into research projects, as participants or consumers, is often logistically and uniquely challenging ( 54 , 57 ). Gaining consent directly from study participants is always the preferred legal and ethical option ( 58 ). In our study, 60% of dying patients were willing and able to provide written study consent. This specific population is under-represented in the research literature, so study consent processes require a balance between appropriate protections, and minimising study exclusion, which could limit patient access to safe and effective interventions ( 58 ). Evidence confirms that many dying adults want to participate in clinical research as an act of ‘giving back’ ( 29 , 53 ). Consenting dying patients into research projects requires RAs to have specific knowledge and skills on how to compassionately engage with potential participants and family members ( 54 , 57 ). As such, we recruited registered nurses with palliative care experience and trained them in obtaining consent from dying patients in a tailored and supportive manner, an approach that contributed to our overall study success. Our interrater reliability percentage agreement between the RA and blinded outcome assessor did not reach our target. We found the difference in ratings occurred at wounds located on the heels and toes, a known location for EOL wound development ( 12 , 16 , 17 ). Evidence suggests the differentiation between an avoidable PI and unavoidable EOL wound is based on clinician judgement following an evaluation of care ( 59 ). Differences in clinical judgement and experience between the raters might in part, explain our findings. The blinded outcome assessor, a palliative care clinical leader, was very familiar with EOL wounds, while our RAs, with 1–3 years clinical palliative care experience and had some knowledge of these wounds. The independent outcome assessor determined one participant with two wounds had an EOL wound as well as a PI. Clinical judgement is a multifaceted and complex concept that requires theoretical knowledge, data, years of clinical experience, and reflection that leads to pattern recognition ( 60 ). In a future larger study, we will obtain resources to support the employment of two experienced palliative care nurses to undertake independent and concurrent bedside clinical assessments, thus replicating real-world clinical practice. Limitations We acknowledge that this feasibility study has limitations. Due to limited funding and resources, our data collection period was extended and interrupted. Also, conducting the research in medical settings did not yield the recruitment results we had hoped for. Future research focussing solely on palliative care units, which have a higher number of dying patients, is one way to increase our recruitment and efficiently use research resources. Although our target sample size was not reached, during the 18-month data collection period we garnered sufficient information to rigorously test the study protocol and learn valuable lessons that will inform a larger study. We acknowledge the lack of variation in the outcome data limited our interrater reliability reporting to percentage agreement, which does not take into account if either rater ‘guessed’ the outcome (EOL wound Yes/No) ( 38 ). However, a Cohen Kappa calculation, which accounts for the possibility of guessing, also has limitations by assuming the raters are independent ( 38 ). The outcome assessor was blinded to the RA outcome yet we cannot be certain if the results of both raters were biased based on the study participant ( 38 ). Our efforts to reduce detection bias included independent assessments, blinding of the outcome assessor, and the use of wound photography. CONCLUSIONS This feasibility study aimed to test the recruitment procedures and to undertake interrater reliability of our EOL wound assessment tool in dying hospital patients. Moderate agreement in the identification of an EOL wound was achieved, with the blinded outcome assessor determining one participant as having both an EOL wound and PI. Although undertaking clinical research in dying patients is challenging, following a few minor modifications to the protocol and setting selection, a larger multisite study, testing the inter- and intrarater reliability of the EOL wound assessment tool, is feasible. Differentiating between avoidable PI and unavoidable EOL wounds in dying patients is an urgent clinical need. Our EOL wound assessment tool has the potential to decrease PI misclassification and help clinicians make informed decisions regarding the delivery of wound care in dying patients. Abbreviations EOL: end-of-life F: female IQR: interquartile range M: male PI: pressure injuries RA: research assistant SD: standard deviation STROBE: Strengthening the Reporting of Observational Studies in Epidemiology Declarations Acknowledgements. We sincerely thank the participants, and their family members involved in this research. We would also like to acknowledge the ongoing support of the managers and clinical staff in the recruited clinical units. Funding. A 2023 Griffith University School of Nursing and Midwifery seed grant supported part of the study data collection. Contributions. CRediT roles: Conceptualisation-SL, RW, JH, G R-B, TH, JS, BG; Data curation-SL; Formal analysis-SL; Funding acquisition- SL, RW, G R-B, BG; Investigation-SL; Methodology: SL, RW, JH, G R-B, BG; Project administration-SL; Writing - original draft-SL; Writing - review & editing: RW, JH, G R-B, TH, JS, BG Data availability statement. The data that support the findings of this study are available on request from the corresponding author, [SL]. The data are not publicly available due to ethical restrictions pertaining to the privacy of research participants. Ethics declarations. Ethics approval and consent to participate We confirm that the data collection, including photographs, data analysis and storage were performed in accordance with relevant guidelines and regulations. Study ethics approval was granted from the Gold Coast University Hospital and Griffith University Human Research Ethics Committees (hospital: HREC/2020/QGC/54403; university: 2020/379). Prior to recruitment, study information was provided. Prior to data collections, an informed written (signed) consent was obtained from participants, their family member or legal guardian. Consent for publication. Consent for publication of photographs was obtained from all participants. Competing interests. The authors declare no competing interests. References National Pressure Injury Advisory Panel EPUAP, Pan Pacific Pressure Injury Alliance, . Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline: The International Guideline Online2025 [4th Edition:[Available from: https://internationalguideline.com/the-international-guideline Sibbald RG, Ayello E. Results of the 2022 wound survey on skin failure/end-of-life terminology and pressure injuries. Adv Skin Wound Care. 2023;36(3):151-7. Melnychuk I, Servetnyk I. Kennedy Terminal Ulcers and Trombley-Brennan Terminal Tissue Injuries: mystery solved? Adv Skin Wound Care. 2024;37(5):233-7. Levine JM. Terminal Ulcer terminology: a critical reappraisal. Wound Manag Prev. 2019;65(8):44-7. Olshansky K. “Kennedy terminal ulcer” and “skin failure,” where are the data? J Wound Ostomy Continence Nurs. 2010;37(5):466-67. Miller M. The death of the Kennedy terminal ulcer. J Am Coll Clin Wound Spec. 2016;8(1-3):44-6. Mitchell A, Elbourne S. Pressure ulcers at the end of life. Br J Community Nurs. 2022;27:S14-S8. Sibbald RG, Krasner D, Lutz J. SCALE: Skin Changes at Life's End: final consensus statement: October 1, 2009. Adv Skin Wound Care. 2010;23(5):225-38. Ayello E, Sibbald RG. CMS guidance for long-term care Section M: Terminal ulcers and pressure injuries. Adv Skin Wound Care. 2024;37(5):230-. Jakobsen T, Pittureri C, Seganti P, Borissova E, Balzani I, Fabbri S, et al. Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: a multicentre prospective cohort study. Int Wound J. 2020;17(3):641-9. Palese A, Trevisani B, Guarnier A, Barelli P, Zambiasi P, Allegrini E, et al. Prevalence and incidence density of unavoidable pressure ulcers in elderly patients admitted to medical units. J Tissue Viability. 2017;26(2):85-8. Latimer S, Walker RM, Ray-Barruel G, Shaw J, Mackrell K, Hunt T, et al. Defining and describing Terminal Ulcers in adults at end of life: an integrative review. Adv Skin Wound Care. 2022;35(4):225-33. Kennedy K. The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 1989;2(2):44-7. Trombley K, Brennan MR, Thomas L, Kline M. Prelude to Death or Practice Failure? Trombley-Brennan Terminal Tissue Injuries. Am J Hosp Palliat Med. 2012;29(7):541-5. Ayello E, Levine J, Langemo D, Kennedy-Evans K, Brennan M, Sibbald RG. Reexamining the literature on terminal ulcers, SCALE, skin failure, and unavoidable pressure injuries. Adv Skin Wound Care. 2019;32(3):109-21. Roca-Biosca A, Rubio-Rico L, De molina-Fernández M, Martinez-Castillo J, Pancorbo-Hidalgo P, García-Fernández F. Kennedy Terminal Ulcer and other skin wounds at the end of life: an integrative review. J Tissue Viability. 2021;30(2):178-82. Latimer S, Shaw J, Hunt T, Mackrell K, Gillespie BM. Kennedy Terminal Ulcers: a scoping review. J Hosp Palliat Nurs. 2019;21(4):257-63. Kennedy-Evans K. Understanding the Kennedy Terminal Ulcer. Ostomy Wound Manage. 2009;55(9):6-. Sezgin D, Geraghty J, Graham T, Blomberg K, Charnley K, Dobbs S, et al. Defining palliative wound care: a scoping review by European Association for Palliative Care wound care taskforce. J Tissue Viability. 2023;32:627-34. de Carvalho M, Xavier É, Pereira I, Carneiro R. Nursing care for patients affected by Kennedy Terminal Ulcer: integrative review. Int J Dev Res. 2020;10(10):41760-3. Nesovic A. Kennedy Terminal Ulcer: a retrospective chart review of ulcers in the hospice setting and educating providers and nurses on the importance of skin changes at life's end. Montana, USA: Montanna State University; 2016. Levine J. Unavoidable pressure injuries, terminal ulceration, and skin failure: in search of a unifying classification system. Adv Skin Wound Care. 2017;30(5):200-2. Ferris A, Price A, Harding K. Pressure ulcers in patients receiving palliative care: a systematic review. Pall Med. 2019;33(7):770-82. Di Maio V, Di Maio T. Homicide by decubitus ulcers. Am J Forensic Med Pathol. 2002;23(1):1-4. Centers for Medicare and Medicaid Services. RAI manual Minimum Data Set 3.0 Resident Assessment Instrument User’s Manual v1.18.11 2023 [Available from: https://www.cms.gov/medicare/quality/nursing-homeimprovement/resident-assessment-instrument-manual Latimer S, Harbeck E, Walker RM, Ray-Barruel G, Shaw J, Hunt T, et al. Development of a wound assessment tool for use in adults at end of life: a modified Delphi Study. Adv Skin Wound Care. 2023;36(3):142-50. Cohen L, Manion L, Morrison K. Validity and reliability. Research Methods in Education. 8th Edition ed. London, UK: Routledge; 2017. p. 245-84. Leon A, Davis L, Kraemer HC. The role and interpretation of pilot studies in clinical research. J Psychiatr Res. 2011;45(5):626-9. Bloomer M, Hutchinson A, Brooks L, Botti M. Dying persons’ perspectives on, or experiences of, participating in research: an integrative review. Pall Med. 2018;32(4):851-60. Lancaster G, Thabane L. Guidelines for reporting non-randomised pilot and feasibility studies. Pilot Feasibility Stud. 2019;5(114):1-6. Von Elm E, Altman D, Egger M, Pocock S, Gøtzsche PC, Vandenbroucke J. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495-9. Queensland Health. My health, Queensland’s future: Advancing health 2026. Brisbane; 2016. Nixon J, Cranny G, Bond S. Pathology, diagnosis, and classification of pressure ulcers: comparing clinical and imaging techniques. Wound Repair Regen. 2005;13(4):365-72. Viera A, Garrett J. Understanding interobserver agreement: the kappa statistic. Fam Med. 2005;37(5):360-3. Harris P, Taylor R, Minor B, Elliott V, Fernandez M, O'Neal L, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. Schüttengruber G, Großschädl F, Lohrmann C. A consensus definition of End of Life from an international and interdisciplinary perspective: a Delphi panel study. J Palliat Med. 2022;25(11):1677-85. IBM Corp. IBM SPSS Statistics for Windows. Armonk, NY.2022. McHugh ML. Interrater reliability: The kappa statistic. Biochemia Medica. 2012;22(3):276-82. Brennan M, Thomas L, Kline M. Prelude to death or practice failure? Trombley-Brennan terminal tissue injury update. Am J Hosp Palliat Med. 2019;36(11):1016-9. Brennan M, Trombley K. Kennedy terminal ulcers: a palliative care unit's experience over a 12-month period of time. WCET J. 2010;30(3):20-2. Padula W, Delarmente B. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J. 2019;16(3):634-40. Walker RM, Aitken L, Huxley L, Juttner M. Prophylactic dressing to minimize sacral pressure injuries in high-risk hospitalized patients: a pilot study. J Adv Nurs. 2015;71(3):688-96. Latimer S, Walker RM, Chaboyer W, Thalib L, Coyer F, Deakin J, et al. Prophylactic dressings to prevent sacral pressure injuries in adult patients admitted to intensive care units: A three-arm feasibility randomized controlled trial. Intensive Crit Care Nurs. 2024;84:103746. Walker RM, Chaboyer W, Cooke M, Whitty J, Thalib L, Lockwood I, et al. EffEctiveness of Prophylactic foam dressings in the prevention of sacral pressure injuries in at-risk hospitalised patients: the EEPOC trial. Trials. 2023;24(1):70-82. Latimer S, Chaboyer W, Walker RM, Thalib L, Deakin J, Gillespie BM. Prophylactic dressings for preventing sacral pressure injuries in adult intensive care unit patients: a randomised feasibility trial. Aust Crit Care. 2024:101133. Clark A, Prosser J, Wiles R. Ethical issues in image-based research. Arts & Health. 2010;2(1):81-93. Persichetti P, Simone P, Langella M, Marangi G, Carusi C. Digital photography in plastic surgery: how to achieve reasonable standardization outside a photographic studio. Aesthet Surg J. 2007;31:194-200. Kashetsky N, Mar K, Liu C, Rivers J, Mukovozov I. Photography in dermatology: a scoping review: Practices, skin of color, patient preferences, and medical‐legal considerations. JDDG. 2023;21(10):1102-7. Kim W, Sivesind T. Patient perceptions of dermatologic photography: scoping review. JMIR dermatology. 2022;5(1):e33361. Buchan C. Therapeutic benefits and limitations of participatory photography for adults with mental health problems: a systematic search and literature review. J Psychiatr Ment Health Nurs. 2020;27(5):657-68. Tian W, Porras Fimbres D, Tran M, Zeng S, Gnaedinger A, Kaplan S, et al. Quality and reliability of 2D and 3D clinical photographs in plastic surgery: a scoping review. Aesthet Plast Surg. 2025:1-11. Wyatt K, Finley A, Uribe R, Pallagi P, Willaert B, Ommen S, et al. Patients' experiences and attitudes of using a secure mobile phone app for medical photography: qualitative survey study. J Med Internet Res. 2020;22(5):e14412. Blum D, Inauen R, Binswanger J, Strasser F. Barriers to research in palliative care: a systematic literature review. Prog Palliat Care. 2015;23(2):75-84. Virdun C, Luckett T, Gilmore I, Brassil M, Lilian R, Lorenz K, et al. Involving consumers with palliative care needs and their families in research: a case study. Collegian. 2019;26(6):645-50. Etkind S, Bone A, Gomes B, Lovell N, Evans C, Higginson I, et al. How many people will need palliative care in 2040? Past trends, future projections and implications for services. BMC Med. 2017;15(102). Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison R. The growth of palliative care in US hospitals: a status report. J Palliat Med. 2016;19(1):8-15. Boland J, Currow D, Wilcock A, Tieman J, Hussain J, Pitsillides C, et al. A systematic review of strategies used to increase recruitment of people with cancer or organ failure into clinical trials: implications for palliative care research. J Pain Symptom Manage. 2015;49(4):762-72. National Health and Medical Research Council, Australian Research Council, Australian Vice-Chancellors' Committee. National statement on ethical conduct in human research. Canberra, Australia2007-updated 2018 [cited Commonwealth of Australia. 1-101]. Available from: https://www.nhmrc.gov.au/research-policy/ethics/national-statement-ethical-conduct-human-research. Black J, Edsberg L, Baharestani M, Langemo D, Goldberg M, McNichol L, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel consensus conference. Ostomy Wound Manage. 2011;57(2):24-37. Connor J, Flenady T, Massey D, Dwyer T. Clinical judgement in nursing: an evolutionary concept analysis. J Clin Nurs. 2023;32(13-14):3328-40. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 Jul, 2025 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 16 Apr, 2025 Reviews received at journal 13 Apr, 2025 Reviewers agreed at journal 26 Mar, 2025 Reviews received at journal 23 Mar, 2025 Reviewers agreed at journal 23 Mar, 2025 Reviewers invited by journal 21 Mar, 2025 Editor invited by journal 19 Mar, 2025 Editor assigned by journal 19 Mar, 2025 Submission checks completed at journal 19 Mar, 2025 First submitted to journal 17 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6241301","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":434365349,"identity":"85ba5065-c1b8-40f8-b273-f99af6a9ce84","order_by":0,"name":"Sharon Latimer","email":"data:image/png;base64,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","orcid":"","institution":"Griffith University","correspondingAuthor":true,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Latimer","suffix":""},{"id":434365350,"identity":"8691ac94-7c66-4a3a-9baa-aa09d261f53e","order_by":1,"name":"Rachel. M. Walker","email":"","orcid":"","institution":"James Cook University","correspondingAuthor":false,"prefix":"","firstName":"Rachel.","middleName":"M.","lastName":"Walker","suffix":""},{"id":434365351,"identity":"ddd4df5a-30a8-4236-857f-ea37cdc16c13","order_by":2,"name":"Jayne Hewitt","email":"","orcid":"","institution":"Griffith University","correspondingAuthor":false,"prefix":"","firstName":"Jayne","middleName":"","lastName":"Hewitt","suffix":""},{"id":434365352,"identity":"2170ca0d-513a-42da-ab7f-b4fdd532b629","order_by":3,"name":"Gillian Ray-Barruel","email":"","orcid":"","institution":"University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Gillian","middleName":"","lastName":"Ray-Barruel","suffix":""},{"id":434365353,"identity":"b6496242-87d5-4c27-8ddc-40488f6c833a","order_by":4,"name":"Joanie Shaw","email":"","orcid":"","institution":"Queensland Health","correspondingAuthor":false,"prefix":"","firstName":"Joanie","middleName":"","lastName":"Shaw","suffix":""},{"id":434365354,"identity":"040ee6ea-7761-4c89-80f3-954d3cc61870","order_by":5,"name":"Tracey Hunt","email":"","orcid":"","institution":"Queensland Health","correspondingAuthor":false,"prefix":"","firstName":"Tracey","middleName":"","lastName":"Hunt","suffix":""},{"id":434365355,"identity":"b561fca2-11f8-4c19-8843-287940881a35","order_by":6,"name":"Brigid.M. Gillespie","email":"","orcid":"","institution":"Griffith University","correspondingAuthor":false,"prefix":"","firstName":"Brigid.M.","middleName":"","lastName":"Gillespie","suffix":""}],"badges":[],"createdAt":"2025-03-17 05:53:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6241301/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6241301/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-025-01853-9","type":"published","date":"2025-07-29T16:38:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79665155,"identity":"fa4be8c1-85b8-4ac9-887b-a05360425738","added_by":"auto","created_at":"2025-04-01 10:07:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":189669,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6241301/v1/81fb6973af03c0417e55f182.png"},{"id":79662273,"identity":"8e3ff118-4238-4df4-aada-6877d9abd957","added_by":"auto","created_at":"2025-04-01 09:51:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1275499,"visible":true,"origin":"","legend":"\u003cp\u003eEOL wound photographs. 2A: Lumbar spine striation; 2B: Coccyx bilateral butterfly shape; 2C: Coccyx bilateral butterfly shape with blister; 2D: Sacro-coccygeal-lumbar horseshoe shape with striations.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6241301/v1/6987b6997b202f421b19835d.png"},{"id":88268445,"identity":"8207aed8-199b-4097-a76c-49502ed47b68","added_by":"auto","created_at":"2025-08-04 16:51:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2647171,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6241301/v1/809c5311-6d73-4c9f-bc5b-7054ddec7688.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAn end-of-life wound assessment tool for dying hospitalised adults: A feasibility study.\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePressure injuries (PIs) are avoidable local skin and tissue injuries caused by pressure in combination with shear and often develop over bony prominences such as the sacrum and heels (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In contrast, some individuals develop unavoidable skin injuries, or end-of-life (EOL) wounds (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), within the hours, days, weeks and months before death (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Once thought to develop due to poor nursing care (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), these wounds are now deemed unavoidable, as pressure is not the main causative factor (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). While the exact aetiology of EOL wounds is unknown, multiorgan failure, hypoperfusion, poor nutrition, and low serum albumin are thought to play a role (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The estimated prevalence and incidence of EOL wounds in any healthcare setting is 2.0\u0026ndash;56.0% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, most of this data was based on retrospective chart audits of deceased patients (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) which has limitations relative to data accuracy. Since 1989, these EOL wounds have been named Kennedy terminal ulcer (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), Kennedy lesion, Trombley-Brennan terminal tissue injuries (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), Skin Changes at Life\u0026rsquo;s End (SCALE) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), and end-stage skin failure (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVisually, PIs and EOL wounds look similar, yet their aetiology and management differ significantly (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). PIs can range from non-blanching erythema with intact skin (stage I), to deep ulceration with exposed muscle, cartilage, and bone (stage IV), along with unstageable and suspected deep tissue injury (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). EOL wounds may appear red, black, or maroon coloured; have intact or deep open wounds; be pear, horseshoe, or butterfly shaped; and develop on the sacrum, buttocks, spine, and extremities (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A distinguishing feature of EOL wounds is that they develop quickly and can progress from non-blanching erythema with intact skin to a deep ulcer within hours or days (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Notably, individuals who are not dying cannot develop an EOL wound, yet those who are dying can concurrently develop PIs and EOL wounds (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The goal of pressure injury (PI) treatment is aggressive wound healing, including surgery (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Conversely, for EOL wounds, comfort care, pain relief, wound exudate management, and goal setting are the care aims (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccurate skin assessment is vital for the delivery of value-based and appropriate care (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), but differentiating between PIs and EOL wounds can be challenging for clinicians. The evidence suggests that many clinicians, especially novices, lack awareness of EOL wounds (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), highlighting the need for targeted education and training (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Compounding this is the lack of an EOL wound classification system (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and an ICD-10-CM code, meaning that these wounds are staged, reported, and treated as a PI (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) despite experienced clinicians knowing that these wounds were not PIs. This misclassification results in inaccurate and potentially inflated PI incidence data, unnecessary aggressive wound treatment and surgical procedures, reduced patient quality of life, increased healthcare costs, organisational fines, litigation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and incarceration for abuse (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Demonstrating progress in the field of EOL wounds, in October 2023, the Centers for Medicare and Medicaid Services revised Section M-skin conditions in the \u003cem\u003eLong Term Care Facility Resident Assessment Instrument (RAI) User\u0026rsquo;s Manual\u003c/em\u003e (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), recognising that EOL wounds were different from PIs. However, how EOL wounds should be coded remains unknown (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEvidence from two systematic reviews revealed that an EOL wound assessment tool for clinicians was non-existent (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), prompting the development of one using a modified Delphi method (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Our tool, described elsewhere (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), can be used by clinicians if they suspect a dying patient has developed an EOL wound. This tool has the potential to increase the accuracy of EOL wound identification and the subsequent delivery of multidisciplinary, comfort-based wound care, and reduce organisational penalties for wound misclassification (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Testing the interrater reliability of the new tool was necessary to establish its credibility (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Nonetheless, we anticipated several potential challenges. First, EOL wounds develop quickly and appear within the hours or days before death, which could make it difficult to recruit study participants. Second, evidence suggests conducting clinical research with dying individuals can result in high participant refusal rates and gatekeeping by clinicians and managers, impacting study recruitment (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Therefore, this feasibility study aimed to test the recruitment procedures and to undertake interrater reliability of the EOL wound assessment tool in dying hospital patients (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The study findings will inform the development of a study protocol and sensitive recruitment procedures, data collection, and staff training for a larger future observational study, testing the tool\u0026rsquo;s inter- and intrarater reliability.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis feasibility study, conducted between\u0026nbsp;March 2021 and November 2023, gathered quantitative data on study procedures in hospitalised dying adult patients with a newly reported PI. Feasibility studies are useful in testing aspects of the methodology, obtaining stakeholder support for a larger study, or determining the ability to collect data on study variables (30). The feasibility research aims were to:\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003eTest participant screening using the study inclusion and exclusion criteria.\u003c/li\u003e\n \u003cli\u003eTest the recruitment procedure (i.e., how participants were identified, approached, and recruited).\u003c/li\u003e\n \u003cli\u003eTest the feasibility of collecting photographs of EOL wounds for inter-rater reliability testing.\u003c/li\u003e\n \u003cli\u003eDescribe who provided study consent: dying patient, family member, legal guardian.\u003c/li\u003e\n \u003cli\u003eUndertake interrater reliability testing of the EOL wound assessment tool.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe study outcomes are outlined in Table 1.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003eTable 1: Study feasibility outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003ePrimary outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003eSecondary outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003col\u003e\n \u003cli\u003eEligibility: \u0026ge;10% of screened patients with a new reported PI\u003c/li\u003e\n \u003cli\u003eRecruitment: \u0026ge;50% of eligible patients are recruited\u003c/li\u003e\n \u003cli\u003eDigital photographs: \u0026ge;95% of recruited participants\u0026rsquo; PI\u0026nbsp;\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 311px;\"\u003e\n \u003col\u003e\n \u003cli\u003eNumber of eligible dying adult patients, family members, or legal guardians who provided study consent.\u003c/li\u003e\n \u003cli\u003eNumber of eligible dying adult patients who died/near death before study recruitment.\u003c/li\u003e\n \u003cli\u003eInterrater reliability: \u0026ge;90% agreement between raters of wounds\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe study reporting followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (31). Ethical approvals were obtained from the relevant hospital and university Human Research Ethics Committees (hospital: HREC/2020/QGC/54403; university: 2020/379).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study settings were acute adult medical and palliative care units at three Australian healthcare facilities (Gold Coast University Hospital, Robina Hospital and Queen Elizabeth II Hospital) located in Queensland\u0026rsquo;s southeastern region. We recruited seven clinical units (one palliative care unit; six medical units) at Gold Coast University Hospital, five clinical units (one palliative care unit; four medical units) at Robina Hospital, and one palliative care unit at Queen Elizabeth II Hospital. These clinical specialties were selected because of the higher reported PI incidence rates and the larger number of dying patients cared for in these units compared to surgical units. Collectively, these hospitals have about 1,500 beds and provide a range of acute healthcare services (emergency, medical, surgical, palliative, maternity and mental health) to a large and diverse population (32). Prior to data collection, Chief Investigators [SL, JH, G R-B, TH] and [JS] delivered study information sessions to the nurses in the recruited units.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample and Recruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDying adult patients (aged \u0026ge;18 years) with a new PI (any stage) reported in the clinical incident management database (RiskMan) in the previous 24 hours were eligible to be invited to participate. Participants were excluded if written consent could not be obtained from the patient, family member or legal guardian. The nature of the study and the lack of hypothesis testing means that our sample size calculation used a pragmatic approach based on patient access and study resources (28). For feasibility studies, a sample size of between 10-50 participants is considered sufficient (28); therefore we aimed to recruit a consecutive sample of 30 dying adult hospital patients meeting the study criteria, or 10 participants per hospital site.\u003c/p\u003e\n\u003cp\u003eRegistered nurses with 1-3 years of clinical experience in palliative care were recruited and trained as Research Assistants (RAs). In addition, a registered nurse who was a palliative wound expert, and independent of the research team, was also recruited and trained as an off-site independent blinded outcome assessor. A four-hour training package was delivered by the Chief Investigator [SL] to the RAs and blinded outcome assessor and included the differences between PIs and EOL wounds, the study protocol, data collection including wound photography, and using the EOL wound assessment tool. After the training, interrater reliability of the RAs, blinded outcome assessor and Chief Investigator [SL] was established by assessing EOL wounds published in the literature (33) to achieve a 0.8 kappa coefficient (34). If this was not achieved, additional training and wound assessments were performed. Data collection commenced after training and a kappa of 0.8 or greater was achieved.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUsing the study criteria, the RAs identified eligible participants in one of two ways. The primary approach involved screening the RiskMan incident reporting database for new PI from the recruited units in the previous 24 hours. When potential participants were identified, the RA contacted the nurse unit manager and verbally confirmed that the identified patient was receiving EOL care. In the second approach, the nurse unit manager (or delegate) from the recruited units identified potential patients and directly contacted Chief Investigators [SL] while the clinical staff concurrently entered the RiskMan PI incident data. Obtaining study consent varied depending on the patient\u0026rsquo;s clinical condition. For conscious patients, the nurse unit manager introduced them to the RA who provided a\u0026nbsp;plain language study overview. Patients were advised of the type of data that would be collected and how it would be used. The RA answered their questions and obtained a written consent from willing participants. For sedated or unconscious patients, the nurse unit manager introduced the RA to the next of kin or legal guardian at the bedside. In a private location, the RA provided them with a plain language study overview, including the type of data collected and how it would be used. All questions were answered and, if willing, a written consent was obtained on behalf of the participant. A\u003cem\u003ell participants and legal guardians were reminded of their right to withdraw from the study at any time.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween March 2021 and November 2023, we undertook 20 months of data collection; March-August 2021 (6 months), June-September 2022 (4 months) and February-November 2023 (10 months funded period). During data collection, the RA collected anonymous, deidentified participant data and entered it directly into the Research Electronic Data Capture (REDCap\u0026reg;) platform (35) hosted at the university. Baseline data (age, sex, primary diagnosis, number of comorbidities) were gathered from participants\u0026rsquo; electronic medical files. Using the EOL wound assessment tool (26), the RA confirmed the patient was in the EOL phase where death was likely in the following hours, days, weeks or months (36). They also confirmed the patient received regular PI prevention strategies, such as repositioning, before developing the \u0026nbsp; new PI. The RA conducted a clinical bedside assessment of the reported PI including a visual inspection of the anatomical location and wound characteristics such as shape, colour, and degree of skin loss, if any. A three-second skin blanching test adjacent to the wound/injury was completed to assess for reperfusion. Finally, a de-identified colour digital photograph of the new PI was taken. Using the gathered data, the trained RA determined if the new PI was an EOL wound (Yes/No) and documented the outcome of their assessment in\u0026nbsp;REDCap\u0026reg;. After data collection, the independent blinded outcome assessor reviewed the data and digital photographs and\u0026nbsp;determined if the new PI\u0026nbsp;was an EOL wound (Yes/No).\u0026nbsp;The assessments of the RA and blinded outcome assessor were used to calculate the interrater reliability between the raters.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing IBM SPSS Statistics (Version 29.0) (37), the study data were cleaned and tested for accuracy, distribution, and missing values. Frequencies and percentages were computed for the primary and secondary feasibility outcomes. Demographic data were analysed using descriptive statistics. Normally distributed continuous variables were reported using mean and standard deviation (SD), while median and interquartile range (IQR) were used to report nonnormally distributed variables. Categorical variables were reported using frequencies and percentages. Cohen\u0026rsquo;s kappa statistic was computed to determine the inter-rater reliability agreement with the binary variable: EOL wound (Yes/No) and reported using 95% confidence intervals with a p-value of \u0026lt;0.05 indicating statistical significance.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAcross the 13 recruited clinical units at the three hospitals, 140 adult inpatients with a new PI reported in the RiskMan clinical incident management database were screened, with 23 (16.4%) meeting the study selection criteria (Figure 1). Of these, four (17.4%) patients died before the RA could commence recruitment. In total, 18 (78.3%) eligible participants, including two others near death at the time, were approached for study recruitment. Eight (34.7%) patients declined to participate due to reasons such as refusing wound photography, not disrupting the patient\u0026rsquo;s comfort, and wanting to spend time with their loved ones. Therefore, 10 (43.5%) patients (Gold Coast University Hospital: n=0; 0.0%, Robina Hospital: n=3; 30.0%, Queen Elizabeth II Hospital: n=7; 70.0%) who consented were enrolled in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFeasibility\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe met two of our three feasibility criteria (Table 2). We exceeded our eligibility criterion target (n=23/140; 16.4%) and achieved 100.0% for digital photography data collection. We recruited fewer participants than our target (n=10/23; 43.5%), with the actual or imminent death of eligible patients (n=6; 26.1%) being the main reason for nonrecruitment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Feasibility Results\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eCriteria and target\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eTarget achieved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cem\u003eEligibility:\u003c/em\u003e \u0026ge;10% of screened patients with a new reported PI are eligible for recruitment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e23/140 (16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cem\u003eRecruitment\u003c/em\u003e: \u0026ge;50% of eligible patients are recruited\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e10/23 (43.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cem\u003eDigital photography:\u003c/em\u003e \u0026ge;95% of recruited participants\u0026rsquo; PI were photographed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e13/13 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe sample of 10 (43.5%) dying adults had 13 new wounds reported in RiskMan. Males (n=7; 70.0%) were mostly recruited, and metastatic cancer was the primary diagnosis for most participants (n=8; 80.0%). The median participant age was 74.0 years (IQR: 63;8; range 44\u0026ndash;95 years). All but one participant (n=9; 90.0%) were in specialist palliative care units. Six (60%) patients provided written study consent with the remaining (n=4; 40.0%) obtained from a partner or adult child. The sample and wound characteristics are presented in Table 3. Most participants (n=7; 70.0%) presented with one new wound, while three (30.0%) participants each had two new wounds. Digital photographs were collected on the 13 (100.0%) wounds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEOL wound assessment tool inter-rater reliability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe did not meet our interrater reliability target of \u0026ge;90% agreement. Using the EOL wound assessment tool, the RA assessed all 13 (100.0%) wounds as EOL wounds. Meanwhile, an independent blinded outcome assessor determined eight (61.5%) of the wounds were EOL wounds, with the remainder assessed as a PI (Table 3). One (10.0%) participant, with two wounds, was assessed by the independent outcome assessor as having an EOL wound on one anatomical site and a PI on another site. Disagreement between the raters occurred for five (38.5%) wounds, all located on the heels and toes. The interrater reliability (EOL wound Yes/No) between the RA and blinded outcome assessor using Cohen\u0026apos;s Kappa coefficient could not be calculated because no variation was observed in the RA rating data (Yes=100.0%), resulting in this being handled as a constant in the SPSS analysis (38). As such, only a percentage agreement was calculated, with a 61.5% (n=8/13) interrater reliability level of agreement, which was considered moderate (38).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"978\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 978px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e\u0026nbsp; Sample and wound characteristics (\u003cem\u003en\u003c/em\u003e = 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003e(M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eStudy consent obtained from\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ePrimary diagnosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNumber of observed wound/s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eWound developed quickly in the absence of pressure (Yes/No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eReceived regular PI prevention care\u003c/p\u003e\n \u003cp\u003e(Yes/No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eWound location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eObserved wound characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eEOL wound or Pressure injury rating\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eInter-rater agreement\u003c/p\u003e\n \u003cp\u003e(Yes/No)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eResearch Assistant\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eOutcome Assessor\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eMetastatic oesophageal cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eCoccyx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: pink, purple and maroon\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: butterfly and pear\u003c/li\u003e\n \u003cli\u003eWound appearance: stage II PI (full thickness skin loss)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ePyloric adenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eSacro-coccygeal-lumbar region (bilateral)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: red, black, purple, and maroon\u003c/li\u003e\n \u003cli\u003eShape: horseshoe and striations\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact) and a stage II PI (full thickness skin loss)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eMetastatic lung cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eSacrum (bilateral)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: pink, purple and maroon\u003c/li\u003e\n \u003cli\u003eShape: butterfly\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact) and a stage II PI (blister with partial-thickness skin loss)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eMetastatic prostate cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eButtock (bilateral)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: red and pink\u003c/li\u003e\n \u003cli\u003eShape: three linear striations\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eBladder cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eLumbar spine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: red\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: linear striation\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAdult child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eSudden clinical deterioration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eRight buttock (unilateral)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: red\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: one linear striation\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eRight posterior upper thigh\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: red\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: two linear striations\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePartner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eMetastatic pancreatic cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eSacrum (bilateral)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: red, deep darkening skin with white center\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: horseshoe\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eLateral right foot and heel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: pink, purple and maroon\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: linear striations\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePressure injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePartner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eMetastatic cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eLeft greater metatarsal joint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: red, pink, purple and maroon\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: circular\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWound appearance: stage II PI (blister with partial-thickness skin loss)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePressure injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eMetastatic Colorectal Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eLeft heel\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: pink, purple and maroon\u003c/li\u003e\n \u003cli\u003eShape: round\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePressure injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eRight heel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: pink, purple and maroon with a white center\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: pear\u003c/li\u003e\n \u003cli\u003eWound appearance: stage II PI (full thickness skin loss)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePressure injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePartner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eSepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eRight heel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-blanchable\u003c/li\u003e\n \u003cli\u003eColour: pink, purple and maroon\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShape: circular\u003c/li\u003e\n \u003cli\u003eWound appearance: bruise like appearance (skin intact)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eEOL wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePressure injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 978px;\"\u003e\n \u003cp\u003eAbbreviations: EOL: end-of-life; F: female; M: male; PI: pressure injury\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eEOL wound characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe eight EOL wounds developed quickly on patient\u0026rsquo;s sacrum (bilateral) (n=2; 25.0%), lumbar spine (n=2; 25.0%), coccyx (n=1; 12.5%), unilateral buttock (n=1; 12.5%), bilateral buttock (n=1; 12.5%) and upper thigh (n=1; 12.5%). Most (n=7; 87.5%) of the EOL wounds had a bruise-like appearance, and all (n=8; 100.0%) were nonblanchable. The skin was intact in five (67.5%) of the EOL wounds and their colour ranged from a single red colour or multiple colours including red, black, pink, purple and maroon and white in the centre of the wound. Various shapes were observed, with linear striations being the most common (n=5; 62.5%). Other shapes included butterfly (n=2; 25.0%), horseshoe (n=2; 25.0%), and pear (n=1; 12.5%) with and without striations (Figure 2 A-D). We did not collect participant data from time to death.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis feasibility study evaluated our study protocol in a sample of dying adult inpatients at three large Queensland hospitals. Although we did not reach our target sample size, we did meet the remaining primary study outcomes. During this study, we gained valuable insights regarding data collection, recruitment and research staff training, which will inform the development of a study protocol for a larger multisite observational study to test the inter- and intrarater reliability of our EOL wound assessment tool.\u003c/p\u003e \u003cp\u003eDying adult patients with a new PI were our target population. Using our study criteria, we achieved an eligibility rate of 16.3%, exceeding our\u0026thinsp;\u0026ge;\u0026thinsp;10% target. We based our study eligibility rate of \u0026ge;\u0026thinsp;10% on the 2.7% Kennedy terminal ulcer incidence rate reported in cancer patients admitted to hospice care (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), a similar cohort and setting used in our study. Our findings support recent research that found 17.3\u0026ndash;19.7% of dying patients developed a Kennedy terminal ulcer or unavoidable PI (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Yet, there is limited reliable EOL wound prevalence and incidence data available in the published literature (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), with estimates varying from 2.0 to 56.0% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) from a handful of observational studies across a range of clinical settings (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Accurately identifying EOL wounds in dying adults will help to reduce the misclassification of PI, guide clinical care and resource allocation, and potentially save money for healthcare organisations (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). As such, further inter- and intrarater reliability testing of our EOL wound assessment tool is needed. Given our encouraging results, we will retain the study eligibility criteria in a larger research project.\u003c/p\u003e \u003cp\u003eWe successfully collected the digital photographs of the reported wounds including those located on the sacrum and buttocks. We attribute this success to our extensive experience of sacral photography in several randomised controlled trials and recruiting registered nurses to gather this data (\u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). This experience informed the RA training on recruitment, consent and photography including potential ethical and legal issues (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). During recruitment, the RA and potential participant/family member discussed the role of photography in data collection and analysis, who (i.e., the RA) and how the photographs would be taken (i.e., patient comfort, de-identified, minimal skin exposure, positioning) (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) and its intended use (i.e., manuscripts, conference presentations) (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Patient clinical photography is used as standard practice to monitor conditions in dermatology (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e), mental health (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), plastic surgery (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) and as a research data collection method (\u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Evidence suggests most patients have a positive attitude toward photography for clinical and education purposes (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) yet, for a handful of our eligible study patients, privacy concerns regarding the photographs were one reason for recruitment refusal. A 2020 qualitative survey of 71 patients also found privacy and confidentiality concerns around photography informed study refusal (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). In a larger study, we will use photography to collect data in a larger study and train the RAs on its legal and ethical issues including a participant\u0026rsquo;s right to refuse.\u003c/p\u003e \u003cp\u003eWe did not achieve our recruitment target of \u0026ge;\u0026thinsp;50% largely because seven eligible patients either died or were close to death at the time of recruitment. Conducting clinical research with dying individuals is challenging (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and requires the timely identification of living participants and local clinician and manager support (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In our study, screening the RiskMan database for potential participants was useful, but we experienced a delay of up to 24-hours between the time clinicians entered the data on the new PI, to when we conducted the daily screening. The fast-developing nature of EOL wounds in the hours or days prior to a person\u0026rsquo;s death was a major challenge in our study which likely contributed to our high rate of \u0026lsquo;near-miss\u0026rsquo; recruitments. When conducting research with patients in palliative care units, barriers to recruitment include clinician gatekeeping and ethical concerns about burdening patients can result in high participant refusal rates (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Yet, in our study, we received positive support from clinicians and managers in the recruited clinical units, which resulted in some staff directly contacting the researchers about potential participants. All our research team and the RAs were affiliated with the three study sites, either as direct employees or an adjunct position, and had collegial relationships with many of the staff in the recruited units, which likely contributed to our positive experience. In addition, many of the palliative care clinicians in our recruited units supported our research because they had extensive experience with EOL wounds including documenting them as a PI in the RiskMan database. In a future study, we will continue to foster collaborations with staff and clinical leaders at potential study sites (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) to build research cross-pollination and develop strategies to increase participant recruitment. In addition, we will invite consumers receiving palliative care and their families as members of our research team and to codesign a future study (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe did not achieve our total target sample size of 30 participants. However, our experience of screening 140 patients and achieving a sample of 10 dying patients was considered sufficient to test the feasibility criteria for a larger study. A lack of research funding was the main reason for not achieving our goal, reducing our access to the resources needed to complete the project. This resulted in ad-hoc screening, missed recruitment opportunities and two data collection stoppages lasting 16 months. In 2022, we secured research funding, enabling us to train a team of RAs to collect daily data for 10 months resulting in increased participant identification and recruitment. It is well documented that EOL wound research is grossly underfunded, which limits research knowledge development and has clinical implications (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Globally, the number of older people and those with chronic health conditions is rapidly growing, placing increased pressure on palliative care in community and healthcare settings (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Recruiting dying patients into research projects, as participants or consumers, is often logistically and uniquely challenging (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). Gaining consent directly from study participants is always the preferred legal and ethical option (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). In our study, 60% of dying patients were willing and able to provide written study consent. This specific population is under-represented in the research literature, so study consent processes require a balance between appropriate protections, and minimising study exclusion, which could limit patient access to safe and effective interventions (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Evidence confirms that many dying adults want to participate in clinical research as an act of \u0026lsquo;giving back\u0026rsquo; (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Consenting dying patients into research projects requires RAs to have specific knowledge and skills on how to compassionately engage with potential participants and family members (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). As such, we recruited registered nurses with palliative care experience and trained them in obtaining consent from dying patients in a tailored and supportive manner, an approach that contributed to our overall study success.\u003c/p\u003e \u003cp\u003eOur interrater reliability percentage agreement between the RA and blinded outcome assessor did not reach our target. We found the difference in ratings occurred at wounds located on the heels and toes, a known location for EOL wound development (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Evidence suggests the differentiation between an avoidable PI and unavoidable EOL wound is based on clinician judgement following an evaluation of care (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Differences in clinical judgement and experience between the raters might in part, explain our findings. The blinded outcome assessor, a palliative care clinical leader, was very familiar with EOL wounds, while our RAs, with 1\u0026ndash;3 years clinical palliative care experience and had some knowledge of these wounds. The independent outcome assessor determined one participant with two wounds had an EOL wound as well as a PI. Clinical judgement is a multifaceted and complex concept that requires theoretical knowledge, data, years of clinical experience, and reflection that leads to pattern recognition (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). In a future larger study, we will obtain resources to support the employment of two experienced palliative care nurses to undertake independent and concurrent bedside clinical assessments, thus replicating real-world clinical practice.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWe acknowledge that this feasibility study has limitations. Due to limited funding and resources, our data collection period was extended and interrupted. Also, conducting the research in medical settings did not yield the recruitment results we had hoped for. Future research focussing solely on palliative care units, which have a higher number of dying patients, is one way to increase our recruitment and efficiently use research resources. Although our target sample size was not reached, during the 18-month data collection period we garnered sufficient information to rigorously test the study protocol and learn valuable lessons that will inform a larger study. We acknowledge the lack of variation in the outcome data limited our interrater reliability reporting to percentage agreement, which does not take into account if either rater \u0026lsquo;guessed\u0026rsquo; the outcome (EOL wound Yes/No) (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). However, a Cohen Kappa calculation, which accounts for the possibility of guessing, also has limitations by assuming the raters are independent (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The outcome assessor was blinded to the RA outcome yet we cannot be certain if the results of both raters were biased based on the study participant (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Our efforts to reduce detection bias included independent assessments, blinding of the outcome assessor, and the use of wound photography.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis feasibility study aimed to test the recruitment procedures and to undertake interrater reliability of our EOL wound assessment tool in dying hospital patients. Moderate agreement in the identification of an EOL wound was achieved, with the blinded outcome assessor determining one participant as having both an EOL wound and PI. Although undertaking clinical research in dying patients is challenging, following a few minor modifications to the protocol and setting selection, a larger multisite study, testing the inter- and intrarater reliability of the EOL wound assessment tool, is feasible. Differentiating between avoidable PI and unavoidable EOL wounds in dying patients is an urgent clinical need. Our EOL wound assessment tool has the potential to decrease PI misclassification and help clinicians make informed decisions regarding the delivery of wound care in dying patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEOL: end-of-life\u003c/p\u003e\n\u003cp\u003eF: female\u003c/p\u003e\n\u003cp\u003eIQR:\u0026nbsp;interquartile range\u003c/p\u003e\n\u003cp\u003eM: male\u003c/p\u003e\n\u003cp\u003ePI: pressure injuries\u003c/p\u003e\n\u003cp\u003eRA: research assistant\u003c/p\u003e\n\u003cp\u003eSD:\u0026nbsp;standard deviation\u003c/p\u003e\n\u003cp\u003eSTROBE: Strengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank the participants, and their family members involved in this research. We would also like to acknowledge the ongoing support of the managers and clinical staff in the recruited clinical units.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u0026nbsp;\u003c/strong\u003eA 2023 Griffith University School of Nursing and Midwifery\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eseed grant supported part of the study data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT roles:\u003c/strong\u003e Conceptualisation-SL, RW, JH, G R-B, TH, JS, BG; Data curation-SL; Formal analysis-SL; Funding acquisition- SL, RW, G R-B, BG; Investigation-SL; Methodology: SL, RW, JH, G R-B, BG; Project administration-SL; Writing - original draft-SL; Writing - review \u0026amp; editing: RW, JH, G R-B, TH, JS, BG\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author, [SL]. The data are not publicly available due to ethical restrictions pertaining to the privacy of research participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe confirm that the data collection, including photographs, data analysis and storage were performed in accordance with relevant guidelines and regulations. Study ethics approval was granted from the Gold Coast University Hospital and Griffith University Human Research Ethics Committees (hospital: HREC/2020/QGC/54403; university: 2020/379). Prior to recruitment, study information was provided. Prior to data collections, an informed written (signed) consent was obtained from participants, their family member or legal guardian.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication of photographs was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Pressure Injury Advisory Panel EPUAP, Pan Pacific Pressure Injury Alliance, . Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline: The International Guideline Online2025 [4th Edition:[Available from: https://internationalguideline.com/the-international-guideline\u003c/li\u003e\n\u003cli\u003eSibbald RG, Ayello E. Results of the 2022 wound survey on skin failure/end-of-life terminology and pressure injuries. Adv Skin Wound Care. 2023;36(3):151-7.\u003c/li\u003e\n\u003cli\u003eMelnychuk I, Servetnyk I. Kennedy Terminal Ulcers and Trombley-Brennan Terminal Tissue Injuries: mystery solved? Adv Skin Wound Care. 2024;37(5):233-7.\u003c/li\u003e\n\u003cli\u003eLevine JM. Terminal Ulcer terminology: a critical reappraisal. Wound Manag Prev. 2019;65(8):44-7.\u003c/li\u003e\n\u003cli\u003eOlshansky K. \u0026ldquo;Kennedy terminal ulcer\u0026rdquo; and \u0026ldquo;skin failure,\u0026rdquo; where are the data? J Wound Ostomy Continence Nurs. 2010;37(5):466-67.\u003c/li\u003e\n\u003cli\u003eMiller M. The death of the Kennedy terminal ulcer. J Am Coll Clin Wound Spec. 2016;8(1-3):44-6.\u003c/li\u003e\n\u003cli\u003eMitchell A, Elbourne S. Pressure ulcers at the end of life. Br J Community Nurs. 2022;27:S14-S8.\u003c/li\u003e\n\u003cli\u003eSibbald RG, Krasner D, Lutz J. SCALE: Skin Changes at Life\u0026apos;s End: final consensus statement: October 1, 2009. Adv Skin Wound Care. 2010;23(5):225-38.\u003c/li\u003e\n\u003cli\u003eAyello E, Sibbald RG. CMS guidance for long-term care Section M: Terminal ulcers and pressure injuries. Adv Skin Wound Care. 2024;37(5):230-.\u003c/li\u003e\n\u003cli\u003eJakobsen T, Pittureri C, Seganti P, Borissova E, Balzani I, Fabbri S, et al. Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: a multicentre prospective cohort study. Int Wound J. 2020;17(3):641-9.\u003c/li\u003e\n\u003cli\u003ePalese A, Trevisani B, Guarnier A, Barelli P, Zambiasi P, Allegrini E, et al. Prevalence and incidence density of unavoidable pressure ulcers in elderly patients admitted to medical units. J Tissue Viability. 2017;26(2):85-8.\u003c/li\u003e\n\u003cli\u003eLatimer S, Walker RM, Ray-Barruel G, Shaw J, Mackrell K, Hunt T, et al. Defining and describing Terminal Ulcers in adults at end of life: an integrative review. Adv Skin Wound Care. 2022;35(4):225-33.\u003c/li\u003e\n\u003cli\u003eKennedy K. The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 1989;2(2):44-7.\u003c/li\u003e\n\u003cli\u003eTrombley K, Brennan MR, Thomas L, Kline M. Prelude to Death or Practice Failure? Trombley-Brennan Terminal Tissue Injuries. Am J Hosp Palliat Med. 2012;29(7):541-5.\u003c/li\u003e\n\u003cli\u003eAyello E, Levine J, Langemo D, Kennedy-Evans K, Brennan M, Sibbald RG. Reexamining the literature on terminal ulcers, SCALE, skin failure, and unavoidable pressure injuries. Adv Skin Wound Care. 2019;32(3):109-21.\u003c/li\u003e\n\u003cli\u003eRoca-Biosca A, Rubio-Rico L, De molina-Fern\u0026aacute;ndez M, Martinez-Castillo J, Pancorbo-Hidalgo P, Garc\u0026iacute;a-Fern\u0026aacute;ndez F. Kennedy Terminal Ulcer and other skin wounds at the end of life: an integrative review. J Tissue Viability. 2021;30(2):178-82.\u003c/li\u003e\n\u003cli\u003eLatimer S, Shaw J, Hunt T, Mackrell K, Gillespie BM. Kennedy Terminal Ulcers: a scoping review. J Hosp Palliat Nurs. 2019;21(4):257-63.\u003c/li\u003e\n\u003cli\u003eKennedy-Evans K. Understanding the Kennedy Terminal Ulcer. Ostomy Wound Manage. 2009;55(9):6-.\u003c/li\u003e\n\u003cli\u003eSezgin D, Geraghty J, Graham T, Blomberg K, Charnley K, Dobbs S, et al. Defining palliative wound care: a scoping review by European Association for Palliative Care wound care taskforce. J Tissue Viability. 2023;32:627-34.\u003c/li\u003e\n\u003cli\u003ede Carvalho M, Xavier \u0026Eacute;, Pereira I, Carneiro R. Nursing care for patients affected by Kennedy Terminal Ulcer: integrative review. Int J Dev Res. 2020;10(10):41760-3.\u003c/li\u003e\n\u003cli\u003eNesovic A. Kennedy Terminal Ulcer: a retrospective chart review of ulcers in the hospice setting and educating providers and nurses on the importance of skin changes at life\u0026apos;s end. Montana, USA: Montanna State University; 2016.\u003c/li\u003e\n\u003cli\u003eLevine J. Unavoidable pressure injuries, terminal ulceration, and skin failure: in search of a unifying classification system. Adv Skin Wound Care. 2017;30(5):200-2.\u003c/li\u003e\n\u003cli\u003eFerris A, Price A, Harding K. Pressure ulcers in patients receiving palliative care: a systematic review. Pall Med. 2019;33(7):770-82.\u003c/li\u003e\n\u003cli\u003eDi Maio V, Di Maio T. Homicide by decubitus ulcers. Am J Forensic Med Pathol. 2002;23(1):1-4.\u003c/li\u003e\n\u003cli\u003eCenters for Medicare and Medicaid Services. RAI manual Minimum Data Set 3.0 Resident Assessment Instrument User\u0026rsquo;s Manual v1.18.11 2023 [Available from: https://www.cms.gov/medicare/quality/nursing-homeimprovement/resident-assessment-instrument-manual\u003c/li\u003e\n\u003cli\u003eLatimer S, Harbeck E, Walker RM, Ray-Barruel G, Shaw J, Hunt T, et al. Development of a wound assessment tool for use in adults at end of life: a modified Delphi Study. Adv Skin Wound Care. 2023;36(3):142-50.\u003c/li\u003e\n\u003cli\u003eCohen L, Manion L, Morrison K. Validity and reliability. Research Methods in Education. 8th Edition ed. London, UK: Routledge; 2017. p. 245-84.\u003c/li\u003e\n\u003cli\u003eLeon A, Davis L, Kraemer HC. The role and interpretation of pilot studies in clinical research. J Psychiatr Res. 2011;45(5):626-9.\u003c/li\u003e\n\u003cli\u003eBloomer M, Hutchinson A, Brooks L, Botti M. Dying persons\u0026rsquo; perspectives on, or experiences of, participating in research: an integrative review. Pall Med. 2018;32(4):851-60.\u003c/li\u003e\n\u003cli\u003eLancaster G, Thabane L. Guidelines for reporting non-randomised pilot and feasibility studies. Pilot Feasibility Stud. 2019;5(114):1-6.\u003c/li\u003e\n\u003cli\u003eVon Elm E, Altman D, Egger M, Pocock S, G\u0026oslash;tzsche PC, Vandenbroucke J. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495-9.\u003c/li\u003e\n\u003cli\u003eQueensland Health. My health, Queensland\u0026rsquo;s future: Advancing health 2026. Brisbane; 2016.\u003c/li\u003e\n\u003cli\u003eNixon J, Cranny G, Bond S. Pathology, diagnosis, and classification of pressure ulcers: comparing clinical and imaging techniques. Wound Repair Regen. 2005;13(4):365-72.\u003c/li\u003e\n\u003cli\u003eViera A, Garrett J. Understanding interobserver agreement: the kappa statistic. Fam Med. 2005;37(5):360-3.\u003c/li\u003e\n\u003cli\u003eHarris P, Taylor R, Minor B, Elliott V, Fernandez M, O\u0026apos;Neal L, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208.\u003c/li\u003e\n\u003cli\u003eSch\u0026uuml;ttengruber G, Gro\u0026szlig;sch\u0026auml;dl F, Lohrmann C. A consensus definition of End of Life from an international and interdisciplinary perspective: a Delphi panel study. J Palliat Med. 2022;25(11):1677-85.\u003c/li\u003e\n\u003cli\u003eIBM Corp. IBM SPSS Statistics for Windows. Armonk, NY.2022.\u003c/li\u003e\n\u003cli\u003eMcHugh ML. Interrater reliability: The kappa statistic. Biochemia Medica. 2012;22(3):276-82.\u003c/li\u003e\n\u003cli\u003eBrennan M, Thomas L, Kline M. Prelude to death or practice failure? Trombley-Brennan terminal tissue injury update. Am J Hosp Palliat Med. 2019;36(11):1016-9.\u003c/li\u003e\n\u003cli\u003eBrennan M, Trombley K. Kennedy terminal ulcers: a palliative care unit\u0026apos;s experience over a 12-month period of time. WCET J. 2010;30(3):20-2.\u003c/li\u003e\n\u003cli\u003ePadula W, Delarmente B. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J. 2019;16(3):634-40.\u003c/li\u003e\n\u003cli\u003eWalker RM, Aitken L, Huxley L, Juttner M. Prophylactic dressing to minimize sacral pressure injuries in high-risk hospitalized patients: a pilot study. J Adv Nurs. 2015;71(3):688-96.\u003c/li\u003e\n\u003cli\u003eLatimer S, Walker RM, Chaboyer W, Thalib L, Coyer F, Deakin J, et al. Prophylactic dressings to prevent sacral pressure injuries in adult patients admitted to intensive care units: A three-arm feasibility randomized controlled trial. Intensive Crit Care Nurs. 2024;84:103746.\u003c/li\u003e\n\u003cli\u003eWalker RM, Chaboyer W, Cooke M, Whitty J, Thalib L, Lockwood I, et al. EffEctiveness of Prophylactic foam dressings in the prevention of sacral pressure injuries in at-risk hospitalised patients: the EEPOC trial. Trials. 2023;24(1):70-82.\u003c/li\u003e\n\u003cli\u003eLatimer S, Chaboyer W, Walker RM, Thalib L, Deakin J, Gillespie BM. Prophylactic dressings for preventing sacral pressure injuries in adult intensive care unit patients: a randomised feasibility trial. Aust Crit Care. 2024:101133.\u003c/li\u003e\n\u003cli\u003eClark A, Prosser J, Wiles R. Ethical issues in image-based research. Arts \u0026amp; Health. 2010;2(1):81-93.\u003c/li\u003e\n\u003cli\u003ePersichetti P, Simone P, Langella M, Marangi G, Carusi C. Digital photography in plastic surgery: how to achieve reasonable standardization outside a photographic studio. Aesthet Surg J. 2007;31:194-200.\u003c/li\u003e\n\u003cli\u003eKashetsky N, Mar K, Liu C, Rivers J, Mukovozov I. Photography in dermatology: a scoping review: Practices, skin of color, patient preferences, and medical‐legal considerations. JDDG. 2023;21(10):1102-7.\u003c/li\u003e\n\u003cli\u003eKim W, Sivesind T. Patient perceptions of dermatologic photography: scoping review. JMIR dermatology. 2022;5(1):e33361.\u003c/li\u003e\n\u003cli\u003eBuchan C. Therapeutic benefits and limitations of participatory photography for adults with mental health problems: a systematic search and literature review. J Psychiatr Ment Health Nurs. 2020;27(5):657-68.\u003c/li\u003e\n\u003cli\u003eTian W, Porras Fimbres D, Tran M, Zeng S, Gnaedinger A, Kaplan S, et al. Quality and reliability of 2D and 3D clinical photographs in plastic surgery: a scoping review. Aesthet Plast Surg. 2025:1-11.\u003c/li\u003e\n\u003cli\u003eWyatt K, Finley A, Uribe R, Pallagi P, Willaert B, Ommen S, et al. Patients\u0026apos; experiences and attitudes of using a secure mobile phone app for medical photography: qualitative survey study. J Med Internet Res. 2020;22(5):e14412.\u003c/li\u003e\n\u003cli\u003eBlum D, Inauen R, Binswanger J, Strasser F. Barriers to research in palliative care: a systematic literature review. Prog Palliat Care. 2015;23(2):75-84.\u003c/li\u003e\n\u003cli\u003eVirdun C, Luckett T, Gilmore I, Brassil M, Lilian R, Lorenz K, et al. Involving consumers with palliative care needs and their families in research: a case study. Collegian. 2019;26(6):645-50.\u003c/li\u003e\n\u003cli\u003eEtkind S, Bone A, Gomes B, Lovell N, Evans C, Higginson I, et al. How many people will need palliative care in 2040? Past trends, future projections and implications for services. BMC Med. 2017;15(102).\u003c/li\u003e\n\u003cli\u003eDumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison R. The growth of palliative care in US hospitals: a status report. J Palliat Med. 2016;19(1):8-15.\u003c/li\u003e\n\u003cli\u003eBoland J, Currow D, Wilcock A, Tieman J, Hussain J, Pitsillides C, et al. A systematic review of strategies used to increase recruitment of people with cancer or organ failure into clinical trials: implications for palliative care research. J Pain Symptom Manage. 2015;49(4):762-72.\u003c/li\u003e\n\u003cli\u003eNational Health and Medical Research Council, Australian Research Council, Australian Vice-Chancellors\u0026apos; Committee. National statement on ethical conduct in human research. Canberra, Australia2007-updated 2018 [cited Commonwealth of Australia. 1-101]. Available from: https://www.nhmrc.gov.au/research-policy/ethics/national-statement-ethical-conduct-human-research.\u003c/li\u003e\n\u003cli\u003eBlack J, Edsberg L, Baharestani M, Langemo D, Goldberg M, McNichol L, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel consensus conference. Ostomy Wound Manage. 2011;57(2):24-37.\u003c/li\u003e\n\u003cli\u003eConnor J, Flenady T, Massey D, Dwyer T. Clinical judgement in nursing: an evolutionary concept analysis. J Clin Nurs. 2023;32(13-14):3328-40.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"skin assessment, end-of-life, Kennedy terminal ulcer, palliative care, skin failure, terminal ulcer, pressure injury","lastPublishedDoi":"10.21203/rs.3.rs-6241301/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6241301/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e End-of-life (EOL) wounds, including unavoidable pressure injuries (PIs) and skin failure, are similar to PIs. Differentiating between these wounds is difficult, so we developed an EOL wound assessment tool for use in dying adults to aid clinicians. \u0026nbsp;The study aim was to determine the feasibility of a larger multisite study by testing the study protocol and establishing the interrater reliability of a new EOL wound assessment tool.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eThis feasibility study was conducted in medical and palliative care units at three hospitals across southeast Queensland, Australia. We gathered quantitative data on study screening, recruitment, consent, and data collection procedures in dying hospitalised adult patients with a new pressure injury (PI). We recruited and trained four research assistants (RAs) and an independent blinded outcome assessor. Following recruitment, clinical data and a deidentified wound photograph were collected. The RAs used the EOL wound assessment tool to determine if the PI was an EOL wound. An off-site independent blinded outcome assessor accessed the same research data and undertook the same assessment using the EOL wound assessment tool. Frequencies and percentages were computed for the feasibility outcomes. Cohen’s kappa statistic was calculated to determine the interrater reliability agreement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eOver 20 months, 140 patients with a new PI were screened, with 23 (16.4%) eligible for recruitment, exceeding our ≥10% target. Ten (43.5%) participants were recruited, which fell short of our ≥50% target, with study refusal and imminent death being the reasons for nonrecruitment. Among the 10 recruited study participants, 13 wounds were observed on the sacrum, coccyx, and lower extremities. The interrater reliability between the two assessors was moderate (n=8/13; 61.5%), with disagreement on five wounds, all located on the heels and toes. One participant with two wounds, was assessed by the independent outcome assessor as having an EOL wound and a PI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003eWith minor study protocol adjustments, conducting a larger multisite study testing the inter- and intrarater reliability of the EOL wound assessment tool is feasible. Differentiating between PI and unavoidable EOL wounds in dying patients is a clinical imperative that will help clinicians make informed comfort-based clinical decisions.\u003c/p\u003e","manuscriptTitle":"An end-of-life wound assessment tool for dying hospitalised adults: A feasibility study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 09:51:37","doi":"10.21203/rs.3.rs-6241301/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-16T08:47:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-13T23:11:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9664819113808553796826552458008862143","date":"2025-03-26T14:24:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-23T13:58:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136566227330314072143384510355311281087","date":"2025-03-23T12:56:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-22T02:20:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-19T16:32:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-19T14:34:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-19T14:30:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-03-17T05:41:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03058d68-088f-4a27-a779-6149f42eeb32","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T16:47:01+00:00","versionOfRecord":{"articleIdentity":"rs-6241301","link":"https://doi.org/10.1186/s12904-025-01853-9","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2025-07-29 16:38:14","publishedOnDateReadable":"July 29th, 2025"},"versionCreatedAt":"2025-04-01 09:51:37","video":"","vorDoi":"10.1186/s12904-025-01853-9","vorDoiUrl":"https://doi.org/10.1186/s12904-025-01853-9","workflowStages":[]},"version":"v1","identity":"rs-6241301","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6241301","identity":"rs-6241301","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}