Terminal ulcers in end-of-life care: a scoping review

Terminal ulcers in end-of-life care: a scoping review | 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 Terminal ulcers in end-of-life care: a scoping review Ilaria SAGUATTI, Romina BALDESSARINI, Dalia CALEFFI, Domenico CANNIZZARO, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8344060/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jan, 2026 Read the published version in BMC Palliative Care → Version 1 posted 12 You are reading this latest preprint version Abstract Background: In the final stage of life, the skin may fail, leading to the development of terminal ulcers. These ulcers are considered unavoidable, since they occur despite all pressure-relieving interventions being implemented and the best quality of care being provided. However, they are often misdiagnosed as pressure injuries, since healthcare professionals are not always adequately prepared for this topic. Thus, effective palliative care and palliative wound care is not provided and prevalence data is missed, despite it being considered a solid indicator of the quality of nursing care. This work aims to clarify the concept of the unavoidability of these wounds, understand the terminology used and describe what is currently known about diagnostic criteria and assessment tools, prevention, management and aetiology of these wounds as well as clinicians’ understanding of the phenomenon. Methods: To achieve this goal a scoping review was performed. Following Arksey and O’Malley’s framework and Joanna Briggs Institute guidelines, we systematically searched the PubMed, Scopus, CINAHL, Embase, Google Scholar, ProQuest databases, up to March 2025, without time or methodological limitations. The review incorporated studies that explicitly referenced terminal injuries occurring at the end of life, written in English. The study encompasses all patients in all healthcare settings. A narrative synthesis was performed. Results: Twenty-six studies were included in the analysis. The review summarises the huge amount of terminology applied to terminal ulcers and identifies multiple potential aetiologies. Diagnostic criteria were outlined, and considerations regarding the prevention, management, and professional education were discussed. The need for validation of assessment tools and clearer diagnostic criteria was highlighted. Conclusions: This review maps current evidence on terminal ulcers and identifies significant gaps. Future research should focus on healthcare professionals’ training, communication skills, and the early recognition and prevention of these lesions to promote dignity in end-of-life care. Nurses are responsible for the proper identification and management of terminal wounds, which raises ethical concerns about the quality of care and the principles of beneficence and non-maleficence. Although correct identification may affect reimbursement, ensuring the best possible care and a dignified end-of-life process remains the priority. Trial Registration: Not applicable. Scoping review Palliative care End-of-life care Terminal ulcer End-of-life wound Palliative wound care Skin failure Figures Figure 1 Figure 2 1. Background Palliative care is an active and holistic approach that aims to achieve the best quality of life for patients with life-threatening illness and their families or caregivers ( 1 ). Terminology such as "end-of-life", "terminally ill" or "actively dying" denote a particular phase of life in which it is imperative to acknowledge that the individual is still alive, likely afflicted by an illness that is progressively deteriorating and will ultimately result in death. As healthcare professionals, it is imperative that we continue to provide the necessary care to this person. Since palliative care’s goal is to achieve the best quality of life possible for patients facing life-limiting illnesses and their families, skin issues need to be taken into account as they frequently result into symptoms of pruritus, discomfort or pain. These symptoms can not only affect the physical well-being of the patient but also have a substantial impact on their emotional state and that of their family members. Despite knowing that, skin condition at the end of life is often a neglected area ( 2 ). Palliative wound care is recognised as a complex concept, extending beyond the management of unpleasant symptoms and not being limited to the end-of-life period. Both palliative care and palliative wound care can be applied across the whole care continuum: as the first one is suitable even during active cure, the latter is indicated for conditions involving long-standing wounds or wounds due to uncorrected physiological pathologies and it is not strictly limited to end-of-life period. A concept analysis has posited that “prevention” is an important antecedent of the concept of palliative wound care assuming that, while it may not be possible to avoid all the instances of skin breakdown, it should be possible to decrease their severity and to avoid the preventable ones ( 3 ). In the human body, the skin represents the largest and most exposed organ and about 15% of the body weight; one third of the blood supply goes to the skin to permit all its functions, which include body protection, thermal homeostasis, sensory function, endocrine and exocrine functions ( 4 ), as well as expression and not-verbal perception. Any organs of the body may undergo dysfunction at any point in life, but especially during the final stages of life or in the context of acute critical illness. As an organ, skin can fail at the end of life, showing signs and symptoms of dysfunction. The concept of skin as an organ that could fail was first advanced in the early nineties, when it was argued that, if other organs such the heart, lungs or kidneys show signs of failure, it might be possible for the same to be true of the skin. Considering that, why should pressure injuries always been seen as indicator of inadequate care, if symptoms of heart, lungs or kidneys disease are not ( 5 )? At the end of life, patients may experience different kinds of skin breakdown, some of them are considered avoidable, whilst others are not. According to the National Pressure Ulcer Advisory Panel (NPUAP) consensus conference results, held in 2011, an ulcer is considered avoidable if it develops because carers don’t implement at least one of the following parts of the care plan ( 6 ): Evaluation of the individual’s clinical conditions and assessment of the pressure injury risk factors Definition and implementation of interventions consistent with individual needs and recognized standard of practice Monitoring and evaluation of the impact of the interventions Revision of the intervention, if needed If an ulcer develops despite any of the aforementioned elements of the process have been implemented, thus it is possible to say that the ulcer is unavoidable. It’s important to note that this also means that the unavoidability of a lesion cannot be predetermined, without evaluating the whole care process ( 6 ). There are more issues concerning how to accurately recognise terminal ulcers, not only because of the complex terminology, but also because they can only be diagnosed after patient’s death. Moreover, since the aetiology is not yet fully understood and these ulcers often occur in areas exposed to pressure, they are difficult to distinguish from pressure injuries ( 7 ). The treatment of this condition should be limited to a palliative approach focusing on caring for the individual rather than curing the skin ( 2 ). It has been stated that a proper care plan should be developed according to the patient’s and, when possible, the family’s priorities, which may differ from those of the healthcare team ( 3 ). According to Emmons and Lachman (2010), possible goals of the palliative wound management are ( 3 ): Preventing the deterioration of the wound, while achieving its stabilization Promoting a clean and protected wound environment Minimizing the risk of infection or sepsis Managing pain, odour and exudate Reducing the frequency of dressing changes Controlling the risk of bleeding Preventing wound bed and periwound skin from the risk of trauma Controlling moisture and preventing maceration Eliminating pruritus The plan of care needs to be implemented by a multidisciplinary team, including different professional roles, such as nurses, physician and many others, according to the specific case ( 3 ). Even if skin care is a part of palliative care, it still exists a issue about management of terminal wounds: while pressure ulcers are considered preventable, some of the ulcers that arise at the end of life are unavoidable. In such cases, it should be considered whether to deliver skin care, what to do or what to withdraw from, according to patient’s preferences and priorities ( 8 ). Research has indicated that approximately 25% of patients receiving palliative care are affected by pressure ulcers, suggesting that the end-of-life population is more susceptible to the development of pressure injuries compared to the general population ( 9 ). However, the development of these ulcers is not always associated to shortfall in standard of care but in some cases, ulcers occur despite a proper pressure relief therapy, or an appropriate care plan, aligned with patient’s wishes ( 10 ). Furthermore, the terminology employed in relation to such ulcers constitutes an additional concern: the literature reveals a necessity to simplify the nomenclature surrounding terminal ulcers, with a view to unifying overlapping concepts and elucidating the relationship between unavoidable pressure injuries and terminal ulcers ( 11 ). In summary, there is a requirement for consistent terminology for this kind of skin ulcer ( 7 ) in order to enhance the quality of care for patients and their families: while misdiagnosing a pressure ulcer as a terminal one may result in undertreatment, inaccurate labelling patients with a terminal ulcer may cause emotional distress to patients and families ( 11 ), preventing them from receiving adequate treatment. 1.2 Aims The scoping review aims to shed light on the current state of knowledge regarding terminal ulcers, which are frequently overlooked and misclassified as other types of lesions, particularly pressure injuries ( 12 ). Specifically, the researchers want to highlight the issues of definition of the concept of unavoidability, the terminology used in relation to terminal ulcers, the diagnostic criteria and assessment tools, prevention and management, and the aetiology of this type of ulcer, for all patients in all healthcare settings. Moreover, we would like to understand the clinicians’ awareness regarding this topic and its repercussions on the quality of care. 2. Methods 2.1 Design To achieve these goals, a scoping review was chosen as the most suitable methodology, since it helps to map evidence and to clarify main concepts ( 13 ). The review followed the five-step process described by Arksey and O’Malley framework ( 14 ). First, the research question was identified. Then, relevant studies were found. Next, studies were selected. Then, the data was charted. Finally, the results were collected, summarised and reported. Moreover, the Preferred Reporting Items for Systematic reviews and Meta-Analysis, extended to Scoping Reviews checklist (PRISMA-ScRs) ( 15 ) and the JBI guidelines ( 16 ) were used as methodological guides for the structure of this study. 2.2 Clarifying the research question To achieve the goals of this scoping review, the following research questions were identified: How can the concept of unavoidability be defined? What is the correct terminology regarding terminal ulcers? Are there any diagnostic criteria or assessment tools that could help healthcare professionals to recognise this type of skin breakdown? Can these injuries be prevented? How should they be managed? What causes these ulcers? How aware are healthcare professionals of terminal ulcers? 2.3 Search methods Following the framework provided by the Joanna Briggs Institute ( 16 ), a search strategy as comprehensive as possible was set up, using the three-step search strategy: First of all, only two databases were used (PubMed and CINAHL) in order to identify the most appropriate keywords Then, the keywords contained in the most significant articles were analysed; a more complete search was carried out across all the included databases based on the newly identified keywords. This step was carried out with the help of a librarian Lastly, the reference lists the articles included were searched for additional sources The search string was created based on the PCC mnemonic (population, concept, context) ( 16 ): P = Population: patients of any age, at the end of life C = Concept: terminal ulcers C = Context: any settings We systematically searched PubMed, Scopus, CINAHL, Embase, Google Scholar, ProQuest databases, up to March 2025, with no time or methodological limitations. The language included was English. The search terms used were “palliative wound care”, “pressure ulcer”, “skin ulcer”, “terminal ulcer”, “Kennedy terminal ulcer”, “Trombley-Brennan terminal ulcer”. Quotation marks and the Boolean operators AND and OR were used, as shown in Table 1 . The reference lists of the identified papers were examined in order to include any other relevant sources. Table 1 presents the full electronic search strategies for each database used. Table 1 Search strategies for each database DATABASE SEARCH STRATEGY NUMBER of RECORDS Scopus (TITLE-ABS-KEY ("pressure injur*" OR "pressure ulcer*" OR "skin ulcer" OR "terminal ulcer*" OR "kennedy terminal" OR "trombley-brennan" OR "terminal injury" OR "deep injury") AND TITLE-ABS-KEY ("palliative care" OR "terminal care" OR "end of life")) OR TITLE-ABS-KEY ("palliative wound care" OR "palliative wound*" OR "palliative pressure ulcer*”) 491 PubMed (palliative wound care[title/abstract] OR palliative wound*[title] OR palliative pressure ulcer*[title]) OR ((pressure injur*[ti] OR pressure ulcer*[ti] OR skin ulcer[mesh:noexp] OR pressure ulcer[mesh] OR terminal ulcer*[title] OR kennedy[title/abstract] OR trombley-brennan[title/abstract] OR terminal injury[title] OR deep injury[title]) AND (palliative care[mesh] OR terminal care[mesh] OR terminal[title] OR palliative[title] OR end of life[title] OR terminally[title])) 354 CINAHL ("pressure injur*" OR "pressure ulcer*" OR "skin ulcer" OR "terminal ulcer*" OR "kennedy terminal" OR "trombley-brennan" OR "terminal injury" OR "deep injury") AND ("palliative care" OR "terminal care" OR "end of life") OR ("palliative wound care" OR "palliative wound*" OR "palliative pressure ulcer*") 409 Google Scholar ("pressure injury*" OR "pressure ulcer*" OR "skin ulcer" OR "terminal ulcer*" OR "kennedy terminal" OR "trombley-brennan" OR "terminal injury" OR "deep injury") AND ("palliative care" OR "terminal care" OR "end of life") OR ("palliative wound care" OR "palliative wound*" OR "palliative pressure ulcer*") 82 Embase (("pressure injur*" OR "pressure ulcer*" OR "skin ulcer" OR "terminal ulcer*" OR "kennedy terminal" OR "trombley-brennan" OR "terminal injury" OR "deep injury") AND ("palliative care" OR "terminal care" OR "end of life")):ti,ab,kw OR ((("palliative wound care" OR "palliative wound*" OR "palliative pressure ulcer*")):ti,ab,kw) 351 Proquest Database (("terminal ulcer*" OR "kennedy terminal" OR "trombley-brennan" OR "terminal injury" OR "deep injury") AND ("palliative care" OR "terminal care" OR "end of life")) OR ("palliative wound care" OR "palliative wound*" OR "palliative pressure ulcer*") 47 Total number of records 1 734 2.4 Inclusion and Exclusion Criteria Inclusion criteria Broad inclusion criteria were selected to avoid the losing of important evidence: Studies that make explicit reference to terminal injuries that occur at the end of life Studies encompassing individuals of all age groups, cared for in any setting Any methodology No restrictions on the publication period Studies published in English Research papers for which the full text is available Exclusion criteria On the other hand, the following criteria were used not to include a research paper in this scoping review: Studies dealing with injuries that arise in the final stages of life different from terminal ulcers, such as fungating malignant wounds Studies published in a language different from English Studies for which the full text cannot be found 2.5 Study selection Initially identified references (n = 1 734) were imported into Rayyan, a free software aimed to assist researchers in the first phases of a review. After the duplicate removal, three researchers (D.C., D.C., I.S.) independently screened the titles and abstracts, assigning a rating to each research paper. The researchers found out a consensus about the inclusion, if it was lacking at the beginning, according to the inclusion and exclusion criteria. The selection process has been documented through the PRISMA diagram (Fig. 1). 2.6 Quality appraisal A quality appraisal of the included studies was not performed, according to the methodology ( 16 ). 2.7 Data charting The research team developed two data-charting tables to collect all the data and summarise the main results of each study included, presented as Table 2 and Table 3 . Table 2 Summary of the included studies REF TITLE, AUTHOR, YEAR METHODOLOGY DEFINITION OF THE CONCEPT OF UNAVOIDABILITY TERMINOLOGY REGARDING TERMINAL ULCERS (See Table 3 ) DIAGNOSTIC CRITERIA AND ASSESSMENT TOOLS PREVENTION AND MANAGEMENT AETIOLOGY OR RISK FACTORS AWARENESS AND EDUCATION 19 Ultrasound evaluation of Kennedy terminal ulcer: case study. Tavares Gomes, 2025 Case study It is important to emphasize that unlike pressure injuries, a KTU cannot be prevented through care, and is considered unavoidable and not attributable to substandard care. Kennedy Terminal Ulcers (KTUs) The use of ultrasound as a tool that complements the clinical examination by nurses is an important milestone for documenting this kind of ulcer. The KTU-type injury exhibited a pattern similar to the cobblestone-like appearance. KTUs are important indicators of imminent mortality, helping to clarify the need for often exclusive palliative care and corroborating the understanding of the exhaustion of therapeutic interventions, avoiding dysthanasia because of therapeutic obstinacy. Nurses involved in this case-study performed the differential diagnosis, informed the family and modified the therapeutic plan from the perspective of palliative care, anticipating death. For cardiology patients several important factors may contribute to skin failure, such as shock states with macro- and micro-hemodynamic alterations and prolonged use of vasopressors and inotropes that directly affect circulation. In this case, the healthcare team was led by a wound care nurse in the unit where the KTU was identified. The team has been strengthening ongoing education about skin prevention and wound treatment, significantly increasing the quality of records. These efforts helped to correctly identify the KTU. 7 Reexamining the literature on terminal ulcer, SCALE, skin failure, and unavoidable pressure injuries. Ayello, 2019. Narrative Review - Kennedy Terminal Ulcer (KTU) - 3:30 Syndrome - Trombley Brennan Terminal Tissue Injury (TB-TTI) - SCALE - Skin Failure - Decubitus Ominosus - Miller Pressure Equivalent Injuries RISK FATCTORS : . Chronic disease, infections, acute injuries. . Pain is associated with more pressure injuries. Having multiple terms to describe these phenomena can be confusing and may impede communication among clinicians, especially across disciplines. 26 Development of a wound assessment tool for use in adults at end of life: a modified Delphi study. Latimer, 2023. Modified Delphi study Terminal ulcers (TUs), which include KTU and TB-TTI, are considered unavoidable injuries associated with dying. TU are pear-, horseshoe- or butterfly-shaped red, black or maroon skin ulcers that quickly develop in the absence of external pressure on the buttock, sacrum, spine and extremities. TU can develop in a matter of hours from intact skin to a deep wound. TU often develop in months, weeks, days or hours before death. A panel of international wound experts developed an “End of Life Wound Assessment Tool”. 28 Prelude to death or practice failure? Trombley-Brennan terminal tissue injury update. Brennan, 2019. Retrospective study - KTU - TB-TTI - SCALE TREATMENT: TB-TTIs, as a prognosticator of death, will allow clinician to make necessary changes in the plan of care and discontinue aggressive interventions and testing, while shifting curative care to comfort care. TB-TTIs are not related to pressure. 27 SCALE: Skin Changes at Life’s End: Final Consensus Statement: October 1, 2009 Sibbald, 2010 Modified Delphi method At the end of life, failure of the homeostatic mechanisms that support the skin can occur, resulting in a diminished reserve to handle insults such as minimal pressure. Therefore, contrary to popular myth, not all PIs are avoidable. - KTU - SCALE - Skin Failure - Decubitus ominosus . Charting by exception is an appropriate method of documentation . SCALE statement describes 5 P’s for determining appropriate intervention strategies The body may react to crisis conditions by shunting blood away from the skin to these vital organs, resulting in decreased skin and soft-tissue perfusion, and a reduction of the normal cutaneous metabolic processes. Diminished tissue perfusion is the most significant risk factor for SCALE. The panel concluded that healthcare practitioners’ current comprehension of skin changes that can occur at life’s end is limited. Healthcare professionals need to facilitate communication and collaboration across care settings and disciplines; organizations need to prepare staff to identify and manage SCALE. 20 Use of electronic health records to identify factors related to skin changes in terminal patients. Chan, 2025 Retrospective study - KTU − 3:30 Syndrome - TB-TTI Skin color changes are indicative of the degree of skin ischemia. Despite the frequent occurrence of terminal ulcers on bony prominences, the literature is inconclusive whether terminal ulcer vary from pressure related injuries, which complicates the precise diagnosis and treatment of these conditions. PREDICTORS OF SCALE : . Elevated ECOG grades (ECOG (Eastern Cooperative Oncology Group) grade, also known as ECOG performance status (PS), is a scale used to assess how a patient's disease affects their daily functioning and physical ability. It ranges from 0 to 5, with 0 indicating full activity and 5 indicating death) . Higher CCI scores (Charlson Comorbidity Index, indicative of greater comorbility burden) . Decreased Braden scale, particularly before death. . The incidence of SCALE increased with age. GOALS OF CARE : . Maximize patient’s comfort and ensuring a dignified dying process. . . Conservative management of the wound, even if preventing all instances of skin breakdown might not be achievable. . Regular repositioning, effective moisture management, adequate nutrition, management of the underlying condition. . Pain management. . Document meticulously all interventions, providing evidence of the quality of care administered. . Communication with family member. The vulnerability of the skin results from inadequate blood perfusion in the skin and subcutaneous tissue, often accompanied by severe dysfunction or failure of other organ systems. SCALE doesn’t stem from external pressures or shear stress, but from intrinsic factors. 11 Unavoidable pressure injuries, terminal ulceration and skin failure: in search of a unifying classification system. Levine, 2017 Commentary The literature is unclear as to whether “terminal ulcers” are different from pressure-related injuries, even though they commonly appear over bony prominences. - Skin Failure HYPOTESIS: . Destructive pathways that share commonalities with other organs system failure, such as inflammation or fibrosis. . Genetic factors that underlie vascular responses to ischemia. Many conditions associated with unavoidable pressure injuries are present in patients in intensive care. Despite this, few intensivists would accept the terminology “terminal ulcer”. 36 Skin failure in patients with a terminal illness. Julian, 2020 Continuing -Education Article The patient who’s terminally ill and entering the final stage of the dying process is at the greatest risk for developing skin breakdown. Pressure injuries that occur in the pre-active or active phases of dying are considered terminal injuries, with unavoidable nature. - Kennedy Terminal Ulcer (KTU) - 3:30 Syndrome - Trombley Brennan Terminal Tissue Injury (TB-TTI) - SCALE - Skin Failure There are no specific biomarkers, as with other organs, to determine whether skin is compromised. Diagnosis is also complicated by the fact that both a pressure injury and skin failure can happen simultaneously. . The SCALE statement also recommends a 5 Ps approach to treatment . The treatment plan may differ as goals shift from complete wound healing to providing the patient with the best quality of life. . Controlling exudate and odor, minimizing pain, environment free of moisture . Frequent repositioning must be weighed against the potential for inflicting unnecessary pain. . Providing counseling and education so families have realistic expectations for wound healing. 24 Skin changes at life’s end: SCALE ulcer or pressure ulcer? Beldon, 2011. Narrative review Pressure damage at the end of life may be inevitable in some individuals. - SCALE - Skin Failure - Decubitus ominosus The ability of predict which patients may develop a pressure ulcer or a SCALE ulcer is currently not possible. TREATMENT : . Plan of care and documentation . Pressure-relieving support surface: not all patients find these surfaces comfortable because they may exacerbate pain, contribute towards nausea and restrict the ability of independent movement. . Total skin assessment performed regularly . Sought advice from an identified expert . Palliation of symptoms, preservation of skin, respect of patient wishes . Education for patient and family Hypoperfusion : at the end of life the patient may be unable to maintain blood pressure sufficiently to adequately perfuse the extremities and the skin. 40 Pressure ulcers at the end of life. Elbourne, 2022 Editorial Lesions appear suddenly and rapidly deteriorate from a superficial ulcer to a category 3 or 4. These ulcers can have a blush or purple color and can look like dirt or fecal remains. Bilateral presentation can cause confusion between SCALE and MASD (moisture associated skin damage), if the patient has incontinence. Lesions may begin as numerous superficial spots and then become a larger lesion in a matter of hours. GOAL OF CARE : wound management and good quality of life, rather than wound healing. Discuss wound management plan with patients and their families. Discuss the necessity for repositioning, so as to establish the best possible treatment for the individual’s end of life care. The main difference between SCALEs and pressure injuries is in etiology: SCALEs are often unavoidable and a result of multiorgan failure. Vasopressor medication may be related to the development of SCALE. PATIENTS AT RISK: those with respiratory, renal, circulatory insufficiency, hypoalbuminemia, hypoxemia, or insufficiency of two or more organs. Hypoperfusion Alteration of elimination of toxic metabolites Decreased defensive capacity of the skin Loss weight, loss appetite, cachexia, poor nutrition, reduced mobility, low albumin levels. 29 End-of-life wounds and pressure injuries in dying adults: distinguishing the difference. Latimer, 2022 Editorial End-of-life (EOL) wounds only occur in some patients who can develop pressure injuries as well. EOL wounds occur on the buttocks, sacrum, extremities and spine. They appear as pear- horseshoe- or butterfly- shaped injuries, red, black or maroon, with the skin intact or ulcerated. They develop suddenly, in days, weeks or months before a person’s death, and they rapidly progress from a Stage 1 to a Stage 4 in several hours. MANAGEMENT : Exudate containment Pain management Educate patient and families about the imminent nature of death Hypoperfusion and multi-organ system failure are thought to be contributing factors. End-of-life wound may develop in absence of pressure. Clinician’s limited awareness of EOL wounds results in their misclassification and reporting as PIs. 12 Kennedy terminal ulcer: a scoping review. Latimer, 2019 Scoping review - Kennedy Terminal Ulcer (KTU) - 3:30 Syndrome - Trombley Brennan Terminal Tissue Injury - SCALE - Skin Failure - Decubitus Ominosus - Miller Pressure Equivalent Injuries Assessing and staging KTU is difficult because of the lack of assessment tools. Treatment requires combined approach of palliative care, pressure relieving skin care, advanced wound management, wound exudate and odor management, family and staff education and counselling. Consultation with specialist wound nurses, physicians and allied health care professionals is the first step for KTU management. Educating families about possible unavailable skin changes Setting realistic wound management goals Maintaining patient’s comfort and dignity Assessing and staging KTU is difficult because of the low rate of KTU awareness among clinicians. It is recommended that only advanced clinical specialists undertake this assessment. It is vital to arise clinician’s awareness of the unavoidable nature of KTU so that realistic wound care expectations will be set. Clinicians often feel ill-prepared to have an open discussion with patients about their impelling death: educating clinicians about KTU will help them to support dying patients and their families. 37 Kennedy terminal ulcer and other skin wounds at the end of life: an integrative review. Roca-Biosca, 2021 Integrative review An unavoidable pressure injury is one that develops even if the caregiver has: evaluated the patient’s clinical condition and PI risk factors; defined and implemented interventions that are consistent with the patient’s needs and goals and with recognized practice standards; monitored and evaluated the impact of interventions; revised these approaches as appropriate. - KTU - TB-TTI - SCALE - Skin Failure There are no clinical studies or validated algorithms that allow us to determine which PUs are unavoidable. 1 Periodic monitoring and recording skin changes, in order to prevent greater deterioration 2 Prioritizing palliative care: manage symptoms, comfort and well-being 3 Wound pain management, infection prevention, avoiding perilesional maceration 4 Non aggressive care plan that seeks the welfare and comfort of patient and family 5 Emotional assistance and support to patient and family The main hypothesis is that KTU and TB-TTI are caused by skin failure or skin death. The skin failure is caused by a decrease of blood flow (hypoperfusion) and hypoxemia, produced by multiple organ failure. OTHER FACTORS THAT COULD INFLUENCE: 1 Pressure and rubbing 2 Vasopressor medication 3 Alteration in the elimination of toxic metabolites 4 Decreased defensive capacity of the skin 5 Low weight, loss of appetite, cachexia, reduced mobility, poor nutrition, low albumin levels. 6 Respiratory, renal or circulatory insufficiency, hypoalbuminemia, hypoxemia, or insufficiency of two or more organs. We are not evaluating wounds but people, so contextual elements, like the patient health status and the context of appearance, are essential for a proper differential diagnosis. It is possible that professionals’ ignorance means that this pathological entity is underdiagnosed in settings different from palliative care or long stay units. 30 Kennedy terminal ulcers and Trombley Brennan terminal tissue injuries: mistery solved? Melnychuck, 2024 Hypothesis from experts Most terminal skin changes occur in the sacral, coccygeal and gluteal areas; fewer report have described them on the lower extremities, spine or ribs. Some don’t ulcerate. Some have been observed in children on vasoactive agents. These lesions have been observed both in areas under pressure and in areas without any external pressure (eg, anterior legs) Some are symmetrical, but unilateral lesion have also been seen. Terminal skin lesions have various degree of epidermolysis with transient blistering. - KTU - TB-TTI - Decubitus ominosus Terminal ulceration develop due to hypoperfusion of tissues in the final stages of life. Everyone develops hypoperfusion before death but not everyone develops terminal skin changes. POSSIBLE CONTRIBUTING FACTORS: 1 Use of vasoactive agents 2 Hypotension 3 External pressure 3 Anatomic arterial aberrancies 4 Reperfusion injury in cases of recurrent hypotension Incidence has not been well established. Some ulceration may be unrecognized and some terminal ulcers may be mistaken for PIs. 18 Understanding the Kennedy Terminal Ulcer. Kennedy-Evans, 2009 Editorial Shaped like a pear, a butterfly or a horseshoe, usually on the coccyx or sacrum but can appear in other areas, had the color of red, yellow and black, had a sudden onset, and death was imminent. The edges are usually irregular and may develop rapidly to a Stage II, III or IV ulcer. KTU is a subset of pressure ulcers. 38 Early skin temperature characteristics of the Kennedy lesion (Kennedy terminal ulcer). Kennedy-Evans, 2023. Observational study - KTU (Kennedy lesion) - TB-TTI Early skin temperature of the KL, occurring within 24 hours of a newly identified area of discoloration. Abnormal if Relative Temperature Differential (RTD) is > + 1.2°C or <-1.2°C. There’s a lack of skin temperature change in several patient with KLs, which contrasts with the majority of the studies examining skin temperature changes of PIs. RISK FACTORS for skin failure and thus for KL are: . Multiple organ disfunction . Hypotension . Use of vasopressor . Use of mechanical ventilation . Co-morbid conditions (cardio-vascular disease, smoking, pneumonia, sepsis…) . Abnormal white cell counts . Malnutrition, low albumin levels . Immobility . Aging, that is associated with altered immune responses and changes in vascular structure 25 Avoidable & Inevitable? Skin Failure: the Kennedy Terminal Lesion. Lepak, 2012. Narrative review Not all PIs are preventable, especially those at the end-of-life. - KTU - Decubitus ominosus TREATMENT : . Pain control . Odor, infection and drainage control . Palliative wound care: the primary goal should shift to symptoms and psychological management. During the physiological process of dying, the body shunts blood from the periphery to maintain vital organs making it more difficult to prevent external stresses from damaging the integumentary. 31 Kennedy Terminal Ulcer #383. Bateman, 2019. Expert opinion - KTU - 3:30 Syndrome - Skin Failure PREVENTION : similar to the one for pressure ulcers. MANAGEMENT : . Similar to any pressure ulcers but with few unique elements . Emotional support and KTU counselling for caregivers . Individual judgement to determine the need for repositioning in dying patients . Premedicating with an as needed analgesic before repositioning . Involve more than one person to assist with the repositioning . Use of pressure-relieving surfaces in order to reduce pain . Manage odor with proper dressing (metronidazole or charcoal) Need for clear documentation. 21 Pediatric Kennedy Terminal Ulcer. Reitz, 2016. Case study KTU most commonly presents as a dark red and pear-shaped with irregular borders on the coccyx, but it may also be yellow or black and may be found in other locations. It progresses dramatically within hours to 2 weeks preceding a patient’s death. It develops rapidly in size and depth; it may appear as an abrasion or blister and can progress to a stage III or IV ulcer. Underrecognized phenomenon in children KTU is in fact distinct from PIs: identifying this difference can have a potential impact on reimbursement. Prevention : KTU develops despite use of preventive measures. Strategies to mitigate risks include: 1 Optimizing nutritional support 2 Using appropriate pressure redistribution surfaces 3 Moisture management 4 Frequent repositioning Treatment in paediatric ICU : 1 Optimize peripheral oxygen and substrate delivery 2 Mantaining skin’s acid mantle 3 Optimize child’s nutrition 4 The underlying cause of organ failure should be treated rather than using pressure redistribution. Set appropriate goals : 1 Controlling pain 2 Preventing infections 3 Managing any drainage to prevent maceration of the peri-wound skin. KTU originates from skin failure rather than from pressure or shearing (PUs). It occurs when skin, like other organ systems, exhibits increasing signs of dysfunction. Intrinsic factors : 1 hypoperfusion and ischemia, associated with multiorgan failure Risk factors are : 1. Multiple organ failure 2. Vasopressor medications 3. Respiratory failure, diabetes mellitus, hypoalbuminemia, hypoxemia, renal disease, failure of two or more organs beside the skin. Factors that contribute are : 1 Use of vasopressors 2 Use of cooling mattress 3 Anemia, malnutrition, immobility The pediatric nurse practitioner can help the team about the pathophysiology of the KTU and lead discussions about the treatment plan. 22 Nursing care plan for the Kennedy terminal ulcer patient. Case report. Alarcón-Alfonso, 2022. Case report There are no unified diagnostic criteria so information on the aetiology and pathophysiology is incomplete. The differential diagnosis of KTU is difficult because of its similarities to Pus. Priority given to patient comfort and pain control, odor management, preventing new ulcers, avoid complications, helping the family to cope with the situation. Individualized care plan. Emotional support and counselling for patient and family. Prevention : strategy similar to that of PUs is recommended. 1 Lack of training of healthcare professionals in ulcers other than PUs. 2 The use of different terms (KTU, TBTL…) is confusing as they are very similar concepts. 23 Kennedy’s terminal ulcer and pressure injury: two different aspects of medical liability related to the same injury. Garcea, 2023. Case series - KTU Medical competence: palliative therapy for local and systemic pain. Nursing competence: nurses are responsible for the correct management of lesions and treatments, together with possible complications. A correct diagnosis of a terminal lesion doesn’t fully protect against convictions because in lawsuits it is necessary to provide proper evidence for every single choice, even that of reducing mobilizations to avoid unless pain. An informed consent, possibly signed by the patient, is a necessary safeguard. 32 The Death of the Kennedy Terminal Ulcer. Miller, 2016. Expert opinion KTU describes a rapid progression of a pressure-based tissue injury or itself is an indicator of terminal status. They propose the concept of Miller Pressure Equivalent Injuries (MPEI). - KTU - Miller Pressure Equivalent Injuries The presumption that a terminal condition alone will result in a pressure-based tissue injury, despite appropriate care, is not a viable consideration because: 1 Systemic diseases have an equal effect on all body tissues 2 If a turning schedule is utilized, pressure, friction and shear would have the same effect on all the body, so why just one specific area is affected by KTU? 33 Poly Ulceration Patient Terminal: Kennedy Terminal Ulcer (KTU). Sarabia-Cobo, 2017. Expert opinion 1983: Karen Lou Kennedy coined the term KTU; 1989: first description at NPUAP. Sudden appearance of multiple PIs in elderly patients may be indicative of closeness to death Unavoidable skin breakdown which occurs in some patients as part of the dying process. Occurs not long before the death. 5 main characteristics : 1 Located in sacrococcygeal area 2 Appears as a discoloration of the skin, in the shape of a butterfly or pear 3 It’s purple, red, blue or black 4 Sudden onsets, sometimes referred to as 3:30 syndrome 5 Irregular borders 1 Differentiate KTU from PIs in order to provide optimal care to patient and family. 2 Don’t abandon the goal of avoiding the emergence of new PIs or not aggravate existing. 3 The treatment of ulcers prioritizes comfort 4 Assess the desirability of postural changes for each patient 5 Involvement of caregivers 6 Relieve pain and the smell of wound A KTU occurs when the body’s vascular system is no longer reliable to adequately perfuse the skin. 34 The Kennedy Terminal Ulcer – Alive and Well Schank, 2016. Letter to the editor Unavoidable skin breakdown which occurs in some patients as part of the dying process. - KTU - Decubitus ominosus Still unknown. It has been suggested that there may be an element of pressure: in the dying patient, the least amount of pressure might result in a major ulceration. KTU appears to be a part of a multiorgan system failure and end-stage disease. 35 Pressure ulcers at the end of life. Mitchell, 2022. Clinical comment - KTU - Decubitus ominosus - SCALE - Skin failure SKIN ASSESSMENT IN END-OF-LIFE-PATIENT: Assessment of skin integrity over bony prominences Assessment of uncommon locations Color changes or discoloration Disparities in heat, firmness and moisture Finger palpation to ascertain if erythema or discoloration is blanchable and reassessment of risk and preventative actions are recommended. MANAGEMENT . Provide the best quality of life for patients and their families . Advanced care planning discussions. . Respect of family expectations . Respect of patients’ cultural preferences . When the duration of pressure cannot be reduced, the appropriate mattress must be used to reduce the intensity . Body image should be discussed with the patient . Manage odor, infection, per-wound skin conditions . The peri-wound skin should be assessed for color and temperature . Management of pain, use of prophylactic dressing. Vasopressor medications administered at the end of life for certain diseases that divert blood flow to other vital organs may also be related to the development of SCALE. Patients at the greatest risk of SCALE and end-of-life ulcers are those with respiratory, renal or circulatory insufficiency, hypoalbuminemia, hypoxemia or insufficiency of two or more organs. Further risk factors are: hypoperfusion, alteration of the elimination of toxic metabolites, decreased defensive capacity of the skin, low weight, loss of appetite and cachexia, inadequate or poor nutrition, reduced mobility and low albumin levels. 39 Skin Failure Clinical Indicator Scale: Proposal of a Tool for Distinguishing Skin Failure From a Pressure Injury. Hill, 2020. Retrospective case control study Skin failure is a concept that include multiple similar phenomena described in the literature, as KTY, TB-TTI, SCALE. No validated assessment tools or clinical indicators are available that can assist in determining aetiology or providing a more definitive diagnosis of skin failure. Currently, discernment of wound etiology is heavily reliant on visual analysis and patient history. Risk factors: . Age, Braden score and BMI were not significant predictor of skin failure . Serum albumin level less than 3.5 g/dl . Impaired blood flow . Sepsis or multiorgan dysfunction syndrome . Vasopressor – inotrope use . Mechanical ventilation Table 3 Terminology related to terminal ulcers TITLE, AUTHOR, YEAR Kennedy Terminal Ulcer KTU 3:30 Syndrome Trombley Brennan Terminal Tissue Injury TB-TTI SCALE Skin Failure Decubitus Ominosus Miller Pressure Equivalent Injuries (MPEI) 19 Ultrasound evaluation of Kennedy terminal ulcer: case study. Tavares Gomes, 2025 KTUs commonly occur in the sacral and gluteal regions, and have a pear, butterfly or horseshoe shape with irregular borders that appear suddenly with rapid and progressive deterioration. It was documented as a hyperchromic purpuric lesion with irregular borders in the left gluteal region. KTU were first reported by Karen Kennedy in 1983, in an intermediate care unit at the Byron Health Center in the US. 7 Reexamining the literature on terminal ulcer, SCALE, skin failure, and unavoidable pressure injuries. Ayello, 2019. Definition: “a pressure ulcer that some people develop as they are dying”. The literature is not clear as so whether KTU should be considered a PI or a separate skin problem that also occur over a bony prominence. Different from a PI because it is attributable to hypoperfusion (local ischemia) of the skin, rather than the pressure. A variant of KTU Life expectancy: from 8 to 24 hours. These lesions could be confused with a DTI. The median time from identification of the injury until death was 36 hours. The 75% of patients died within 72 hours of the first identification of these skin changes. There are degrees of skin impact during the dying process and not everyone with SCALE has skin failure. Not all patients with SCALE necessarily have multi-organ failure: more research is needed to determine which diagnostic criteria should be used to document the severity and the extent of skin (as an organ) failure. Definition provided by Langemo (2006): “an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems”. Three types of SF are described: ACUTE: with an acute illness. There are no clear-cut diagnostic criteria for Acute Skin Failure (there are predictors, eg. Peripheral arterial disease, mechanical ventilation for more than 72 hours, respiratory failure, liver failure, sever sepsis or septic shock). CHRONIC: concurrently with a chronic condition END STAGE: with an end-of-life issue Definition provided by Levine (2017): “the state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiologic impairment such as hypoxia, local mechanical stresses, impaired delivery of nutrients and buildup of toxic metabolic byproducts”. Levine uses Skin Failure as a unifying concept that encompasses broader etiologies, including pressure ulcers, KTU, TB-TTI, SCALE and so on. Pressure is not a necessary component of skin failure. Jean Martin Charcot recognized some kind of ulcers that occurred at the end of life that used to precede death. Miller introduced the idea that systemic physiologic effect and local stressor, rather than just terminal status, may explain this status. There’s not a unique consensus on Miller’s assumptions. 28 Prelude to death or practice failure? Trombley-Brennan terminal tissue injury update. Brennan, 2019. Reported in 1989. KTU were described as an indicator of potential death in 6 to 8 weeks, caused by shunting the blood away from the skin to other organs, during the dying process. KTUs are considered as end stage skin failure: “a subgroup of pressure injury that may develop during the dying process”; typical measures to prevent occurrence or progression of these pressure injuries failed. They appear as full-thickness wounds. Pear shaped wounds, usually located on the sacrum, rapidly change in size and depth. Considered as Skin Failure at End of life. Originally classified as pressure injury or DTI. The skin remains intact, with purple reddish discoloration. Seen in patients ranging from 35 to 95 years old. The interval between the occurrence of the wound and the death was from 20 minutes to several days. Despite preventive measures, these lesions never progress to open wounds or wound presenting nonviable tissue. They may show a linear presentation occurring on the extremities and butterfly shapes on the sacrum. Different from KTU and DTI for the evolution (doesn’t evolve as a PI and doesn’t resolve after its appearance) and the surface area. TB-TTI is a unique, unavoidable, irreversible phenomenon occurring at the end of life. SF is an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrently to severe dysfunction or failure of other organ systems. Skin Failure is classified as ACUTE (associated with critical illness), CHRONIC (associated with chronic disease) and END STAGE (associated with end-of-life). 27 SCALE: Skin Changes at Life’s End: Final Consensus Statement: October 1, 2009. Sibbald, 2010 1989: KTU as a specific subgroup of PIs that some individuals develop as they are dying. They are usually shaped like a pear, butterfly, or horseshoe and are located predominantly on the coccyx or sacrum (but have been reported in other anatomical areas). The ulcers are a variety of colors, including red, yellow, or black; are sudden in onset; typically deteriorate rapidly; and usually indicate that death is imminent. SCALE is a mnemonic used to describe a group of clinical phenomena and should not be confused with a risk assessment tool In 2003, Langemo proposed a working definition of skin failure such as the result of hypoperfusion, creating an extreme inflammatory reaction concomitant with severe dysfunction or failure of multiple organ systems. Although the term skin failure has been introduced, it is not currently a widely accepted term in the dermatologic or the wound literature. In 1877, Charcot described a specific type of ulcer that is butterfly-shaped and occurred over the sacrum. Charcot’s writings of decubitus ominosus were basically forgotten in the medical literature until recently with renewed interest in skin organ compromise. 20 Use of electronic health records to identify factors related to skin changes in terminal patients. Chan, 2025 The term was conied in 1989. Clinical features of PIs, as sacrococcygeal or butterfly-shaped lesions with irregular borders that exhibit varying colors, were identified. Characterized by discoloration expansion irrespective of pressure relief measures. Notion introduced in 2012. It delineates a rapid alteration in skin conditions among terminal patients, even in noncompressed skin. 11 Unavoidable pressure injuries, terminal ulceration and skin failure: in search of a unifying classification system. Levine, 2017 Skin Failure The state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiologic impairment such as hypoxia, local mechanical stress, impaired delivery of nutrients, and buildup of toxic metabolic byproducts. Skin failure is a unifying concept. 36 Skin failure in patients with a terminal illness. Julian, 2020 A KTU presents on the sacrum as an irregularly shaped wound (like a butterfly or pear) that may be red, yellow, black, or purple. One of the most distinguishing features of a KTU is how quickly it can appear. It’s also much larger at the onset than other pressure injuries, initially beginning very superficially and rapidly progressing. There are five key characteristics to differentiate between a pressure injury and a KTU. A KTU is usually: • shaped like a butterfly or pear and contains irregular borders • located bilaterally on the coccyx or sacrum • initially erythematous and/or purpuric • sudden in development • noted within 2 weeks to several months before a patient’s death. Pressure is a contributing factor, with other physiologic changes such as hypoperfusion possibly potentiating the effects of pressure. A variation of the KTU, which develops more rapidly than a KTU and may initially appear as small black specks on the patient’s skin. Gets its name from a nurse’s description of the spots appearing between completion of the morning assessment and when skin is assessed later in the afternoon. 3:30 syndrome is significant because many patients who develop it have a very short life expectancy, approximately 8 to 24 hours. The TB-TTI presents as a pink, purple, or maroon discoloration of the skin that remains intact and shouldn’t be confused with a suspected deep tissue injury. The TB-TTI can occur in areas not considered to be pressure points and may appear as linear striations. The TB-TTI is a unique, irreversible phenomenon associated with end-of-life organ failure and can be predictive of impending death. Some research has shown that death occurs within 72 hours of a patient developing a TB-TTI. SCALE encompasses a range of alterations that can occur at the end of life, including cancer wounds, deep tissue injuries, gangrene, ischemic wounds, pressure injuries, skin tears, KTUs, and inflammatory and infectious wounds. This statement was the product of a panel of experts who met in 2008 with the purpose of clarifying what was known about skin breakdown in patients with a terminal illness. Although the SCALE statement does agree that skin integrity is impacted by exposure to moisture, irritants, friction, and shear, it also recognizes that skin changes occur as the result of decreased tissue perfusion, impaired skin oxygenation, mottling, and decreased skin temperature. The process in which skin, as an organ, can fail in the same way other organs in the body can fail. The skin receives up to one-third of the body’s circulating blood volume, and it’s believed that skin failure happens as blood is shunted away from the peripheral tissue to the vital organs. Skin failure is associated with multi organ failure and end- stage illness and can occur despite the provision of quality skin care. Skin failure may be acute, chronic or End-stage. The latter happens in the final days or weeks of life, with skin breakdown occurring rapidly within days or even hours. 24 Skin changes at life’s end: SCALE ulcer or pressure ulcer? Beldon, 2011. 1989 – investigation started in 1983. “Physiologic changes that occur as a result of the dying process may affect the skin and the soft tissues and may manifest as observable changes in skin color, turgor, or integrity, or as a subjective symptoms such as localized pain. These changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care” Signs and symptoms of SCALE: . Muscle weakness and mobility impairment . Loss of appetite, loss of weight, sarcopenia, dehydration . Reduced skin perfusion . Loss of skin integrity (due to incontinence, devices…) . Reduced immunity, leading to an increased risk of infection . Loss of vascular supply to extremities Acute skin failure : related to acute illness. When multi-organ failure occurs, the body protects the vital organs shunting blood to these organs and depriving extremities and skin. Hypoperfusion may also occur in chronic conditions In 1877 Charcot described a specific butterfly-shaped lesion which appeared on the buttocks of dying patients shortly before dying. 12 Kennedy terminal ulcer: a scoping review. Latimer, 2019 1989 KTUs, before named Kennedy terminal lesion, are a subset of pressure injuries. Two possible presentations: unilateral and bilateral. Bilateral: butterfly- horseshoe- or pear-shaped with irregular margins. The lesion usually appears on the patient’s sacrum or coccyx, 2 weeks to several months prior to death. Unilateral: 3.30 syndrome. Unavoidable Etiology unknown: however, it is theorized that it is due to hypoperfusion and multisystem failure. Underrecognized in the pediatric population The unilateral presentation of KTU is known as 3:30 syndrome. Macular lesion of less than 1 cm, with purpuric or black irregular margins, that appears in only one buttock. This rapidly developing lesion is seen 8 to 24 hours before death, without epidermal erosion. The name is due to the time of the day when staff observed these skin changes. Unstageable tissue injuries that remain intact. Unavoidable. Located on body parts where there are no pressure points and caused by end-of-life organ failure. Unavoidable phenomenon that, despite appropriate care, may occur in the period prior to death. Removing pressure from tissue doesn’t guarantee skin survival. Is a term used to describe skin changes at the end of life, which include KTU, SCALE, TB-TTI and Charcot’s Decubitus ominosus. 1877: Charcot described a butterfly shaped lesion on the buttocks of dying people. Miller stated the concept of KTU is not viable because “systemic diseases should have an equal effect on all body”. Miller proposed the concept of “Miller Pressure Equivalent Injuries” which accepts the dying process as another systemic stressor, not main causative factor of pressure-based tissue injuries. 37 Kennedy terminal ulcer and other skin wounds at the end of life: an integrative review. Roca-Biosca, 2021 KTU was defined as a pressure injury that appears at the end of life, usually located at the sacrum or coccyx, in the shape of a pear, butterfly or horseshoe, with rapid progression, producing ulceration of total sickness. It is indicator of imminent death. It coincides with the description of the “decubitus ominosus”. Standard presentation, bilateral or unilateral. For KTU, no assessment tools are available. TB-TTI are injuries that spontaneously appear, with rapid evolution, enlargement and progression. They appear in areas with little to no pressure and they can be mirroring imaging. Aetiology unknown The skin is intact, never evolve into a deep wound. Defined in 2008 by a panel of 18 experts. SCALE are “physiological” changes that occur as a result of a dying process and affect the skin color, turgor or integrity, or as subjective symptoms such as localized pain”. It is a broad term that includes all the skin changes at the end of life, regardless of whether they are avoidable. In 2006, Langemo and Brown defined it as “an event in which the skin and underlying tissues die due to hypoperfusion that occur currently with severe dysfunction or failure of other organ systems”. In 2017, Jeffrey Levine defined it as “the state in which the tissue tolerance is so compromised that cells can no longer survive in zones of physiological impairment…” According to Levine, PI and SCALE could be a consequence of skin failure. 30 Kennedy terminal ulcers and Trombley Brennan terminal tissue injuries: mistery solved? Melnychuck, 2024. Characteristics of KTU: . Frequent locations: sacrum, buttocks . Shape: butterfly or pear shaped . Color: purple . Time of onset: sudden . Time to death: days to weeks Characteristic of TB-TTI: . Frequent locations: sacrum, buttocks, legs . Shape: butterfly shaped in the sacrum; linear in the legs. . Color: bruise-like 4 Time of onset: sudden 5 Time to death: hours to days TB- TTI don’t ulcerate, perhaps since patients die rapidly. The additional locations seen in TB-TTI may be due to speed and degree of hypotension. In 1877, dr Jean-Martin Charcot described “decubitus ominosus”, a pear shaped sacral skin ulcer which heralded death and he ascribed it to a neurotrophic theory. 38 Early skin temperature characteristics of the Kennedy lesion (Kennedy terminal ulcer). Kennedy-Evans, 2023. Kennedy Lesion is used instead of KTU because the term “terminal” may not always apply, due to the increased use of advanced technologies to sustain lives. KLs have some observable characteristic: intact skin discoloration that occur suddenly, mostly in the sacrococcygeal area, that can be yellow, purple, pink and black in color, are generally in the shape of a butterfly, a pear or horseshoe with irregular borders, and are generally associated with death within weeks or months. Similar to KL with respect to color and sudden onset. Compared to KL, TB-TTI develop in a shorter time to death after first discoloration and skin remains intact; linear discoloration patterns are observed in the extremities. 25 Avoidable & Inevitable? Skin Failure: the Kennedy Terminal Lesion. Lepak, 2012. KTU, also known as terminal pressure ulcer. KTUs occurred at the sacrum or coccyx, were pear-shaped, had sudden onset and the color varied from yellow to black. Stage 3 or 4 and/or suspected deep tissue injury, according to the nomenclature NPUAP. In the 1800s, Jean Martin Charcot described this phenomenon with the term Decubitus ominosus. 31 Kennedy Terminal Ulcer #383. Bateman, 2019. KTU is a skin wound that occurs despite best preventative measures and results from the moribund status and underlying skin failure associated with the dying process. Often go underdiagnosed or may be misdiagnosed as a usual pressure ulcer. . TIMING: can develop within a matter of hours . LOCATION: sacral region, but also bony prominences . DESCRIPTION: the wound is usually irregularly shaped or butterfly shaped; >2 inches of diameter; may include red, yellow, black, purple discoloration. . PATIENT: KTU occur primarily in adult or pediatric patients in the final 2 weeks of life. The most distinguishing factors of a KTU is the quickness of the wound development in the setting of terminal illness. KTU has been referred as the 3:30 syndrome for their sudden appearance. In the early a.m. clinicians note intact skin, hours later a small black spots appear that may resemble “specks of dirt”, and by the midafternoon flat black blisters emerge. Skin failure is a term used in literature to conceptualize the overall breakdown of the skin as an organ system that is associated with the end-stages of a chronic progressive illness and/or multi-organ failure, even when excellent skin care is provided. 22 Nursing care plan for the Kennedy terminal ulcer patient. Case report. Alarcón-Alfonso, 2022. Appear mainly on sacrum or coccyx, as bilateral ulcer, shaped like a horseshoe or butterfly, with red, purple, yellow or black colorations and irregular borders. KTU starts as a category 2 ulcer or as a blister that will rapidly progress to category 3 or 4. Differential diagnosis : KTU are more superficial in onset and develop more rapidly in both size and depth compared to PUs. 23 Kennedy’s terminal ulcer and pressure injury: two different aspects of medical liability related to the same injury. Garcea, 2023. KTU’s incidence is higher than it is believed to be. Almost exclusively in the sacro-coccygeal area and heel, but it is also been seen on calves, arms, elbows. It emerges in a few hours, that’s why it’s been called a “ah ah ulcer”. KTU is the most observed and known lesion and it requires specific attention since it is constantly mistaken for a pressure injury. 32 The Death of the Kennedy Terminal Ulcer. Miller, 2016. The name is based on observations in which the a.m. evaluation did not identify any skin issues but at 3:30 p.m. the skin showed evidence of injury, which progressed. Life expectancy was found to be 8–24 hours. Miller Pressure Equivalent Injuries (MPEI): terminal status becomes a systemic stressor instead of a definitive cause for pressure-based tissue injuries. 34 The Kennedy Terminal Ulcer – Alive and Well Schank, 2016. 1989: Kennedy presented her research on KTU, not being aware of Charcot’s previous work. It often appears on the sacrum or coccyx, but also elsewhere. Two presentations: bilateral (death within 2 weeks to several months) or unilateral (onset to death of 24–48 hours). 1877: Charcot described the phenomenon of Decubitus Ominosus. 35 Pressure ulcers at the end of life. Mitchell, 2022. Kennedy (1989) described these as pressure ulcers that developed during the dying process. Usually pear, butterfly or horseshoe shaped and primarily located on the coccyx or sacrum, these ulcers were described to appear suddenly and deteriorate rapidly. It should be noted that this mnemonic is to describe the phenomenon and is not a risk assessment tool. SCALE is used to describe cellular or molecular dysfunction leading to tissue hypoxia. The main difference between SCALE and pressure ulcers is in aetiology. SCALE is associated with hypoperfusion due to multiorgan failure that leads to skin failure. SCALE is influenced more by intrinsic than extrinsic factors. ‘Skin failure’ described by La Puma (1991) was identified as a component of multiorgan failure. 1877, Charcot described a specific type of ulcer in a butterfly shape occurring over the sacrum. He termed these ulcers “debcubitus ominosus”, as patients tended to die shortly after the appearance of these ulcers. The first table collects the following information, according to the studies included: Title of the study, first author and year of publication Methodology used Definition of the concept of unavoidability Terminology regarding terminal ulcers Diagnostic criteria and assessment tools Prevention and management of these ulcers Aetiology or risk factors identified for terminal ulcers Healthcare professional’s awareness and education To facilitate the process of data extraction in the fourth area, a specific table about terminology was developed. This form was used only for the studies that provided a detailed description of different types of terminal ulcer. In this case, the information collected was as follow: Title of the study, first author and year of publication Kennedy Terminal Ulcer (KTU) 3:30 Syndrome Trombley-Brennan Terminal Tissue Injury (TB-TTI) SCALE Skin Failure Decubitus ominosus Miller pressure equivalent injury (MPEI) The first author performed the initial data extraction. Other authors verified the data charting approach and that all the process was in line with the aims of the scoping review. 2.8 Data synthesis and Analysis The findings were collated and synthesised narratively in relation to the scope of the review. The data collected have been organised thematically in order to present an effective overview of the studies included ( 14 ). [Insert Tables 2 and 3 ] 3. Results A total of 1 734 sources were initially identified from databases and grey literature. Following the inclusion and exclusion criteria, 19 studies were included through the screening and 7 were added from reference lists. The total number of studies included in this scoping review is 26. The process for selecting sources of evidence is described in Fig. 1. [Insert Fig. 1 here] Fig. 1: PRISMA diagram demonstrating selection process ( 17 ). 3.1 Characteristics of the included studies The 26 articles included in the scoping review were published between 2009 ( 18 ) and 2025 ( 19 ), ( 20 ). The methodologies employed in the studies were as follows: Case study or case series ( 19 ), ( 21 ), ( 22 ), ( 23 ) Narrative review ( 7 ), ( 24 ), ( 25 ) Modified Delphi study ( 26 ), ( 27 ) Retrospective study ( 28 ), ( 20 ) Commentary or editorial or letter to the editor ( 11 ), ( 18 ), ( 29 ), ( 30 ), ( 31 ), ( 32 ), ( 33 ), ( 34 ), ( 35 ), ( 36 ) Continuing education article ( 29 ) Scoping review ( 12 ) Integrative review ( 37 ) Observational study ( 38 ) Retrospective case-control study ( 39 ) Despite the search strings used, most of the studies focused on Kennedy Terminal Ulcers (KTUs). The studies that focused exclusively on this type of lesion are listed thereafter: ( 19 ), ( 12 ), ( 37 ), ( 30 ), ( 38 ), ( 18 ), ( 25 ), ( 31 ), ( 21 ), ( 22 ), ( 23 ), ( 32 ), ( 33 ), ( 34 ). Of the studies considered, only one focused on pediatric patients ( 21 ). The care settings in which this type of injury has been most frequently studied include palliative care ( 28 ), ( 20 ), intensive care units (ICU) ( 19 ), ( 40 ), ( 38 ), ( 21 ), ( 39 ) and primary care ( 22 ). 3.2 The concept of unavoidability for terminal ulcers The differential diagnosis between avoidable and unavoidable wounds is not merely a matter of words: this classification is the basis on which to plan achievable goals. If an injury is unavoidable, the purpose of completely healing it will probably be unrealistic ( 37 ). Nowadays, there is a broad consensus in literature that terminal ulcers are unavoidable ( 19 ), ( 26 ), ( 24 ), ( 12 ), unlike pressure injuries, thus they cannot be prevented even through the best quality of care, and they are not attributable to substandard care ( 19 ). However, this concept deserves further elucidation for at least two reasons: on one side, not all end-of-life patients develop a terminal ulcer but only a proportion of them do so ( 29 ); on the other side, it’s not fully clarified how terminal ulcers are different from pressure-related injuries, since both of them commonly occur over bony prominences ( 11 ). 3.3 Terminology related to terminal ulcers Multiple types of skin changes may occur in patients at the end of life. These patients are prone to develop terminal ulcers during the preactive and active stages of dying ( 36 ). Although it doesn’t exist only one accepted definition, end-of-life is considered as a time frame of six or less months of estimated life, while it should last even less, such as days or hours ( 41 ). According to the fact that dying is a process, patients entering this period, from months until few hours before death, are at great risk of terminal ulcers, which are considered unavoidable ( 36 ). A synopsis of the terminology regarding terminal ulcers is outlined below: Decubitus Ominosus : in 1877, Jean-Martin Charcot described a specific butterfly-shaped lesion which appeared on the buttocks of patients, shortly before dying and he termed it decubitus ominosus (7), (27), (30), (25), (34). In Latin language, “ ominosus ” refers to something that brings misfortune, according to the observation that patients tended to die shortly after the occurrence of this ulcer. His observations have been basically forgotten until Kennedy raised the interest on this topic, describing the same kind of terminal wounds (27), not being aware of Charcot’s previous work (34). Kennedy Terminal Ulcer (KTU) is a term that was firstly coined in 1983 by Karen Lou Kennedy and that was presented for the first time at NPUAP in 1989 (24), (33). She, along with her team, noticed that some patients used to suddenly develop a specific kind of pressure injury, typically on sacrum or coccyx, just few weeks before dying and started measuring this phenomenon. After 5 years of data examination, they noticed that 55,7% of patients died within 6 weeks from the ulcer’s occurrence (42), leading to the conclusion that these skin changes were part of the dying process. In 2023, she started referring to this ulcer as “Kennedy lesion” (KL), since the term “terminal” was not suitable any longer, considering how long life could be prolonged with new technologies (38). To avoid confusion, this scoping review will refer to this kind of wound as KTU, since the majority of papers still use this terminology. KTUs are considered a subset of pressure injuries (PI) (27), (12), (18), that’s why they are also known as “terminal pressure injuries” (25) or “end-stage skin failure” (28): indeed, this kind of ulcer is defined as “a pressure ulcer that some people develop as they are dying” (7). These ulcers are reported in adults as well as in pediatric patients, in the final weeks of life (31). They are indicators of imminent death (19), (7), (28), (37) thus, their proper identification may help clinicians in shift goals of care towards palliative care as soon as possible (19). Death is estimated in days to weeks since the occurrence of the ulcer (28), (30). However, they are often mistaken for pressure injuries, leading not only to missed care but also to lack of prevalence data (12), (31), (22), (23). It seems that, at the moment, no validated assessment tools for KTUs are available (12), (37). KTUs usually develop in a matter of hours and for this reason they are also called “ah ah ulcer” (23): this is the most peculiar characteristic, which may facilitate a proper diagnosis (36), (31). KTUs may have bilateral or unilateral presentations (12), (37): in the first case, they are observed in the sacral and gluteal regions, as well as on calves, arms and elbows (23), and have a pear, butterfly or horseshoe shape with irregular borders; they appear suddenly with rapid and progressive deterioration (19), (28), (27), (20), (36), (30), (25), (21), (22), (35); color of the skin may vary from yellow, to purple, to black (27), (30), (25), (31). The unilateral presentation is known as a 3:30 syndrome (12), which will be detailed later. All the papers included assessed KTU according to the NPUAP nomenclature (43), reporting that KTUs often turn very quickly into a Stage 3 or 4 or deep tissue injury (DTI) (25), (21), (22). Nowadays, it has been reached a large consensus on the unavoidable nature of these lesions (12), (21) thus on the fact that they may occur despite the best preventative measures (31). On the other hand, some authors consider pressure as a contributing factor, along with other physiological changes, such as hypoperfusion, that could eventually increase the effects of pressure (36). 3:30 Syndrome is considered a variant of KTU (7), (36), with unilateral presentation (12). The name is due to the rapid onset (31): clinicians usually reported not to have identified any skin issue during the morning evaluation; instead, at 3:30 p.m., they used to note some evidence of skin injury, which would have progressed in the next hours (32). These lesions appear as small black spots that look like “specks of dirt”, rapidly turning into flat black blisters (36), (31) or macular lesions of less than 1 cm 2 , with purpuric or black irregular margins, without epidermal erosion (12). Life expectancy after the occurrence of these lesions is from 8 to 24 hours (7), (36), (12): prompt modification of the treatment plan would be possible with a correct diagnosis. This kind of ulcer seems to develop despite any pressure-relieving measures (20). Trombley-Brennan Terminal Tissue Injuries (TB-TTI) were introduced in 2012 by a team of palliative care nurses who recognized a type of injury different from KTU, but still occurring at the end of life and despite any evidence-based interventions (36). Together with KTUs, TB-TTIs are counted as part of terminal ulcers, thus are considered unavoidable (26), (28), prognosticators of death and not related to pressure (28), (20), (12). Life expectancy from identification of the injury is 36 hours, with the 75% of patients who died within 72 hours of these skin changes noticed (7), (36), or from 20 minutes to several days (28). They have been reported in patients aged from 35 to 95 years old (28). Clinical characteristics of TB-TTIs are similar to those of KTUs regarding colors and sudden onset; in particular, they appear as pink, purple, or maroon discoloration (36). However, TB-TTIs develop in a shorter time to death after first discoloration and skin remains intact. Compared to KTU, an additional location where the ulcers may occur is the extremities, with linear discoloration patterns, similar to linear striations (28),(36), (30), (38). These lesions could be confused with a DTI (7) since the skin remains intact and they never turn into a deep wound (28), (12), (37). It has been hypothesized that TB-TTIs don’t ulcerate because of the patient’s rapid death (30). Skin Failure is a broad concept that includes many multiple similar phenomena, such as KTU, TB-TTI, SCALE and others (7), (12), (39). This term unifies all kinds of breakdowns that skin, as an organ, may go through, although the best quality of care is provided (31). Talking about failure, multi-organ failure is described as the “presence of altered organ function in acutely ill patients such that homeostasis cannot be maintained without interventions. It usually involves two or more organs” (7). As all the other organs, skin can fail as well. There are two subsequent definitions of skin failure that deserve to be mentioned: in 2006, Langemo described skin failure as “an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems” (44). Later, Levine defined it as “the state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiologic impairment such as hypoxia, local mechanical stresses, impaired delivery of nutrients and buildup of toxic metabolic byproducts” (11). Literature reports that pressure is not a necessary component of skin failure (7). Three types of skin failure are listed in literature (7), (28), (36): acute (associated with acute illness) (24), chronic (associated with a chronic condition) and end stage, that occurs during the last period of life, such as days or weeks (7), (36). While for other organs biomarkers or screening tools are disposable, for the diagnosis of “skin failure” it doesn’t exist any classification system, as well as diagnostic tools for clinical signs (27) or biomarkers diagnostic nor blood test (11), (36), (39). SCALE: In 2008, an international panel of experts met to define a set of ten statements called Skin Changes At Life’s End, known with the mnemonic of SCALE; its aim is to describe a group of clinical manifestations and it’s not to be considered as a risk assessment tool (27), (35). SCALE is a broad term that includes “all the physiological changes that occur as a result of a dying process and affect the skin color, turgor or integrity, or as subjective symptoms such as localized pain, regardless of whether they are avoidable” (24), (37). The term SCALE doesn’t only include KTUs and TB-TTIs, but it also encompasses fungating wounds, ischemic wounds, pressure injuries, skin tears and many more (36). To sum up, it’s possible to claim that SCALE could be considered as a consequence of skin failure, according to the previous seen definition by Levine (37). However, it should be considered that not everyone with SCALE has skin failure or multi-organ failure, since the death process affects skin with different degrees (7). Likewise, we still miss detailed diagnostic criteria to fully understand the extent of skin failure (7) which would have been very useful for a deeper understanding of this issue. Signs and symptoms of SCALE are recognized as follows (24): Muscle weakness and mobility impairment Loss of appetite, loss of weight, sarcopenia, dehydration Reduced skin perfusion Loss of skin integrity (due to incontinence, devices…) Reduced immunity, leading to an increased risk of infection Loss of vascular supply to extremities SCALEs are encompassed in the unavoidable skin ulcers and are often the result of multiorgan failure (40), (12). For this reason, pressure-relieving interventions could not be effective in maintaining skin integrity (12). The most significant risk factor for SCALE is the diminished tissue perfusion, thus in some cases, pressure ulcer can be markers of SCALE (27), (37), (35). Miller Pressure Equivalent Injuries (MPEI) : In 2016, Miller proposed the concept of MPEI, assuming that multiorgan failure due to systemic disease should have an equal effect on all the body (12), (32). Miller argued that if it is true that systemic diseases have systemic effects (as a cardiac disease affects the entire body, for instance) and that if it is true that pressure is equally distributed (since patients are regularly positioned), then the presumption that the terminal status itself will result in a pressure-related injury cannot be considered valid, mostly if the injury develops only in one area, usually in the sacrum (32). Thus, he considered the terminal status as a systemic stressor, instead of a definitive cause for pressure-based tissue injuries (12), (32). There’s not a unique consensus on Miller’s assumptions (7). 3.4 Diagnostic criteria and assessment tools When an ulcer occurs, especially in vulnerable patients at the end of life, nurses and health care professionals may experience a sense of guilt or may feel blamed, since the wound is often attributed to poor quality of care and it will probably lead to financial or legal issues (29). However, at the best of our knowledge, we miss a unified classification system for terminal ulcers, with clinical signs and symptoms, that could be useful for reporting these wounds differently from other kinds of ulcers (20). This classification is even more complicated by the fact that end-of-life wounds may occur together with PIs (29), and we still miss standardized diagnostic criteria to differentiate between the two (20). As clinicians, who spend most of our time at the bedside, it’s true that the first diagnostic criterion for assess a terminal ulcer is the recognition that the patient is dying (11): we must always recall that, before evaluating wounds, we are taking care of people, so we have to consider the overall health conditions in order to perform a correct differential diagnosis (37). Research, although still limited, is mainly focused on the validation of an assessment tool (26), (39) and diagnostic criteria (19), (38). As an assessment tool, in 2023, a Delphi panel of 16 international experts in terminal ulcers found a consensus around the “End-of-life wound assessment tool”. The aim of this tool is to gain a better identification of terminal ulcers but also to decrease legal controversy and improve wound care and palliative care for these patients (26). The tool doesn’t discriminate between end-of-life wounds and PIs, but it should be used if the health care professional suspects that the ulcer is indeed a terminal one. At the moment, a moderate interrater reliability of this tool has been achieved and a larger study is needed (45). A “Skin failure indicator scale” has also been proposed, which considers the serum albumin level, a diagnosis related to impaired blood flow, the presence of sepsis or multiple organ dysfunction syndrome, the use of vasopressor or inotrope medication and the mechanical ventilation as predictors of skin failure; the tool still needs to be validated but it may represent an effective way to predict skin failure (39). Concerning diagnostic criteria that can be used to assess a terminal ulcer, a case study published in 2025 reported the use of ultrasound as a complement to the clinical examination done by nurses (19): it was observed a mild oedema in the subcutaneous tissue of the perilesional skin and a cobblestone-like tissue in the lesion bed; both sites showed absence of blood flow. For the future, it is possible to figure out that the use of ultrasound will become more frequent and that this will help in assessing the wounds, differentiating between terminal and pressure injuries. Another new diagnostic criterion proposed in literature consists in skin temperature changes, since it’s known that, for PIs, areas of inflammation or hyperemia are warmer than the surrounding skin and areas of ischemia are cooler. Only one of the studies included in this scoping review reported assessing this parameter (38): skin temperature was evaluated within 24 hours from a newly identified area of discoloration. The study stated that the Relative Temperature Differential (RTD) between the discolored area and a control point of intact skin was not normal if it was > +1.2°C or < -1.2°C, based on previous literature. While for PIs skin temperature used to decrease or increase compared to the control point, for KTUs it doesn’t seem to happen. More research on this topic is needed to fully understand the pathophysiology of KTUs and thus to explain why the early skin temperature doesn’t change in the first 24 hours, but it could be an interesting starting point, since it could help in differentiating PIs from terminal ones. 3.5 Aetiology The main point to be considered when talking about SCALE is that these kinds of ulcers don’t stem from external stressors but, instead, from internal factors (20): it’s often the result of hypoperfusion and multi-organ failure, rather than pressure and shear, and thus it should be considered an unavoidable phenomenon, as said (40). The most widely accepted aetiology for the onset of these lesions is related to the concept of hypoperfusion linked to multiple organ failure: in crisis situations, the body reacts by diverting blood flow from the skin to vital organs, thereby reducing skin perfusion. The consequence of this is that hypoxia and a slowdown in normal metabolic processes will occur at the skin and subcutaneous levels (27), (20), (24), (29), (37), (30), (25), (21), (33), (34), (35). However, starting from this assumption, the question remains as to why only some people develop terminal lesions, despite hypoperfusion being associated with the end-of-life period in almost all patients (30). Furthermore, as seen, in 2016 Miller levelled significant criticism at this line of thinking, asserting that the terminal condition alone could not explain the onset of such lesions. From his perspective, if the skin fails as an organ, lesions should be found everywhere and not just in specific areas (32). Consequently, other contributing causal factors have been proposed, and alternative hypotheses have been advanced. Since the validation of predictive criteria to identify which patients may develop a pressure ulcer or a SCALE ulcer is currently not possible (24), literature describes the following factors as contributing causes: Use of vasopressors or inotropes (19), (40), (37), (30), (38), (21), (35), (39): in order to remain viable, the skin requires from 25% to 33% of cardiac output (21); since vasopressors divert the blood flow to vital organs, skin becomes more prone to breakdown and death. This type of medication is often used in ICUs or for cardiological patients. Respiratory, renal or circulatory insufficiency (40), (37), (35) Insufficiency of two or more organs (40), (38), (21), (39) Co-morbid conditions, such as cardiovascular diseases, smoking, sepsis or pneumonia, diabetes (38), (21), (39) Hypoalbuminemia (40), (37), (21), (35), (39): serum albumin level less than 3,5 g/dl (39) Hypoxemia (40), (37), (21), (35) Hypotension (30), (38) Alteration of elimination of toxic metabolites (40), (37), (35) Decreased defensive capacity of the skin (40), (37), (38), (35): in particular, aging could be considered associated with altered immune responses and changes in vascular structure (38) Loss weight, loss appetite, cachexia, poor nutrition (40), (37), (38), (35) Reduced mobility or immobility (40), (38), (35) Anatomic arterial aberrancies (30): the researchers’ observations moved from the fact that many patient characteristics don’t explain why just some of them manifest terminal ulcers. However, they wanted to find out the peculiar feature that could explain why someone, and not everyone, develops terminal injury. Looking at the anatomy of the human body, they speculated that changes or agenesis of specific arteries (median sacral artery, lateral sacral artery and sciatic artery, that may be persistent, instead of regressing by the third month of embryonic development) could lead to the occurrence of ulcers, but only in case of hypotension, since otherwise a collateral circulation would prevent it. At the same time, the authors refused the “angiosomal hypothesis”: an angiosome is a vascular territory that is supplied by a specific blood vessel. The human body has 40 angiosomes. Considering the most frequent locations where terminal ulcers usually appear (sacrum, coccyx…), the authors considered that the angiosomal hypothesis could not explain it (30). Reperfusion, in cases of recurrent hypotension (30): in case of recurrent hypoperfusion, the skin can go through different alterations, that are linked to the typical manifestations of terminal ulcers. It may move into a whitish change, indicating ischemic necrosis, or it can move into a purplish discoloration, due to the accumulation of red blood cells caused by damaged blood vessels. The process of the reperfusion injury may vary based on factors such as the degree and duration of the hypotension, the size of the blood vessel involved, the characteristic of the vessel itself, the existence of a collateral arterial supply (30). It is known that commonly, capillary refill is a good way to assess skin perfusion: it has to be considered that the capillary refill could appear for the first 12 hours after skin death, because of the blood remaining in the area for the capillary collapse; for this reason it could be difficult to evaluate skin failure exactly at the moment of its occurrence (25) Use of mechanical ventilation (38), (39) Abnormal white cell counts (38) Anemia (38) Alternative hypotheses that have been advanced are the existence of some catabolic patterns that may have something in common with other systems’ failure or there may be some genetic factors at the basis of vascular responses to ischemia. These factors, if studied and understood, could lead to personalized therapies for both preventing and managing this kind of ulcer (11). It could be interesting to note that age, Braden score and Body Mass Index were found not to be significant predictors of skin failure (39). 3.6 Prevention and management Since terminal ulcers are considered solid prognosticators of imminent death, the goals of care need to shift from curative to palliative care, in order to avoid therapeutic obstinacy (19), dismiss aggressive interventions and tests (28), (37) and to guarantee comfort and a dignified dying process (20), (12), (37), (22). Thus, the main objective of the new treatment plan isn’t wound healing any longer (40), while it should be providing the patient with the best quality of life (36), managing wound symptoms and psychological issues (25). Even if terminal ulcers are considered unavoidable, prevention interventions need to be implemented not to exacerbate existing ones. The literature agrees on the fact that prevention of terminal ulcers is similar to the one for pressure ulcers (31), (22). Strategies to mitigate the risk may include optimizing nutritional support, using appropriate pressure redistribution surfaces, effectively managing moisture and frequent repositioning (21). Although pressure is not a causative factor for terminal ulcers (29), pressure-relieving support surfaces could be useful for a conservative approach (24), (31), (21), (35), as well as regular repositioning (20), (36), (21). However, pressure-relieving support surfaces are not always comfortable for patients, and they could even worsen pain and nausea or reduce the ability of independent movement, if still present (24). Furthermore, frequent repositioning may cause unnecessary pain (36). Before their implementation, these interventions should be accurately evaluated and discussed with patients and families, in order to establish the best treatment according to patients’ preferences and wishes (36), (24), (40), (33). The decision regarding whether and how often to reposition such a vulnerable person should be taken under individual judgement, considering the patient’s clinical conditions, and the need of premedication with an analgesic before the procedure (31). Jakobsen et al. (2020) did not find a significant correlation between the incidence of SCALE and the use of pressure redistribution equipment (46). Great importance is given to the communication with patients and family members, as well as caregivers (20), (40), (12), in order to help them cope better with the situation (22). Emotional support and education concerning terminal ulcers are often needed to better understand the situation, to get awareness of the terminality and to know how to assist the person (24), (37), (31), having realistic expectations for wound healing (36). Especially in this phase of life, patients’ cultural preferences and families’ expectations should be taken into account and respected (35). Caregivers should be involved in the care plan (33). Since it’s not always simple to properly diagnose terminal ulcers, and they are often misdiagnosed as pressure injuries, it is important to clearly document all the interventions, providing evidence of the quality of care administered (20), (24), (31). From the perspective of the law, even a correct diagnosis of a terminal lesion, if possible, doesn’t fully protect against legal disputes. Therefore, it becomes mandatory to provide proper evidence for every single choice, for example, the decision of reducing mobilizations to avoid unnecessary pain. If possible, it would be useful an informed consent, possibly signed by the patient (23) or considering a written Advance Care Planning. Charting by exception has been proposed as a good method of documentation (27). This type of charting assumes that the patient manifests normal responses to all the interventions performed. The only responses that are documented are the ones that deviate from the standard or from what it is expected (47). Wound care nurses should be involved in the care team as soon as an ulcer is recognized as a terminal one (24), (12). It is recommended that only advanced clinical specialists undertake the assessment of terminal lesions so that an appropriate individual care plan could be set (12). The SCALE Statement (27) has proposed a list of five P’s for determining appropriate intervention strategies. The five P’s mnemonic consists of: Prevention: since the skin goes through decreased oxygen availability during the last part of the life, it’s important to consider reducing pressure, moisture and other risk factors, as well as ameliorating nutrition and mobility, according to the patient’s clinical conditions. The aim of prevention is to improve well-being and quality of life. Prescription: this point comprehends all the interventions that are considered appropriate for the treatment of wounds that are considered healable, even in this phase of life. Preservation: this point refers to the interventions suitable when maintenance is considered a proper goal, despite limited possibilities of gaining complete healing. Palliation: this section involves the interventions to be implemented when the goal of the treatment is managing symptoms, such as pain or odor, and achieving the best quality of life possible, rather than healing or maintenance of the wound. Preference: this last P reminds clinicians to always include patient’s preferences and wishes in the decision-making process; the document gives importance to patient’s circle of care’s opinion as well. A more detailed overview of the interventions suggested by literature is provided in Figure 2 . [Insert Figure 2 about here] Figure 2: Management of terminal ulcers. 3.7 Health professionals’ education Literature reveals that there’s an issue of misclassification of terminal ulcers that are often reported as pressure injuries (29). This leads to wrong treatment, bad quality of life for the dying person, that probably won’t receive the proper palliative care, emotional and practical burden for caregivers. In this field, nurses are responsible for the correct management and treatment of terminal lesions, together with the avoidance of possible complications (23). But how could it be possible if nurses don’t even know how to recognize them? This matter involves ethical issues, concerning quality of care and the principles of beneficence and non-maleficence; moreover, the proper identification of a terminal ulcers can have a potential impact on reimbursement (21). Healthcare professionals are the ones expected to facilitate communication and collaboration, both across care settings and disciplines (27), and towards patients and their circle of care: however, they often show a limited awareness of the skin changes that happen at life’s end (27), (29), (12). Moreover, it is possible that in certain settings such as ICUs, clinicians are not so prone to accept the terminology “terminal ulcer” for a cultural issue based on seeing death as something that must be overcome at all costs (11). On the other hand, it is paramount that clinicians are educated about terminal ulcers: this will help them to support dying patients and their families and to have open discussions not only regarding the ulcer itself, but also on the impending death, which is quite a difficult topic, if not well-prepared (12). As many of the studies included in this scoping review involve the settings of palliative care or long stay units, it should be considered that maybe this professional’s lack of awareness means that terminal ulcers are completely underdiagnosed outside of these settings (37). One of the main problems that could explain this difficult situation is having so many terms to describe this kind of ulcer: it can be confusing and it may impede a good communication, even among clinicians (7). Educational topics that deserve to be implemented in order to better recognize terminal ulcers concern the skin prevention and wound treatment (19), and training of healthcare professionals in the management of ulcers that are different from pressure ulcers (22). 4. Discussion The prevalence of pressure injuries is considered a solid indicator of the quality of nursing care, thus the nursing staff should be able to recognize this kind of ulcer and to distinguish it from all the others ( 24 ). Moreover, the occurrence of pressure ulcers is seen as patient safety incidences and is linked with the concept of “inadequate care” ( 9 ). That’s why it appears of paramount importance that nurses can correctly recognize, report and manage terminal ulcers. This kind of ulcer involves people at the end of their life, at any age, affected by many different clinical conditions: as said, the onset is often very rapid so that both patients and families could feel unprepared and hopeless facing this new reality. We, as health care professionals, cannot consider merely the theme of reimbursement or legal disputes when referring to this topic, but we have to focus on providing our patients and their circle of care with the best possible care, trying to achieve the goal of a dignified dying process. There still exists a big concern around the real prevalence and incidence of this phenomenon, mostly because it is often misdiagnosed as pressure injury: an Italian multicentric study found an incidence of 2.7% in palliative settings ( 46 ), while other studies noted that a differentiation between KTUs and PIs was missing in intensive care units ( 48 ). As long as we miss detailed diagnostic criteria, we won’t be able to understand the real dimension of the issue. As seen, new technologies, like ultrasound ( 19 ), are reaching out as important milestones for assessing this kind of ulcer, along with the clinical examination. On the other hand, we still miss a specific and validated terminal ulcer assessment tool and a proper staging system ( 29 ): actually, while an assessment tool has been proposed in the last few years, literature demonstrates that all the terminal ulcers are documented with the same classification system used for pressure injuries. The aetiology is the main difference between pressure injuries and SCALE: the first ones are due to external factors such as pressure and shear and the latter are associated to hypoperfusion and multi-organ failure, thus we can say that the root cause is completely different ( 40 ), ( 35 ). The differential diagnosis is further complicated by the fact that the two of them may occur at the same time ( 36 ). Moreover, the bilateral presentation of KTU could eventually be misdiagnosed with Moisture-Associated Skin Damage (MASD), especially if the patient has incontinence or some other risk factors ( 40 ), ( 35 ) or if the lesions begin as numerous superficial spots, that are going to merge in a larger ulcer in a brief period of time ( 35 ). Thus, the correct identification of terminal ulcers is complicated by the similar manifestations, the classification system equal to the one used for PIs but also by the available terminology. In 2019, Levine introduced the concept of potential defensive bias for the terminal ulcer terminology: since the incidence of PIs is considered as an indicator of the quality of nursing care, with thousands of lawsuits each year, talking about “terminal ulcers” relies on the unavoidability of death and, in some way, seems to relieve caregivers from the responsibility of providing quality care. Levine proposes to replace this terminal ulcer terminology with a more prognosis-neutral nomenclature, in line with the one concerning other organs, such as “skin failure” ( 49 ). 4.1 Limitations Since the literature review is updated by March 2025, we are aware that relevant literature may have been published later. We also recognize that it has been difficult to accurately choose the sources of evidence, since the studies were very often focused only on the topic of KTU and, moreover, because information regarding terminal ulcers were strictly embedded in the larger topic of pressure ulcers. A large part of the studies included in this scoping review have been conducted with a poor methodological quality, as many of them are editorials or are based on the opinion of experts. Furthermore, according to the methodology used, a critical appraisal of the included studies wasn’t performed. Therefore, we suggest using these evidences with caution and awareness. 5 Conclusions Some patients, during the end-of-life period, experience a specific kind of wound that is related to hypoperfusion and multi-organ failure: these terminal ulcers, which include a broad number of injuries, usually develop very quickly, with typical patterns. They are considered unavoidable, since they occur despite all pressure-relieving interventions are implemented and the best quality of care is provided. However, these ulcers are often misdiagnosed as pressure injuries, since nurses and health care professionals are often found to be not so well-prepared on this topic: thus, we miss prevalence data and, even more important, we avoid providing effective palliative care and palliative wound care. The goals of end-of-life wound management should be focused on comfort care, for the patient, which includes pain relief and conservative management of all the wound’s symptoms such as odour or exudate; moreover, other goals for both patients and their circle of care include communication and emotional support regarding the imminent death. This scoping review has highlighted several points that warrant further investigation, including the role of pressure in the occurrence of these lesions, some hypotheses regarding their aetiology, the validation of effective assessment tools as well as the definition of solid diagnostic criteria and the issue of healthcare professionals’ education. The authors hope that more research will address all these topics in order to further improve the quality of care for dying people and for their families. Abbreviations KTU: Kennedy Terminal Ulcer KL: Kennedy Lesion TB-TTI: Trombley-Brennan Terminal Tissue Injury PI: Pressure Injury SCALE: Skin Changes At Life’s End MASD: Moisture-Associated Skin Damage DTI: Deep Tissue Injury MPEI: Miller pressure equivalent injury NPUAP: National Pressure Ulcer Advisory Panel RTD: Relative Temperature Differential Declarations Ethical Approval Not applicable. This article is a review of previously published literature and does not involve any new studies with human participants or animals performed by the author. Consent for publication Not applicable. Availability of data materials All data generated or analysed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions The conception and design of the study were undertaken by IS, RB and PF IS, RB and PF developed the search strategy and conducted the literature search. The screening of the articles was conducted by IS, DC and DC, with the supervision of PF. IS, DC and DC completed data charting, followed by data synthesis. The initial draft of the manuscript was prepared by IS. All authors contributed to successive iterations of the manuscript, and the final version was approved by all. Acknowledgements The authors would like to express their gratitude to Dr. Carmela Palazzi, the university librarian at University of Modena and Reggio Emilia (Italy), for her invaluable assistance in formulating a comprehensive search strategy and in conducting literature searches. References Radbruch L, De Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. 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Br J Community Nurs. 2011;16(10):491–4. Lepak V. Avoidable & Inevitable? Skin Failure: The Kennedy Terminal Lesion. J Leg Nurse Consult. 2012;23(1):24–7. 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. Sibbald RG, Krasner DL, Lutz J. SCALE: Skin Changes at Life’s End Final Consensus Statement: October 1, 2009©. Adv Skin Wound Care. 2010;23(5):225–36. Brennan MR, 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. Latimer S, Walker RM, Gillespie BM. End-of-life wounds and pressure injuries in dying adults: distinguishing the difference. InScope. 2022;51. Melnychuk I, Servetnyk I. Kennedy Terminal Ulcers and Trombley-Brennan Terminal Tissue Injuries: Mystery Solved? Adv Skin Wound Care. 2024;37(5):233–7. Bateman J. Kennedy Terminal Ulcer #383. J Palliat Med. 2019;22(12):1612–3. Miller MS. The Death of the Kennedy Terminal Ulcer. J Am Coll Clin Wound Spec. 2016;8(1–3):44–6. Sarabia-Cobo C. Poly Ulceration Patient Terminal: Kennedy Terminal Ulcer (KTU). J Palliat Care Med [Internet]. 2017;7(01). https://www.omicsgroup.org/journals/poly-ulceration-patient-terminal-kennedy-terminal-ulcer-ktu-2165-7386-1000297.php?aid=85087. Accessed 20 August 2025. Schank JE. The Kennedy Terminal Ulcer – Alive and Well. J Am Coll Clin Wound Spec. 2016;8(1–3):54–5. Mitchell A, Elbourne S. Pressure ulcers at the end of life. Community Wound Care. 2022;27(Sup3):S14–8. Julian MK. Skin failure in patients with a terminal illness. Nurs. Made Incred. Easy. 2020; 18(4): 28-35. Roca-Biosca A, Rubio-Rico L, De molina-Fernández MI, Martinez-Castillo JF, Pancorbo-Hidalgo PL, García-Fernández FP. Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review. J Tissue Viability. 2021;30(2):178–82. Kennedy-Evans K, Vargo D, Ritter L, Adams D, Koerner S, Duell E. Early Skin Temperature Characteristics of the Kennedy Lesion (Kennedy Terminal Ulcer). Wound Manag Prev. 2023;69(1):14–24. Hill R, Petersen A. Skin Failure Clinical Indicator Scale: Proposal of a Tool for Distinguishing Skin Failure From a Pressure Injury. Wounds Compend Clin Res Pract. 2020;32(10):272–8. Elbourne S. Pressure ulcers at the end of life. Br J Community Nurs. 2022;27(Sup6):S5–6. Huffman JL, Harmer B. End-of-Life Care. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2025. http://www.ncbi.nlm.nih.gov/books/NBK544276/. Accessed 21 August 2025. Kennedy KL. The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 1989;2(2):44–5. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Cont Nurs Off Publ Wound Ostomy Cont Nurses Soc. 2016;43(6):585–97. Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206–11. Latimer S, Walker RM, Hewitt J, Ray-Barruel G, Shaw J, Hunt T, et al. Testing the study protocol and interrater reliability of a new end-of-life wound assessment tool: a feasibility study. BMC Palliat Care. 2025;24(1):216. Jakobsen TBT, 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. Murphy EK. Charting by exception. AORN J. 2003;78(5):821–3. Strazzieri-Pulido KC, S González CV, Nogueira PC, Padilha KG, G Santos VLC. Pressure injuries in critical patients: Incidence, patient-associated factors, and nursing workload. J Nurs Manag. 2019;27(2):301–10. Levine JM. Terminal Ulcer Terminology: A Critical Reappraisal. Wound Manag Prev. 2019;65(8):44–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Jan, 2026 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 02 Jan, 2026 Reviews received at journal 28 Dec, 2025 Reviews received at journal 26 Dec, 2025 Reviews received at journal 25 Dec, 2025 Reviewers agreed at journal 19 Dec, 2025 Reviewers agreed at journal 18 Dec, 2025 Reviewers agreed at journal 18 Dec, 2025 Reviewers invited by journal 18 Dec, 2025 Editor invited by journal 16 Dec, 2025 Editor assigned by journal 14 Dec, 2025 Submission checks completed at journal 14 Dec, 2025 First submitted to journal 12 Dec, 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. 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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-8344060","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":563020496,"identity":"6967df8d-4b0d-4eba-9304-c1f8e1c55d76","order_by":0,"name":"Ilaria 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17:16:33","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":265171,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8344060/v1/7ce7caae4a295b5023d206d0.html"},{"id":98820445,"identity":"bc0a051e-05d3-4d1e-9416-8f29638fa820","added_by":"auto","created_at":"2025-12-22 17:16:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61748,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA diagram demonstrating selection process (17).\u003c/p\u003e","description":"","filename":"Figure1PRISMAdiagram.png","url":"https://assets-eu.researchsquare.com/files/rs-8344060/v1/7d3ee0bd808e7e73d8f8469e.png"},{"id":99307462,"identity":"1d9d4cc1-c395-46ba-9e83-59cdc373952a","added_by":"auto","created_at":"2025-12-31 16:06:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":263655,"visible":true,"origin":"","legend":"\u003cp\u003eManagement of terminal ulcers.\u003c/p\u003e","description":"","filename":"Figure2BMCPalliativeCare.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8344060/v1/f757a395091ccdf8c3b5d7f0.jpg"},{"id":101690429,"identity":"106cfe60-9632-4cad-8f75-b282d3bfe12e","added_by":"auto","created_at":"2026-02-02 16:02:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3217448,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8344060/v1/ad804369-0fbe-4372-b6ef-dd552a881635.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Terminal ulcers in end-of-life care: a scoping review","fulltext":[{"header":"1. Background","content":"\u003cp\u003ePalliative care is an active and holistic approach that aims to achieve the best quality of life for patients with life-threatening illness and their families or caregivers (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTerminology such as \"end-of-life\", \"terminally ill\" or \"actively dying\" denote a particular phase of life in which it is imperative to acknowledge that the individual is still alive, likely afflicted by an illness that is progressively deteriorating and will ultimately result in death. As healthcare professionals, it is imperative that we continue to provide the necessary care to this person.\u003c/p\u003e \u003cp\u003eSince palliative care\u0026rsquo;s goal is to achieve the best quality of life possible for patients facing life-limiting illnesses and their families, skin issues need to be taken into account as they frequently result into symptoms of pruritus, discomfort or pain. These symptoms can not only affect the physical well-being of the patient but also have a substantial impact on their emotional state and that of their family members. Despite knowing that, skin condition at the end of life is often a neglected area (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePalliative wound care is recognised as a complex concept, extending beyond the management of unpleasant symptoms and not being limited to the end-of-life period. Both palliative care and palliative wound care can be applied across the whole care continuum: as the first one is suitable even during active cure, the latter is indicated for conditions involving long-standing wounds or wounds due to uncorrected physiological pathologies and it is not strictly limited to end-of-life period. A concept analysis has posited that \u0026ldquo;prevention\u0026rdquo; is an important antecedent of the concept of palliative wound care assuming that, while it may not be possible to avoid all the instances of skin breakdown, it should be possible to decrease their severity and to avoid the preventable ones (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the human body, the skin represents the largest and most exposed organ and about 15% of the body weight; one third of the blood supply goes to the skin to permit all its functions, which include body protection, thermal homeostasis, sensory function, endocrine and exocrine functions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), as well as expression and not-verbal perception.\u003c/p\u003e \u003cp\u003eAny organs of the body may undergo dysfunction at any point in life, but especially during the final stages of life or in the context of acute critical illness. As an organ, skin can fail at the end of life, showing signs and symptoms of dysfunction. The concept of skin as an organ that could fail was first advanced in the early nineties, when it was argued that, if other organs such the heart, lungs or kidneys show signs of failure, it might be possible for the same to be true of the skin. Considering that, why should pressure injuries always been seen as indicator of inadequate care, if symptoms of heart, lungs or kidneys disease are not (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)?\u003c/p\u003e \u003cp\u003eAt the end of life, patients may experience different kinds of skin breakdown, some of them are considered avoidable, whilst others are not. According to the National Pressure Ulcer Advisory Panel (NPUAP) consensus conference results, held in 2011, an ulcer is considered avoidable if it develops because carers don\u0026rsquo;t implement at least one of the following parts of the care plan (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEvaluation of the individual\u0026rsquo;s clinical conditions and assessment of the pressure injury risk factors\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDefinition and implementation of interventions consistent with individual needs and recognized standard of practice\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMonitoring and evaluation of the impact of the interventions\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRevision of the intervention, if needed\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIf an ulcer develops despite any of the aforementioned elements of the process have been implemented, thus it is possible to say that the ulcer is unavoidable. It\u0026rsquo;s important to note that this also means that the unavoidability of a lesion cannot be predetermined, without evaluating the whole care process (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are more issues concerning how to accurately recognise terminal ulcers, not only because of the complex terminology, but also because they can only be diagnosed after patient\u0026rsquo;s death. Moreover, since the aetiology is not yet fully understood and these ulcers often occur in areas exposed to pressure, they are difficult to distinguish from pressure injuries (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe treatment of this condition should be limited to a palliative approach focusing on caring for the individual rather than curing the skin (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It has been stated that a proper care plan should be developed according to the patient\u0026rsquo;s and, when possible, the family\u0026rsquo;s priorities, which may differ from those of the healthcare team (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to Emmons and Lachman (2010), possible goals of the palliative wound management are (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePreventing the deterioration of the wound, while achieving its stabilization\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePromoting a clean and protected wound environment\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMinimizing the risk of infection or sepsis\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eManaging pain, odour and exudate\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eReducing the frequency of dressing changes\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eControlling the risk of bleeding\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePreventing wound bed and periwound skin from the risk of trauma\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eControlling moisture and preventing maceration\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEliminating pruritus\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe plan of care needs to be implemented by a multidisciplinary team, including different professional roles, such as nurses, physician and many others, according to the specific case (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEven if skin care is a part of palliative care, it still exists a issue about management of terminal wounds: while pressure ulcers are considered preventable, some of the ulcers that arise at the end of life are unavoidable. In such cases, it should be considered whether to deliver skin care, what to do or what to withdraw from, according to patient\u0026rsquo;s preferences and priorities (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearch has indicated that approximately 25% of patients receiving palliative care are affected by pressure ulcers, suggesting that the end-of-life population is more susceptible to the development of pressure injuries compared to the general population (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, the development of these ulcers is not always associated to shortfall in standard of care but in some cases, ulcers occur despite a proper pressure relief therapy, or an appropriate care plan, aligned with patient\u0026rsquo;s wishes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, the terminology employed in relation to such ulcers constitutes an additional concern: the literature reveals a necessity to simplify the nomenclature surrounding terminal ulcers, with a view to unifying overlapping concepts and elucidating the relationship between unavoidable pressure injuries and terminal ulcers (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn summary, there is a requirement for consistent terminology for this kind of skin ulcer (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) in order to enhance the quality of care for patients and their families: while misdiagnosing a pressure ulcer as a terminal one may result in undertreatment, inaccurate labelling patients with a terminal ulcer may cause emotional distress to patients and families (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), preventing them from receiving adequate treatment.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Aims\u003c/h2\u003e \u003cp\u003eThe scoping review aims to shed light on the current state of knowledge regarding terminal ulcers, which are frequently overlooked and misclassified as other types of lesions, particularly pressure injuries (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Specifically, the researchers want to highlight the issues of definition of the concept of unavoidability, the terminology used in relation to terminal ulcers, the diagnostic criteria and assessment tools, prevention and management, and the aetiology of this type of ulcer, for all patients in all healthcare settings. Moreover, we would like to understand the clinicians\u0026rsquo; awareness regarding this topic and its repercussions on the quality of care.\u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Design\u003c/h2\u003e \u003cp\u003eTo achieve these goals, a scoping review was chosen as the most suitable methodology, since it helps to map evidence and to clarify main concepts (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe review followed the five-step process described by Arksey and O\u0026rsquo;Malley framework (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). First, the research question was identified. Then, relevant studies were found. Next, studies were selected. Then, the data was charted. Finally, the results were collected, summarised and reported.\u003c/p\u003e \u003cp\u003eMoreover, the Preferred Reporting Items for Systematic reviews and Meta-Analysis, extended to Scoping Reviews checklist (PRISMA-ScRs) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and the JBI guidelines (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) were used as methodological guides for the structure of this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Clarifying the research question\u003c/h2\u003e \u003cp\u003eTo achieve the goals of this scoping review, the following research questions were identified:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHow can the concept of unavoidability be defined?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhat is the correct terminology regarding terminal ulcers?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAre there any diagnostic criteria or assessment tools that could help healthcare professionals to recognise this type of skin breakdown?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCan these injuries be prevented?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHow should they be managed?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhat causes these ulcers?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHow aware are healthcare professionals of terminal ulcers?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Search methods\u003c/h2\u003e \u003cp\u003eFollowing the framework provided by the Joanna Briggs Institute (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), a search strategy as comprehensive as possible was set up, using the three-step search strategy:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFirst of all, only two databases were used (PubMed and CINAHL) in order to identify the most appropriate keywords\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThen, the keywords contained in the most significant articles were analysed; a more complete search was carried out across all the included databases based on the newly identified keywords. This step was carried out with the help of a librarian\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLastly, the reference lists the articles included were searched for additional sources\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe search string was created based on the PCC mnemonic (population, concept, context) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e):\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;Population: patients of any age, at the end of life\u003c/p\u003e \u003cp\u003eC\u0026thinsp;=\u0026thinsp;Concept: terminal ulcers\u003c/p\u003e \u003cp\u003eC\u0026thinsp;=\u0026thinsp;Context: any settings\u003c/p\u003e \u003cp\u003eWe systematically searched PubMed, Scopus, CINAHL, Embase, Google Scholar, ProQuest databases, up to March 2025, with no time or methodological limitations. The language included was English. The search terms used were \u0026ldquo;palliative wound care\u0026rdquo;, \u0026ldquo;pressure ulcer\u0026rdquo;, \u0026ldquo;skin ulcer\u0026rdquo;, \u0026ldquo;terminal ulcer\u0026rdquo;, \u0026ldquo;Kennedy terminal ulcer\u0026rdquo;, \u0026ldquo;Trombley-Brennan terminal ulcer\u0026rdquo;. Quotation marks and the Boolean operators AND and OR were used, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The reference lists of the identified papers were examined in order to include any other relevant sources.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the full electronic search strategies for each database used.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSearch strategies for each database\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDATABASE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSEARCH STRATEGY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNUMBER of RECORDS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScopus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(TITLE-ABS-KEY (\"pressure injur*\" OR \"pressure ulcer*\" OR \"skin ulcer\" OR \"terminal ulcer*\" OR \"kennedy terminal\" OR \"trombley-brennan\" OR \"terminal injury\" OR \"deep injury\") AND TITLE-ABS-KEY (\"palliative care\" OR \"terminal care\" OR \"end of life\")) OR TITLE-ABS-KEY (\"palliative wound care\" OR \"palliative wound*\" OR \"palliative pressure ulcer*\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e491\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePubMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(palliative wound care[title/abstract] OR palliative wound*[title] OR palliative pressure ulcer*[title]) OR ((pressure injur*[ti] OR pressure ulcer*[ti] OR skin ulcer[mesh:noexp] OR pressure ulcer[mesh] OR terminal ulcer*[title] OR kennedy[title/abstract] OR trombley-brennan[title/abstract] OR terminal injury[title] OR deep injury[title]) AND (palliative care[mesh] OR terminal care[mesh] OR terminal[title] OR palliative[title] OR end of life[title] OR terminally[title]))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e354\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCINAHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\"pressure injur*\" OR \"pressure ulcer*\" OR \"skin ulcer\" OR \"terminal ulcer*\" OR \"kennedy terminal\" OR \"trombley-brennan\" OR \"terminal injury\" OR \"deep injury\") AND (\"palliative care\" OR \"terminal care\" OR \"end of life\") OR (\"palliative wound care\" OR \"palliative wound*\" OR \"palliative pressure ulcer*\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e409\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoogle Scholar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\"pressure\u0026nbsp;injury*\" OR \"pressure ulcer*\" OR \"skin ulcer\" OR \"terminal ulcer*\" OR \"kennedy terminal\" OR \"trombley-brennan\" OR \"terminal injury\" OR \"deep injury\") AND (\"palliative care\" OR \"terminal care\" OR \"end of life\") OR (\"palliative wound care\" OR \"palliative wound*\" OR \"palliative pressure ulcer*\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmbase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e((\"pressure injur*\" OR \"pressure ulcer*\" OR \"skin ulcer\" OR \"terminal ulcer*\" OR \"kennedy terminal\" OR \"trombley-brennan\" OR \"terminal injury\" OR \"deep injury\") AND (\"palliative care\" OR \"terminal care\" OR \"end of life\")):ti,ab,kw OR (((\"palliative wound care\" OR \"palliative wound*\" OR \"palliative pressure ulcer*\")):ti,ab,kw)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e351\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProquest Database\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e((\"terminal ulcer*\" OR \"kennedy terminal\" OR \"trombley-brennan\" OR \"terminal injury\" OR \"deep injury\") AND (\"palliative care\" OR \"terminal care\" OR \"end of life\")) OR (\"palliative wound care\" OR \"palliative wound*\" OR \"palliative pressure ulcer*\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTotal number of records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 734\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003e \u003cem\u003eInclusion criteria\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBroad inclusion criteria were selected to avoid the losing of important evidence:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eStudies that make explicit reference to terminal injuries that occur at the end of life\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStudies encompassing individuals of all age groups, cared for in any setting\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAny methodology\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNo restrictions on the publication period\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStudies published in English\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eResearch papers for which the full text is available\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eExclusion criteria\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOn the other hand, the following criteria were used not to include a research paper in this scoping review:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eStudies dealing with injuries that arise in the final stages of life different from terminal ulcers, such as fungating malignant wounds\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStudies published in a language different from English\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStudies for which the full text cannot be found\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Study selection\u003c/h2\u003e \u003cp\u003eInitially identified references (n\u0026thinsp;=\u0026thinsp;1 734) were imported into Rayyan, a free software aimed to assist researchers in the first phases of a review. After the duplicate removal, three researchers (D.C., D.C., I.S.) independently screened the titles and abstracts, assigning a rating to each research paper. The researchers found out a consensus about the inclusion, if it was lacking at the beginning, according to the inclusion and exclusion criteria. The selection process has been documented through the PRISMA diagram (Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Quality appraisal\u003c/h2\u003e \u003cp\u003eA quality appraisal of the included studies was not performed, according to the methodology (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Data charting\u003c/h2\u003e \u003cp\u003eThe research team developed two data-charting tables to collect all the data and summarise the main results of each study included, presented as Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eREF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTITLE, AUTHOR, YEAR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMETHODOLOGY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDEFINITION OF THE CONCEPT OF UNAVOIDABILITY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTERMINOLOGY REGARDING TERMINAL ULCERS\u003c/p\u003e \u003cp\u003e(See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDIAGNOSTIC CRITERIA AND ASSESSMENT TOOLS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePREVENTION AND MANAGEMENT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAETIOLOGY OR RISK FACTORS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAWARENESS AND EDUCATION\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound evaluation of Kennedy terminal ulcer: case study.\u003c/p\u003e \u003cp\u003eTavares Gomes, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIt is important to\u003c/p\u003e \u003cp\u003eemphasize that unlike pressure injuries, a KTU cannot be prevented through care, and is considered unavoidable and not attributable to substandard care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKennedy Terminal Ulcers (KTUs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe use of ultrasound as a tool that complements the clinical examination by nurses is an important milestone for documenting this kind of ulcer.\u003c/p\u003e \u003cp\u003eThe KTU-type injury exhibited a pattern similar to the cobblestone-like appearance.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKTUs are important indicators of imminent mortality,\u003c/p\u003e \u003cp\u003ehelping to clarify the need for often exclusive palliative care\u003c/p\u003e \u003cp\u003eand corroborating the understanding of the exhaustion of\u003c/p\u003e \u003cp\u003etherapeutic interventions, avoiding dysthanasia because of\u003c/p\u003e \u003cp\u003etherapeutic obstinacy.\u003c/p\u003e \u003cp\u003eNurses involved in this case-study performed the differential diagnosis,\u003c/p\u003e \u003cp\u003einformed the family and modified the therapeutic plan from\u003c/p\u003e \u003cp\u003ethe perspective of palliative care, anticipating death.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFor cardiology patients several important factors may contribute to skin failure, such as shock states with macro- and micro-hemodynamic alterations and prolonged use of vasopressors and inotropes that directly affect circulation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIn this case, the healthcare team was led by a wound\u003c/p\u003e \u003cp\u003ecare nurse in the unit where the KTU was identified. The team has been strengthening ongoing education about skin\u003c/p\u003e \u003cp\u003eprevention and wound treatment, significantly increasing the quality of records. These efforts helped to correctly identify\u003c/p\u003e \u003cp\u003ethe KTU.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReexamining the literature on terminal ulcer, SCALE, skin failure, and unavoidable pressure injuries.\u003c/p\u003e \u003cp\u003eAyello, 2019.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNarrative Review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- Kennedy Terminal Ulcer (KTU)\u003c/p\u003e \u003cp\u003e- 3:30 Syndrome\u003c/p\u003e \u003cp\u003e- Trombley Brennan Terminal Tissue Injury (TB-TTI)\u003c/p\u003e \u003cp\u003e- SCALE\u003c/p\u003e \u003cp\u003e- Skin Failure\u003c/p\u003e \u003cp\u003e- Decubitus Ominosus\u003c/p\u003e \u003cp\u003e- Miller Pressure Equivalent Injuries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRISK FATCTORS\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e. Chronic disease, infections, acute injuries.\u003c/p\u003e \u003cp\u003e. Pain is associated with more pressure injuries.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHaving multiple terms to describe these phenomena can be confusing and may impede communication among clinicians, especially across disciplines.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDevelopment of a wound assessment tool for use in adults at end of life: a modified Delphi study.\u003c/p\u003e \u003cp\u003eLatimer, 2023.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModified Delphi study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTerminal ulcers (TUs), which include KTU and TB-TTI, are considered unavoidable injuries associated with dying.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTU are pear-, horseshoe- or butterfly-shaped red, black or maroon skin ulcers that quickly develop in the absence of external pressure on the buttock, sacrum, spine and extremities.\u003c/p\u003e \u003cp\u003eTU can develop in a matter of hours from intact skin to a deep wound.\u003c/p\u003e \u003cp\u003eTU often develop in months, weeks, days or hours before death.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA panel of international wound experts developed an \u0026ldquo;End of Life Wound Assessment Tool\u0026rdquo;.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrelude to death or practice failure? Trombley-Brennan terminal tissue injury update.\u003c/p\u003e \u003cp\u003eBrennan, 2019.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- TB-TTI\u003c/p\u003e \u003cp\u003e- SCALE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTREATMENT:\u003c/p\u003e \u003cp\u003eTB-TTIs, as a prognosticator of death, will allow clinician to make necessary changes in the plan of care and discontinue aggressive interventions and testing, while shifting curative care to comfort care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTB-TTIs are not related to pressure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCALE: Skin Changes at Life\u0026rsquo;s End: Final Consensus Statement: October 1, 2009\u003c/p\u003e \u003cp\u003eSibbald, 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModified Delphi method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAt the end of life, failure of the homeostatic mechanisms that support the skin can occur, resulting in a diminished reserve to handle insults such as minimal pressure. Therefore, contrary to popular myth, not all PIs are avoidable.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- SCALE\u003c/p\u003e \u003cp\u003e- Skin Failure\u003c/p\u003e \u003cp\u003e- Decubitus ominosus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e. Charting by exception is an appropriate method of documentation\u003c/p\u003e \u003cp\u003e. SCALE statement describes 5 P\u0026rsquo;s for determining appropriate intervention strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe body may react to crisis conditions by shunting blood away from the skin to these vital organs, resulting in decreased skin and soft-tissue perfusion, and a reduction of the normal cutaneous metabolic processes.\u003c/p\u003e \u003cp\u003eDiminished tissue perfusion is the most significant risk factor for SCALE.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eThe panel concluded that healthcare practitioners\u0026rsquo; current comprehension of skin changes that can occur at life\u0026rsquo;s end is limited.\u003c/p\u003e \u003cp\u003eHealthcare professionals need to facilitate communication and collaboration across care settings and disciplines; organizations need to prepare staff to identify and manage SCALE.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse of electronic health records to identify factors related to skin changes in terminal patients.\u003c/p\u003e \u003cp\u003eChan, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e\u0026minus;\u0026thinsp;3:30 Syndrome\u003c/p\u003e \u003cp\u003e- TB-TTI\u003c/p\u003e \u003cp\u003eSkin color changes are indicative of the degree of skin ischemia.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDespite the frequent occurrence of terminal ulcers on bony prominences, the literature is inconclusive whether terminal ulcer vary from pressure related injuries, which complicates the precise diagnosis and treatment of these conditions.\u003c/p\u003e \u003cp\u003e\u003cb\u003ePREDICTORS OF SCALE\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e. Elevated ECOG grades (ECOG (Eastern Cooperative Oncology Group) grade, also known as ECOG performance status (PS), is\u0026nbsp;a scale used to assess how a patient's disease affects their daily functioning and physical ability.\u0026nbsp;It ranges from 0 to 5, with 0 indicating full activity and 5 indicating death)\u003c/p\u003e \u003cp\u003e. Higher CCI scores (Charlson Comorbidity Index, indicative of greater comorbility burden)\u003c/p\u003e \u003cp\u003e. Decreased Braden scale, particularly before death.\u003c/p\u003e \u003cp\u003e. The incidence of SCALE increased with age.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eGOALS OF CARE\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e. Maximize patient\u0026rsquo;s comfort and ensuring a dignified dying process.\u003c/p\u003e \u003cp\u003e.\u003c/p\u003e \u003cp\u003e. Conservative management of the wound, even if preventing all instances of skin breakdown might not be achievable.\u003c/p\u003e \u003cp\u003e. Regular repositioning, effective moisture management, adequate nutrition, management of the underlying condition.\u003c/p\u003e \u003cp\u003e. Pain management.\u003c/p\u003e \u003cp\u003e. Document meticulously all interventions, providing evidence of the quality of care administered.\u003c/p\u003e \u003cp\u003e. Communication with family member.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe vulnerability of the skin results from inadequate blood perfusion in the skin and subcutaneous tissue, often accompanied by severe dysfunction or failure of other organ systems.\u003c/p\u003e \u003cp\u003eSCALE doesn\u0026rsquo;t stem from external pressures or shear stress, but from intrinsic factors.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnavoidable pressure injuries, terminal ulceration and skin failure: in search of a unifying classification system.\u003c/p\u003e \u003cp\u003eLevine, 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommentary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe literature is unclear as to whether \u0026ldquo;terminal ulcers\u0026rdquo; are different from pressure-related injuries, even though they commonly appear over bony prominences.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- Skin Failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHYPOTESIS:\u003c/p\u003e \u003cp\u003e. Destructive pathways that share commonalities with other organs system failure, such as inflammation or fibrosis.\u003c/p\u003e \u003cp\u003e. Genetic factors that underlie vascular responses to ischemia.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMany conditions associated with unavoidable pressure injuries are present in patients in intensive care. Despite this, few intensivists would accept the terminology \u0026ldquo;terminal ulcer\u0026rdquo;.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin failure in patients with a terminal illness.\u003c/p\u003e \u003cp\u003eJulian, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContinuing -Education Article\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe patient who\u0026rsquo;s terminally ill and entering the final stage of the dying process is at the greatest risk for developing skin breakdown.\u003c/p\u003e \u003cp\u003ePressure injuries that occur in the pre-active or active phases of dying are considered terminal injuries, with unavoidable nature.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- Kennedy Terminal Ulcer (KTU)\u003c/p\u003e \u003cp\u003e- 3:30 Syndrome\u003c/p\u003e \u003cp\u003e- Trombley Brennan Terminal Tissue Injury (TB-TTI)\u003c/p\u003e \u003cp\u003e- SCALE\u003c/p\u003e \u003cp\u003e- Skin Failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThere are no specific biomarkers, as\u003c/p\u003e \u003cp\u003ewith other organs, to determine whether\u003c/p\u003e \u003cp\u003eskin is compromised. Diagnosis is also\u003c/p\u003e \u003cp\u003ecomplicated by the fact that both a pressure injury and skin failure can happen simultaneously.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e. The SCALE statement also recommends a 5 Ps approach to treatment\u003c/p\u003e \u003cp\u003e. The treatment plan may differ as goals shift from complete wound healing to providing the patient with the best quality of life.\u003c/p\u003e \u003cp\u003e. Controlling exudate and odor, minimizing pain, environment free of moisture\u003c/p\u003e \u003cp\u003e. Frequent repositioning must be weighed against the potential for\u003c/p\u003e \u003cp\u003einflicting unnecessary pain.\u003c/p\u003e \u003cp\u003e. Providing counseling and education so families have realistic expectations for wound healing.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin changes at life\u0026rsquo;s end: SCALE ulcer or pressure ulcer?\u003c/p\u003e \u003cp\u003eBeldon, 2011.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNarrative review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePressure damage at the end of life may be inevitable in some individuals.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- SCALE\u003c/p\u003e \u003cp\u003e- Skin Failure\u003c/p\u003e \u003cp\u003e- Decubitus ominosus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe ability of predict which patients may develop a pressure ulcer or a SCALE ulcer is currently not possible.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eTREATMENT\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e. Plan of care and documentation\u003c/p\u003e \u003cp\u003e. Pressure-relieving support surface: not all patients find these surfaces comfortable because they may exacerbate pain, contribute towards nausea and restrict the ability of independent movement.\u003c/p\u003e \u003cp\u003e. Total skin assessment performed regularly\u003c/p\u003e \u003cp\u003e. Sought advice from an identified expert\u003c/p\u003e \u003cp\u003e. Palliation of symptoms, preservation of skin, respect of patient wishes\u003c/p\u003e \u003cp\u003e. Education for patient and family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eHypoperfusion\u003c/b\u003e: at the end of life the patient may be unable to maintain blood pressure sufficiently to adequately perfuse the extremities and the skin.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePressure ulcers at the end of life.\u003c/p\u003e \u003cp\u003eElbourne, 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEditorial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLesions appear suddenly and rapidly deteriorate from a superficial ulcer to a category 3 or 4.\u003c/p\u003e \u003cp\u003eThese ulcers can have a blush or purple color and can look like dirt or fecal remains.\u003c/p\u003e \u003cp\u003eBilateral presentation can cause confusion between SCALE and MASD (moisture associated skin damage), if the patient has incontinence.\u003c/p\u003e \u003cp\u003eLesions may begin as numerous superficial spots and then become a larger lesion in a matter of hours.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eGOAL OF CARE\u003c/b\u003e: wound management and good quality of life, rather than wound healing.\u003c/p\u003e \u003cp\u003eDiscuss wound management plan with patients and their families.\u003c/p\u003e \u003cp\u003eDiscuss the necessity for repositioning, so as to establish the best possible treatment for the individual\u0026rsquo;s end of life care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe main difference between SCALEs and pressure injuries is in etiology: SCALEs are often unavoidable and a result of multiorgan failure.\u003c/p\u003e \u003cp\u003eVasopressor medication may be related to the development of SCALE.\u003c/p\u003e \u003cp\u003ePATIENTS AT RISK:\u003c/p\u003e \u003cp\u003ethose with respiratory, renal, circulatory insufficiency, hypoalbuminemia, hypoxemia, or insufficiency of two or more organs.\u003c/p\u003e \u003cp\u003eHypoperfusion\u003c/p\u003e \u003cp\u003eAlteration of elimination of toxic metabolites\u003c/p\u003e \u003cp\u003eDecreased defensive capacity of the skin\u003c/p\u003e \u003cp\u003eLoss weight, loss appetite, cachexia, poor nutrition, reduced mobility, low albumin levels.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnd-of-life wounds and pressure injuries in dying adults: distinguishing the difference.\u003c/p\u003e \u003cp\u003eLatimer, 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEditorial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnd-of-life (EOL) wounds only occur in some patients who can develop pressure injuries as well.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEOL wounds occur on the buttocks, sacrum, extremities and spine. They appear as pear- horseshoe- or butterfly- shaped injuries, red, black or maroon, with the skin intact or ulcerated.\u003c/p\u003e \u003cp\u003eThey develop suddenly, in days, weeks or months before a person\u0026rsquo;s death, and they rapidly progress from a Stage 1 to a Stage 4 in several hours.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eMANAGEMENT\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eExudate containment\u003c/p\u003e \u003cp\u003ePain management\u003c/p\u003e \u003cp\u003eEducate patient and families about the imminent nature of death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypoperfusion and multi-organ system failure are thought to be contributing factors.\u003c/p\u003e \u003cp\u003eEnd-of-life wound may develop in absence of pressure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClinician\u0026rsquo;s limited awareness of EOL wounds results in their misclassification and reporting as PIs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy terminal ulcer: a scoping review.\u003c/p\u003e \u003cp\u003eLatimer, 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- Kennedy Terminal Ulcer (KTU)\u003c/p\u003e \u003cp\u003e- 3:30 Syndrome\u003c/p\u003e \u003cp\u003e- Trombley Brennan Terminal Tissue Injury\u003c/p\u003e \u003cp\u003e- SCALE\u003c/p\u003e \u003cp\u003e- Skin Failure\u003c/p\u003e \u003cp\u003e- Decubitus Ominosus\u003c/p\u003e \u003cp\u003e- Miller Pressure Equivalent Injuries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAssessing and staging KTU is difficult because of the lack of assessment tools.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTreatment requires combined approach of palliative care, pressure relieving skin care, advanced wound management, wound exudate and odor management, family and staff education and counselling.\u003c/p\u003e \u003cp\u003eConsultation with specialist wound nurses, physicians and allied health care professionals is the first step for KTU management.\u003c/p\u003e \u003cp\u003eEducating families about possible unavailable skin changes\u003c/p\u003e \u003cp\u003eSetting realistic wound management goals\u003c/p\u003e \u003cp\u003eMaintaining patient\u0026rsquo;s comfort and dignity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAssessing and staging KTU is difficult because of the low rate of KTU awareness among clinicians.\u003c/p\u003e \u003cp\u003eIt is recommended that only advanced clinical specialists undertake this assessment.\u003c/p\u003e \u003cp\u003eIt is vital to arise clinician\u0026rsquo;s awareness of the unavoidable nature of KTU so that realistic wound care expectations will be set.\u003c/p\u003e \u003cp\u003eClinicians often feel ill-prepared to have an open discussion with patients about their impelling death: educating clinicians about KTU will help them to support dying patients and their families.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy terminal ulcer and other skin wounds at the end of life: an integrative review.\u003c/p\u003e \u003cp\u003eRoca-Biosca, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntegrative review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAn unavoidable pressure injury is one that develops even if the caregiver has: evaluated the patient\u0026rsquo;s clinical condition and PI risk factors; defined and implemented interventions that are consistent with the patient\u0026rsquo;s needs and goals and with recognized practice standards; monitored and evaluated the impact of interventions; revised these approaches as appropriate.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- TB-TTI\u003c/p\u003e \u003cp\u003e- SCALE\u003c/p\u003e \u003cp\u003e- Skin Failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThere are no clinical studies or validated algorithms that allow us to determine which PUs are unavoidable.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 Periodic monitoring and recording skin changes, in order to prevent greater deterioration\u003c/p\u003e \u003cp\u003e2 Prioritizing palliative care: manage symptoms, comfort and well-being\u003c/p\u003e \u003cp\u003e3 Wound pain management, infection prevention, avoiding perilesional maceration\u003c/p\u003e \u003cp\u003e4 Non aggressive care plan that seeks the welfare and comfort of patient and family\u003c/p\u003e \u003cp\u003e5 Emotional assistance and support to patient and family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe main hypothesis is that KTU and TB-TTI are caused by skin failure or skin death. The skin failure is caused by a decrease of blood flow (hypoperfusion) and hypoxemia, produced by multiple organ failure.\u003c/p\u003e \u003cp\u003eOTHER FACTORS THAT COULD INFLUENCE:\u003c/p\u003e \u003cp\u003e1 Pressure and rubbing\u003c/p\u003e \u003cp\u003e2 Vasopressor medication\u003c/p\u003e \u003cp\u003e3 Alteration in the elimination of toxic metabolites\u003c/p\u003e \u003cp\u003e4 Decreased defensive capacity of the skin\u003c/p\u003e \u003cp\u003e5 Low weight, loss of appetite, cachexia, reduced mobility, poor nutrition, low albumin levels.\u003c/p\u003e \u003cp\u003e6 Respiratory, renal or circulatory insufficiency, hypoalbuminemia, hypoxemia, or insufficiency of two or more organs.\u003c/p\u003e \u003cp\u003eWe are not evaluating wounds but people, so contextual elements, like the patient health status and the context of appearance, are essential for a proper differential diagnosis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIt is possible that professionals\u0026rsquo; ignorance means that this pathological entity is underdiagnosed in settings different from palliative care or long stay units.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy terminal ulcers and Trombley Brennan terminal tissue injuries: mistery solved?\u003c/p\u003e \u003cp\u003eMelnychuck, 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHypothesis from experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMost terminal skin changes occur in the sacral, coccygeal and gluteal areas; fewer report have described them on the lower extremities, spine or ribs. Some don\u0026rsquo;t ulcerate.\u003c/p\u003e \u003cp\u003eSome have been observed in children on vasoactive agents.\u003c/p\u003e \u003cp\u003eThese lesions have been observed both in areas under pressure and in areas without any external pressure (eg, anterior legs)\u003c/p\u003e \u003cp\u003eSome are symmetrical, but unilateral lesion have also been seen.\u003c/p\u003e \u003cp\u003eTerminal skin lesions have various degree of epidermolysis with transient blistering.\u003c/p\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- TB-TTI\u003c/p\u003e \u003cp\u003e- Decubitus ominosus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTerminal ulceration develop due to hypoperfusion of tissues in the final stages of life.\u003c/p\u003e \u003cp\u003eEveryone develops hypoperfusion before death but not everyone develops terminal skin changes.\u003c/p\u003e \u003cp\u003ePOSSIBLE CONTRIBUTING FACTORS:\u003c/p\u003e \u003cp\u003e1 Use of vasoactive agents\u003c/p\u003e \u003cp\u003e2 Hypotension\u003c/p\u003e \u003cp\u003e3 External pressure\u003c/p\u003e \u003cp\u003e3 Anatomic arterial aberrancies\u003c/p\u003e \u003cp\u003e4 Reperfusion injury in cases of recurrent hypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIncidence has not been well established.\u003c/p\u003e \u003cp\u003eSome ulceration may be unrecognized and some terminal ulcers may be mistaken for PIs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstanding the Kennedy Terminal Ulcer.\u003c/p\u003e \u003cp\u003eKennedy-Evans, 2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEditorial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eShaped like a pear, a butterfly or a horseshoe, usually on the coccyx or sacrum but can appear in other areas, had the color of red, yellow and black, had a sudden onset, and death was imminent.\u003c/p\u003e \u003cp\u003eThe edges are usually irregular and may develop rapidly to a Stage II, III or IV ulcer.\u003c/p\u003e \u003cp\u003eKTU is a subset of pressure ulcers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly skin temperature characteristics of the Kennedy lesion (Kennedy terminal ulcer).\u003c/p\u003e \u003cp\u003eKennedy-Evans, 2023.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObservational study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU (Kennedy lesion)\u003c/p\u003e \u003cp\u003e- TB-TTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEarly skin temperature of the KL, occurring within 24 hours of a newly identified area of discoloration.\u003c/p\u003e \u003cp\u003eAbnormal if Relative Temperature Differential (RTD) is \u0026gt;\u0026thinsp;+\u0026thinsp;1.2\u0026deg;C or \u0026lt;-1.2\u0026deg;C.\u003c/p\u003e \u003cp\u003eThere\u0026rsquo;s a lack of skin temperature change in several patient with KLs, which contrasts with the majority of the studies examining skin temperature changes of PIs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eRISK FACTORS\u003c/b\u003e for skin failure and thus for KL are:\u003c/p\u003e \u003cp\u003e. Multiple organ disfunction\u003c/p\u003e \u003cp\u003e. Hypotension\u003c/p\u003e \u003cp\u003e. Use of vasopressor\u003c/p\u003e \u003cp\u003e. Use of mechanical ventilation\u003c/p\u003e \u003cp\u003e. Co-morbid conditions (cardio-vascular disease, smoking, pneumonia, sepsis\u0026hellip;)\u003c/p\u003e \u003cp\u003e. Abnormal white cell counts\u003c/p\u003e \u003cp\u003e. Malnutrition, low albumin levels\u003c/p\u003e \u003cp\u003e. Immobility\u003c/p\u003e \u003cp\u003e. Aging, that is associated with altered immune responses and changes in vascular structure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvoidable \u0026amp; Inevitable? Skin Failure: the Kennedy Terminal Lesion.\u003c/p\u003e \u003cp\u003eLepak, 2012.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNarrative review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot all PIs are preventable, especially those at the end-of-life.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- Decubitus ominosus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eTREATMENT\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e. Pain control\u003c/p\u003e \u003cp\u003e. Odor, infection and drainage control\u003c/p\u003e \u003cp\u003e. Palliative wound care: the primary goal should shift to symptoms and psychological management.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDuring the physiological process of dying, the body shunts blood from the periphery to maintain vital organs making it more difficult to prevent external stresses from damaging the integumentary.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy Terminal Ulcer #383.\u003c/p\u003e \u003cp\u003eBateman, 2019.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpert opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- 3:30 Syndrome\u003c/p\u003e \u003cp\u003e- Skin Failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003ePREVENTION\u003c/b\u003e: similar to the one for pressure ulcers.\u003c/p\u003e \u003cp\u003e\u003cb\u003eMANAGEMENT\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e. Similar to any pressure ulcers but with few unique elements\u003c/p\u003e \u003cp\u003e. Emotional support and KTU counselling for caregivers\u003c/p\u003e \u003cp\u003e. Individual judgement to determine the need for repositioning in dying patients\u003c/p\u003e \u003cp\u003e. Premedicating with an as needed analgesic before repositioning\u003c/p\u003e \u003cp\u003e. Involve more than one person to assist with the repositioning\u003c/p\u003e \u003cp\u003e. Use of pressure-relieving surfaces in order to reduce pain\u003c/p\u003e \u003cp\u003e. Manage odor with proper dressing (metronidazole or charcoal)\u003c/p\u003e \u003cp\u003eNeed for clear documentation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric Kennedy Terminal Ulcer.\u003c/p\u003e \u003cp\u003eReitz, 2016.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKTU most commonly presents as a dark red and pear-shaped with irregular borders on the coccyx, but it may also be yellow or black and may be found in other locations.\u003c/p\u003e \u003cp\u003eIt progresses dramatically within hours to 2 weeks preceding a patient\u0026rsquo;s death.\u003c/p\u003e \u003cp\u003eIt develops rapidly in size and depth; it may appear as an abrasion or blister and can progress to a stage III or IV ulcer.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnderrecognized phenomenon in children\u003c/p\u003e \u003cp\u003eKTU is in fact distinct from PIs: identifying this difference can have a potential impact on reimbursement.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003ePrevention\u003c/b\u003e: KTU develops despite use of preventive measures. Strategies to mitigate risks include:\u003c/p\u003e \u003cp\u003e1 Optimizing nutritional support\u003c/p\u003e \u003cp\u003e2 Using appropriate pressure redistribution surfaces\u003c/p\u003e \u003cp\u003e3 Moisture management\u003c/p\u003e \u003cp\u003e4 Frequent repositioning\u003c/p\u003e \u003cp\u003e\u003cb\u003eTreatment in paediatric ICU\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e1 Optimize peripheral oxygen and substrate delivery\u003c/p\u003e \u003cp\u003e2 Mantaining skin\u0026rsquo;s acid mantle\u003c/p\u003e \u003cp\u003e3 Optimize child\u0026rsquo;s nutrition\u003c/p\u003e \u003cp\u003e4 The underlying cause of organ failure should be treated rather than using pressure redistribution.\u003c/p\u003e \u003cp\u003e\u003cb\u003eSet appropriate goals\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e1 Controlling pain\u003c/p\u003e \u003cp\u003e2 Preventing infections\u003c/p\u003e \u003cp\u003e3 Managing any drainage to prevent maceration of the peri-wound skin.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKTU originates from skin failure rather than from pressure or shearing (PUs).\u003c/p\u003e \u003cp\u003eIt occurs when skin, like other organ systems, exhibits increasing signs of dysfunction.\u003c/p\u003e \u003cp\u003e\u003cb\u003eIntrinsic factors\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e1 hypoperfusion and ischemia, associated with multiorgan failure\u003c/p\u003e \u003cp\u003e\u003cb\u003eRisk factors are\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e1. Multiple organ failure\u003c/p\u003e \u003cp\u003e2. Vasopressor medications\u003c/p\u003e \u003cp\u003e3. Respiratory failure, diabetes mellitus, hypoalbuminemia, hypoxemia, renal disease, failure of two or more organs beside the skin.\u003c/p\u003e \u003cp\u003e\u003cb\u003eFactors that contribute are\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e1 Use of vasopressors\u003c/p\u003e \u003cp\u003e2 Use of cooling mattress\u003c/p\u003e \u003cp\u003e3 Anemia, malnutrition, immobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eThe pediatric nurse practitioner can help the team about the pathophysiology of the KTU and lead discussions about the treatment plan.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing care plan for the Kennedy terminal ulcer patient. Case report.\u003c/p\u003e \u003cp\u003eAlarc\u0026oacute;n-Alfonso, 2022.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThere are no unified diagnostic criteria so information on the aetiology and pathophysiology is incomplete.\u003c/p\u003e \u003cp\u003eThe differential diagnosis of KTU is difficult because of its similarities to Pus.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePriority given to patient comfort and pain control, odor management, preventing new ulcers, avoid complications, helping the family to cope with the situation.\u003c/p\u003e \u003cp\u003eIndividualized care plan.\u003c/p\u003e \u003cp\u003eEmotional support and counselling for patient and family.\u003c/p\u003e \u003cp\u003e\u003cb\u003ePrevention\u003c/b\u003e: strategy similar to that of PUs is recommended.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1 Lack of training of healthcare professionals in ulcers other than PUs.\u003c/p\u003e \u003cp\u003e2 The use of different terms (KTU, TBTL\u0026hellip;) is confusing as they are very similar concepts.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy\u0026rsquo;s terminal ulcer and pressure injury: two different aspects of medical liability related to the same injury.\u003c/p\u003e \u003cp\u003eGarcea, 2023.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase series\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMedical competence: palliative therapy for local and systemic pain.\u003c/p\u003e \u003cp\u003eNursing competence: nurses are responsible for the correct management of lesions and treatments, together with possible complications.\u003c/p\u003e \u003cp\u003eA correct diagnosis of a terminal lesion doesn\u0026rsquo;t fully protect against convictions because in lawsuits it is necessary to provide proper evidence for every single choice, even that of reducing mobilizations to avoid unless pain. An informed consent, possibly signed by the patient, is a necessary safeguard.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Death of the Kennedy Terminal Ulcer.\u003c/p\u003e \u003cp\u003eMiller, 2016.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpert opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKTU describes a rapid progression of a pressure-based tissue injury or itself is an indicator of terminal status.\u003c/p\u003e \u003cp\u003eThey propose the concept of Miller Pressure Equivalent Injuries (MPEI).\u003c/p\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- Miller Pressure Equivalent Injuries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe presumption that a terminal condition alone will result in a pressure-based tissue injury, despite appropriate care, is not a viable consideration because:\u003c/p\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e Systemic diseases have an equal effect on all body tissues\u003c/p\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e If a turning schedule is utilized, pressure, friction and shear would have the same effect on all the body, so why just one specific area is affected by KTU?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoly Ulceration Patient Terminal: Kennedy Terminal Ulcer (KTU).\u003c/p\u003e \u003cp\u003eSarabia-Cobo, 2017.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpert opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1983: Karen Lou Kennedy coined the term KTU; 1989: first description at NPUAP.\u003c/p\u003e \u003cp\u003eSudden appearance of multiple PIs in elderly patients may be indicative of closeness to death\u003c/p\u003e \u003cp\u003eUnavoidable skin breakdown which occurs in some patients as part of the dying process.\u003c/p\u003e \u003cp\u003eOccurs not long before the death.\u003c/p\u003e \u003cp\u003e\u003cb\u003e5 main characteristics\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e1 Located in sacrococcygeal area\u003c/p\u003e \u003cp\u003e2 Appears as a discoloration of the skin, in the shape of a butterfly or pear\u003c/p\u003e \u003cp\u003e3 It\u0026rsquo;s purple, red, blue or black\u003c/p\u003e \u003cp\u003e4 Sudden onsets, sometimes referred to as 3:30 syndrome\u003c/p\u003e \u003cp\u003e5 Irregular borders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 Differentiate KTU from PIs in order to provide optimal care to patient and family.\u003c/p\u003e \u003cp\u003e2 Don\u0026rsquo;t abandon the goal of avoiding the emergence of new PIs or not aggravate existing.\u003c/p\u003e \u003cp\u003e3 The treatment of ulcers prioritizes comfort\u003c/p\u003e \u003cp\u003e4 Assess the desirability of postural changes for each patient\u003c/p\u003e \u003cp\u003e5 Involvement of caregivers\u003c/p\u003e \u003cp\u003e6 Relieve pain and the smell of wound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eA KTU occurs when the body\u0026rsquo;s vascular system is no longer reliable to adequately perfuse the skin.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Kennedy Terminal Ulcer \u0026ndash; Alive and Well\u003c/p\u003e \u003cp\u003eSchank, 2016.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLetter to the editor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnavoidable skin breakdown which occurs in some patients as part of the dying process.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- Decubitus ominosus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStill unknown.\u003c/p\u003e \u003cp\u003eIt has been suggested that there may be an element of pressure: in the dying patient, the least amount of pressure might result in a major ulceration.\u003c/p\u003e \u003cp\u003eKTU appears to be a part of a multiorgan system failure and end-stage disease.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePressure ulcers at the end of life.\u003c/p\u003e \u003cp\u003eMitchell, 2022.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical comment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- KTU\u003c/p\u003e \u003cp\u003e- Decubitus ominosus\u003c/p\u003e \u003cp\u003e- SCALE\u003c/p\u003e \u003cp\u003e- Skin failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSKIN ASSESSMENT IN END-OF-LIFE-PATIENT:\u003c/p\u003e \u003cp\u003eAssessment of skin integrity over bony prominences\u003c/p\u003e \u003cp\u003eAssessment of uncommon locations\u003c/p\u003e \u003cp\u003eColor changes or discoloration\u003c/p\u003e \u003cp\u003eDisparities in heat, firmness and moisture\u003c/p\u003e \u003cp\u003eFinger palpation to ascertain if erythema or discoloration\u003c/p\u003e \u003cp\u003eis blanchable and reassessment of risk and preventative actions are recommended.\u003c/p\u003e \u003cp\u003eMANAGEMENT\u003c/p\u003e \u003cp\u003e. Provide the best quality of life for patients and their families\u003c/p\u003e \u003cp\u003e. Advanced care planning discussions.\u003c/p\u003e \u003cp\u003e. Respect of family expectations\u003c/p\u003e \u003cp\u003e. Respect of patients\u0026rsquo; cultural preferences\u003c/p\u003e \u003cp\u003e. When the duration of\u003c/p\u003e \u003cp\u003epressure cannot be reduced, the appropriate mattress must be\u003c/p\u003e \u003cp\u003eused to reduce the intensity\u003c/p\u003e \u003cp\u003e. Body image should be discussed with the patient\u003c/p\u003e \u003cp\u003e. Manage odor, infection, per-wound skin conditions\u003c/p\u003e \u003cp\u003e. The peri-wound skin\u003c/p\u003e \u003cp\u003eshould be assessed for color and temperature\u003c/p\u003e \u003cp\u003e. Management of pain, use of prophylactic dressing.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVasopressor medications administered at the end of life for\u003c/p\u003e \u003cp\u003ecertain diseases that divert blood flow to other vital organs may\u003c/p\u003e \u003cp\u003ealso be related to the development of SCALE.\u003c/p\u003e \u003cp\u003ePatients at the greatest risk of SCALE and end-of-life ulcers\u003c/p\u003e \u003cp\u003eare those with respiratory, renal or circulatory insufficiency,\u003c/p\u003e \u003cp\u003ehypoalbuminemia, hypoxemia or insufficiency of two or more organs.\u003c/p\u003e \u003cp\u003eFurther risk factors are: hypoperfusion, alteration of the elimination of toxic metabolites, decreased defensive capacity of the skin, low weight, loss of appetite and cachexia, inadequate or poor nutrition, reduced mobility and low albumin levels.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin Failure Clinical Indicator Scale:\u003c/p\u003e \u003cp\u003eProposal of a Tool for Distinguishing Skin\u003c/p\u003e \u003cp\u003eFailure From a Pressure Injury.\u003c/p\u003e \u003cp\u003eHill, 2020.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective case control study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSkin failure is a concept that include multiple similar phenomena described in the literature, as KTY, TB-TTI, SCALE.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo validated assessment tools or clinical indicators are available that can assist in determining aetiology or providing a more definitive diagnosis of skin failure.\u003c/p\u003e \u003cp\u003eCurrently, discernment of wound etiology is heavily reliant on visual analysis and patient history.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRisk factors:\u003c/p\u003e \u003cp\u003e. Age, Braden score and BMI were not significant predictor of skin failure\u003c/p\u003e \u003cp\u003e. Serum albumin level less than 3.5 g/dl\u003c/p\u003e \u003cp\u003e. Impaired blood flow\u003c/p\u003e \u003cp\u003e. Sepsis or multiorgan dysfunction syndrome\u003c/p\u003e \u003cp\u003e. Vasopressor \u0026ndash; inotrope use\u003c/p\u003e \u003cp\u003e. Mechanical ventilation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTerminology related to terminal ulcers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTITLE, AUTHOR, YEAR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKennedy Terminal Ulcer\u003c/p\u003e \u003cp\u003eKTU\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3:30 Syndrome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTrombley Brennan Terminal Tissue Injury\u003c/p\u003e \u003cp\u003eTB-TTI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCALE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSkin Failure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDecubitus Ominosus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMiller Pressure Equivalent Injuries (MPEI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound evaluation of Kennedy terminal ulcer: case study.\u003c/p\u003e \u003cp\u003eTavares Gomes, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKTUs commonly occur in the sacral and gluteal regions, and have a pear, butterfly or horseshoe shape with irregular borders that appear suddenly with rapid and progressive deterioration.\u003c/p\u003e \u003cp\u003eIt was documented as a hyperchromic purpuric lesion with irregular borders in the left gluteal region.\u003c/p\u003e \u003cp\u003eKTU were first reported by Karen Kennedy in 1983, in an intermediate care unit at the Byron Health Center in the US.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReexamining the literature on terminal ulcer, SCALE, skin failure, and unavoidable pressure injuries.\u003c/p\u003e \u003cp\u003eAyello, 2019.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefinition: \u0026ldquo;a pressure ulcer that some people develop as they are dying\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe literature is not clear as so whether KTU should be considered a PI or a separate skin problem that also occur over a bony prominence.\u003c/p\u003e \u003cp\u003eDifferent from a PI because it is attributable to hypoperfusion (local ischemia) of the skin, rather than the pressure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA variant of KTU\u003c/p\u003e \u003cp\u003eLife expectancy: from 8 to 24 hours.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThese lesions could be confused with a DTI.\u003c/p\u003e \u003cp\u003eThe median time from identification of the injury until death was 36 hours. The 75% of patients died within 72 hours of the first identification of these skin changes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThere are degrees of skin impact during the dying process and not everyone with SCALE has skin failure.\u003c/p\u003e \u003cp\u003eNot all patients with SCALE necessarily have multi-organ failure: more research is needed to determine which diagnostic criteria should be used to document the severity and the extent of skin (as an organ) failure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDefinition provided by Langemo (2006): \u0026ldquo;an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThree types of SF are described:\u003c/p\u003e \u003cp\u003eACUTE: with an acute illness. There are no clear-cut diagnostic criteria for Acute Skin Failure (there are predictors, eg. Peripheral arterial disease, mechanical ventilation for more than 72 hours, respiratory failure, liver failure, sever sepsis or septic shock).\u003c/p\u003e \u003cp\u003eCHRONIC: concurrently with a chronic condition\u003c/p\u003e \u003cp\u003eEND STAGE: with an end-of-life issue\u003c/p\u003e \u003cp\u003eDefinition provided by Levine (2017): \u0026ldquo;the state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiologic impairment such as hypoxia, local mechanical stresses, impaired delivery of nutrients and buildup of toxic metabolic byproducts\u0026rdquo;.\u003c/p\u003e \u003cp\u003eLevine uses Skin Failure as a unifying concept that encompasses broader etiologies, including pressure ulcers, KTU, TB-TTI, SCALE and so on.\u003c/p\u003e \u003cp\u003ePressure is not a necessary component of skin failure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eJean Martin Charcot recognized some kind of ulcers that occurred at the end of life that used to precede death.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMiller introduced the idea that systemic physiologic effect and local stressor, rather than just terminal status, may explain this status. There\u0026rsquo;s not a unique consensus on Miller\u0026rsquo;s assumptions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e28\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrelude to death or practice failure? Trombley-Brennan terminal tissue injury update.\u003c/p\u003e \u003cp\u003eBrennan, 2019.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReported in 1989.\u003c/p\u003e \u003cp\u003eKTU were described as an indicator of potential death in 6 to 8 weeks, caused by shunting the blood away from the skin to other organs, during the dying process.\u003c/p\u003e \u003cp\u003eKTUs are considered as end stage skin failure: \u0026ldquo;a subgroup of pressure injury that may develop during the dying process\u0026rdquo;; typical measures to prevent occurrence or progression of these pressure injuries failed.\u003c/p\u003e \u003cp\u003eThey appear as full-thickness wounds.\u003c/p\u003e \u003cp\u003ePear shaped wounds, usually located on the sacrum, rapidly change in size and depth.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConsidered as Skin Failure at End of life.\u003c/p\u003e \u003cp\u003eOriginally classified as pressure injury or DTI.\u003c/p\u003e \u003cp\u003eThe skin remains intact, with purple reddish discoloration.\u003c/p\u003e \u003cp\u003eSeen in patients ranging from 35 to 95 years old.\u003c/p\u003e \u003cp\u003eThe interval between the occurrence of the wound and the death was from 20 minutes to several days.\u003c/p\u003e \u003cp\u003eDespite preventive measures, these lesions never progress to open wounds or wound presenting nonviable tissue.\u003c/p\u003e \u003cp\u003eThey may show a linear presentation occurring on the extremities and butterfly shapes on the sacrum.\u003c/p\u003e \u003cp\u003eDifferent from KTU and DTI for the evolution (doesn\u0026rsquo;t evolve as a PI and doesn\u0026rsquo;t resolve after its appearance) and the surface area.\u003c/p\u003e \u003cp\u003eTB-TTI is a unique, unavoidable, irreversible phenomenon occurring at the end of life.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSF is an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrently to severe dysfunction or failure of other organ systems.\u003c/p\u003e \u003cp\u003eSkin Failure is classified as ACUTE (associated with critical illness), CHRONIC (associated with chronic disease) and END STAGE (associated with end-of-life).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e27\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCALE: Skin Changes at Life\u0026rsquo;s End: Final Consensus Statement: October 1, 2009.\u003c/p\u003e \u003cp\u003eSibbald, 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1989: KTU as a specific subgroup of PIs that some individuals develop as they are dying. They are usually shaped like a pear, butterfly, or horseshoe and are located predominantly on the coccyx or sacrum (but have been reported in other anatomical areas). The ulcers are a variety of colors, including red, yellow, or black; are sudden in onset; typically deteriorate rapidly; and usually indicate that death is imminent.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCALE is a mnemonic used to describe a group of clinical phenomena and should not be confused with a risk assessment tool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIn 2003, Langemo proposed a working definition of skin failure such as the result of hypoperfusion, creating an extreme inflammatory reaction concomitant with severe dysfunction or failure of multiple organ systems.\u003c/p\u003e \u003cp\u003eAlthough the term skin failure has been introduced, it is not currently a widely accepted term in the dermatologic or the wound literature.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn 1877, Charcot described a specific type of ulcer that is butterfly-shaped and occurred over the sacrum. Charcot\u0026rsquo;s writings of decubitus ominosus were basically forgotten in the medical literature until recently with renewed interest in skin organ compromise.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse of electronic health records to identify factors related to skin changes in terminal patients.\u003c/p\u003e \u003cp\u003eChan, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe term was conied in 1989.\u003c/p\u003e \u003cp\u003eClinical features of PIs, as sacrococcygeal or butterfly-shaped lesions with irregular borders that exhibit varying colors, were identified.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCharacterized by discoloration expansion irrespective of pressure relief measures.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNotion introduced in 2012. It delineates a rapid alteration in skin conditions among terminal patients, even in noncompressed skin.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnavoidable pressure injuries, terminal ulceration and skin failure: in search of a unifying classification system.\u003c/p\u003e \u003cp\u003eLevine, 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSkin Failure\u003c/p\u003e \u003cp\u003eThe state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiologic impairment such as hypoxia, local mechanical stress, impaired delivery of nutrients, and buildup of toxic metabolic byproducts.\u003c/p\u003e \u003cp\u003eSkin failure is a unifying concept.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e36\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin failure in patients with a terminal illness.\u003c/p\u003e \u003cp\u003eJulian, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA KTU presents on\u003c/p\u003e \u003cp\u003ethe sacrum as an irregularly shaped\u003c/p\u003e \u003cp\u003ewound (like a butterfly or pear) that may be red, yellow, black, or purple.\u003c/p\u003e \u003cp\u003eOne of the most distinguishing features\u003c/p\u003e \u003cp\u003eof a KTU is how quickly it can appear. It\u0026rsquo;s also much larger at the onset than other pressure injuries, initially beginning very superficially and rapidly progressing.\u003c/p\u003e \u003cp\u003eThere are five key characteristics to differentiate between a pressure\u003c/p\u003e \u003cp\u003einjury and a KTU.\u003c/p\u003e \u003cp\u003eA KTU is usually:\u003c/p\u003e \u003cp\u003e\u0026bull; shaped like a butterfly or pear and contains irregular borders\u003c/p\u003e \u003cp\u003e\u0026bull; located bilaterally on the coccyx or\u003c/p\u003e \u003cp\u003esacrum\u003c/p\u003e \u003cp\u003e\u0026bull; initially erythematous and/or purpuric\u003c/p\u003e \u003cp\u003e\u0026bull; sudden in development\u003c/p\u003e \u003cp\u003e\u0026bull; noted within 2 weeks to several months before a patient\u0026rsquo;s death.\u003c/p\u003e \u003cp\u003ePressure is a contributing factor, with other physiologic changes such as hypoperfusion possibly\u003c/p\u003e \u003cp\u003epotentiating the effects of pressure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA variation of the KTU, which develops more\u003c/p\u003e \u003cp\u003erapidly than a KTU and may initially appear as small black specks on the patient\u0026rsquo;s skin.\u003c/p\u003e \u003cp\u003eGets its name from a nurse\u0026rsquo;s description of the spots appearing between completion of the morning assessment and\u003c/p\u003e \u003cp\u003ewhen skin is assessed later in the afternoon.\u003c/p\u003e \u003cp\u003e3:30 syndrome is significant because many patients who develop it have a very short life expectancy,\u003c/p\u003e \u003cp\u003eapproximately 8 to 24 hours.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe TB-TTI presents as a\u003c/p\u003e \u003cp\u003epink, purple, or maroon discoloration of the skin that remains intact and\u003c/p\u003e \u003cp\u003eshouldn\u0026rsquo;t be confused with a suspected deep tissue injury.\u003c/p\u003e \u003cp\u003eThe TB-TTI can occur in areas not considered to be pressure points and may appear as linear striations.\u003c/p\u003e \u003cp\u003eThe TB-TTI is a unique, irreversible phenomenon associated with end-of-life organ failure and can be predictive of impending death.\u003c/p\u003e \u003cp\u003eSome research has shown that death occurs within 72 hours of a patient developing a TB-TTI.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSCALE encompasses a range of alterations that can occur at the end of life, including cancer wounds, deep tissue injuries, gangrene, ischemic\u003c/p\u003e \u003cp\u003ewounds, pressure injuries, skin tears, KTUs, and inflammatory and infectious\u003c/p\u003e \u003cp\u003ewounds.\u003c/p\u003e \u003cp\u003eThis statement\u003c/p\u003e \u003cp\u003ewas the product of a panel of experts\u003c/p\u003e \u003cp\u003ewho met in 2008 with the purpose of clarifying what was known about skin\u003c/p\u003e \u003cp\u003ebreakdown in patients with a terminal illness.\u003c/p\u003e \u003cp\u003eAlthough the SCALE statement does agree that skin integrity is impacted by\u003c/p\u003e \u003cp\u003eexposure to moisture, irritants, friction, and shear, it also recognizes that skin changes occur as the result of decreased tissue perfusion, impaired skin oxygenation, mottling, and decreased skin\u003c/p\u003e \u003cp\u003etemperature.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe process in which skin, as an organ, can fail in the same way other organs in the body can fail. The skin receives up to one-third of the body\u0026rsquo;s circulating blood volume, and it\u0026rsquo;s believed that skin failure happens as blood is shunted away from the peripheral tissue to the vital organs. Skin failure is associated with multi organ failure and end-\u003c/p\u003e \u003cp\u003estage illness and can occur despite the provision of quality skin care.\u003c/p\u003e \u003cp\u003eSkin failure may be acute, chronic or End-stage.\u003c/p\u003e \u003cp\u003eThe latter happens in the final days or weeks of life, with skin breakdown\u003c/p\u003e \u003cp\u003eoccurring rapidly within days or even hours.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e24\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin changes at life\u0026rsquo;s end: SCALE ulcer or pressure ulcer?\u003c/p\u003e \u003cp\u003eBeldon, 2011.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1989 \u0026ndash; investigation started in 1983.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026ldquo;Physiologic changes that occur as a result of the dying process may affect the skin and the soft tissues and may manifest as observable changes in skin color, turgor, or integrity, or as a subjective symptoms such as localized pain. These changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care\u0026rdquo;\u003c/p\u003e \u003cp\u003eSigns and symptoms of SCALE:\u003c/p\u003e \u003cp\u003e. Muscle weakness and mobility impairment\u003c/p\u003e \u003cp\u003e. Loss of appetite, loss of weight, sarcopenia, dehydration\u003c/p\u003e \u003cp\u003e. Reduced skin perfusion\u003c/p\u003e \u003cp\u003e. Loss of skin integrity (due to incontinence, devices\u0026hellip;)\u003c/p\u003e \u003cp\u003e. Reduced immunity, leading to an increased risk of infection\u003c/p\u003e \u003cp\u003e. Loss of vascular supply to extremities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eAcute skin failure\u003c/b\u003e: related to acute illness. When multi-organ failure occurs, the body protects the vital organs shunting blood to these organs and depriving extremities and skin.\u003c/p\u003e \u003cp\u003eHypoperfusion may also occur in chronic conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn 1877 Charcot described a specific butterfly-shaped lesion which appeared on the buttocks of dying patients shortly before dying.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy terminal ulcer: a scoping review.\u003c/p\u003e \u003cp\u003eLatimer, 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1989 KTUs, before named Kennedy terminal lesion, are a subset of pressure injuries.\u003c/p\u003e \u003cp\u003eTwo possible presentations: unilateral and bilateral.\u003c/p\u003e \u003cp\u003eBilateral: butterfly- horseshoe- or pear-shaped with irregular margins.\u003c/p\u003e \u003cp\u003eThe lesion usually appears on the patient\u0026rsquo;s sacrum or coccyx, 2 weeks to several months prior to death.\u003c/p\u003e \u003cp\u003eUnilateral: 3.30 syndrome.\u003c/p\u003e \u003cp\u003eUnavoidable\u003c/p\u003e \u003cp\u003eEtiology unknown: however, it is theorized that it is due to hypoperfusion and multisystem failure.\u003c/p\u003e \u003cp\u003eUnderrecognized in the pediatric population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe unilateral presentation of KTU is known as 3:30 syndrome.\u003c/p\u003e \u003cp\u003eMacular lesion of less than 1 cm, with purpuric or black irregular margins, that appears in only one buttock.\u003c/p\u003e \u003cp\u003eThis rapidly developing lesion is seen 8 to 24 hours before death, without epidermal erosion.\u003c/p\u003e \u003cp\u003eThe name is due to the time of the day when staff observed these skin changes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnstageable tissue injuries that remain intact.\u003c/p\u003e \u003cp\u003eUnavoidable.\u003c/p\u003e \u003cp\u003eLocated on body parts where there are no pressure points and caused by end-of-life organ failure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavoidable phenomenon that, despite appropriate care, may occur in the period prior to death.\u003c/p\u003e \u003cp\u003eRemoving pressure from tissue doesn\u0026rsquo;t guarantee skin survival.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIs a term used to describe skin changes at the end of life, which include KTU, SCALE, TB-TTI and Charcot\u0026rsquo;s Decubitus ominosus.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1877: Charcot described a butterfly shaped lesion on the buttocks of dying people.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMiller stated the concept of KTU is not viable because \u0026ldquo;systemic diseases should have an equal effect on all body\u0026rdquo;.\u003c/p\u003e \u003cp\u003eMiller proposed the concept of \u0026ldquo;Miller Pressure Equivalent Injuries\u0026rdquo; which accepts the dying process as another systemic stressor, not main causative factor of pressure-based tissue injuries.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e37\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy terminal ulcer and other skin wounds at the end of life: an integrative review.\u003c/p\u003e \u003cp\u003eRoca-Biosca, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKTU was defined as a pressure injury that appears at the end of life, usually located at the sacrum or coccyx, in the shape of a pear, butterfly or horseshoe, with rapid progression, producing ulceration of total sickness. It is indicator of imminent death.\u003c/p\u003e \u003cp\u003eIt coincides with the description of the \u0026ldquo;decubitus ominosus\u0026rdquo;.\u003c/p\u003e \u003cp\u003eStandard presentation, bilateral or unilateral.\u003c/p\u003e \u003cp\u003eFor KTU, no assessment tools are available.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTB-TTI are injuries that spontaneously appear, with rapid evolution, enlargement and progression.\u003c/p\u003e \u003cp\u003eThey appear in areas with little to no pressure and they can be mirroring imaging.\u003c/p\u003e \u003cp\u003eAetiology unknown\u003c/p\u003e \u003cp\u003eThe skin is intact, never evolve into a deep wound.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDefined in 2008 by a panel of 18 experts.\u003c/p\u003e \u003cp\u003eSCALE are \u0026ldquo;physiological\u0026rdquo; changes that occur as a result of a dying process and affect the skin color, turgor or integrity, or as subjective symptoms such as localized pain\u0026rdquo;.\u003c/p\u003e \u003cp\u003eIt is a broad term that includes all the skin changes at the end of life, regardless of whether they are avoidable.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIn 2006, Langemo and Brown defined it as \u0026ldquo;an event in which the skin and underlying tissues die due to hypoperfusion that occur currently with severe dysfunction or failure of other organ systems\u0026rdquo;.\u003c/p\u003e \u003cp\u003eIn 2017, Jeffrey Levine defined it as \u0026ldquo;the state in which the tissue tolerance is so compromised that cells can no longer survive in zones of physiological impairment\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003cp\u003eAccording to Levine, PI and SCALE could be a consequence of skin failure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy terminal ulcers and Trombley Brennan terminal tissue injuries: mistery solved?\u003c/p\u003e \u003cp\u003eMelnychuck, 2024.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCharacteristics of KTU:\u003c/p\u003e \u003cp\u003e. Frequent locations: sacrum, buttocks\u003c/p\u003e \u003cp\u003e. Shape: butterfly or pear shaped\u003c/p\u003e \u003cp\u003e. Color: purple\u003c/p\u003e \u003cp\u003e. Time of onset: sudden\u003c/p\u003e \u003cp\u003e. Time to death: days to weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCharacteristic of TB-TTI:\u003c/p\u003e \u003cp\u003e. Frequent locations: sacrum, buttocks, legs\u003c/p\u003e \u003cp\u003e. Shape: butterfly shaped in the sacrum; linear in the legs.\u003c/p\u003e \u003cp\u003e. Color: bruise-like\u003c/p\u003e \u003cp\u003e4 Time of onset: sudden\u003c/p\u003e \u003cp\u003e5 Time to death: hours to days\u003c/p\u003e \u003cp\u003eTB- TTI don\u0026rsquo;t ulcerate, perhaps since patients die rapidly.\u003c/p\u003e \u003cp\u003eThe additional locations seen in TB-TTI may be due to speed and degree of hypotension.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn 1877, dr Jean-Martin Charcot described \u0026ldquo;decubitus ominosus\u0026rdquo;, a pear shaped sacral skin ulcer which heralded death and he ascribed it to a neurotrophic theory.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly skin temperature characteristics of the Kennedy lesion (Kennedy terminal ulcer).\u003c/p\u003e \u003cp\u003eKennedy-Evans, 2023.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKennedy Lesion is used instead of KTU because the term \u0026ldquo;terminal\u0026rdquo; may not always apply, due to the increased use of advanced technologies to sustain lives.\u003c/p\u003e \u003cp\u003eKLs have some observable characteristic: intact skin discoloration that occur suddenly, mostly in the sacrococcygeal area, that can be yellow, purple, pink and black in color, are generally in the shape of a butterfly, a pear or horseshoe with irregular borders, and are generally associated with death within weeks or months.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSimilar to KL with respect to color and sudden onset.\u003c/p\u003e \u003cp\u003eCompared to KL, TB-TTI develop in a shorter time to death after first discoloration and skin remains intact; linear discoloration patterns are observed in the extremities.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvoidable \u0026amp; Inevitable? Skin Failure: the Kennedy Terminal Lesion.\u003c/p\u003e \u003cp\u003eLepak, 2012.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKTU, also known as terminal pressure ulcer.\u003c/p\u003e \u003cp\u003eKTUs occurred at the sacrum or coccyx, were pear-shaped, had sudden onset and the color varied from yellow to black.\u003c/p\u003e \u003cp\u003eStage 3 or 4 and/or suspected deep tissue injury, according to the nomenclature NPUAP.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn the 1800s, Jean Martin Charcot described this phenomenon with the term Decubitus ominosus.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e31\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy Terminal Ulcer #383.\u003c/p\u003e \u003cp\u003eBateman, 2019.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKTU is a skin wound that occurs despite best preventative measures and results from the moribund status and underlying skin failure associated with the dying process.\u003c/p\u003e \u003cp\u003eOften go underdiagnosed or may be misdiagnosed as a usual pressure ulcer.\u003c/p\u003e \u003cp\u003e. TIMING: can develop within a matter of hours\u003c/p\u003e \u003cp\u003e. LOCATION: sacral region, but also bony prominences\u003c/p\u003e \u003cp\u003e. DESCRIPTION: the wound is usually irregularly shaped or butterfly shaped; \u0026gt;2 inches of diameter; may include red, yellow, black, purple discoloration.\u003c/p\u003e \u003cp\u003e. PATIENT: KTU occur primarily in adult or pediatric patients in the final 2 weeks of life.\u003c/p\u003e \u003cp\u003eThe most distinguishing factors of a KTU is the quickness of the wound development in the setting of terminal illness.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKTU has been referred as the 3:30 syndrome for their sudden appearance. In the early a.m. clinicians note intact skin, hours later a small black spots appear that may resemble \u0026ldquo;specks of dirt\u0026rdquo;, and by the midafternoon flat black blisters emerge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSkin failure is a term used in literature to conceptualize the overall breakdown of the skin as an organ system that is associated with the end-stages of a chronic progressive illness and/or multi-organ failure, even when excellent skin care is provided.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e22\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing care plan for the Kennedy terminal ulcer patient. Case report.\u003c/p\u003e \u003cp\u003eAlarc\u0026oacute;n-Alfonso, 2022.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAppear mainly on sacrum or coccyx, as bilateral ulcer, shaped like a horseshoe or butterfly, with red, purple, yellow or black colorations and irregular borders. KTU starts as a category 2 ulcer or as a blister that will rapidly progress to category 3 or 4.\u003c/p\u003e \u003cp\u003e\u003cb\u003eDifferential diagnosis\u003c/b\u003e: KTU are more superficial in onset and develop more rapidly in both size and depth compared to PUs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKennedy\u0026rsquo;s terminal ulcer and pressure injury: two different aspects of medical liability related to the same injury.\u003c/p\u003e \u003cp\u003eGarcea, 2023.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKTU\u0026rsquo;s incidence is higher than it is believed to be.\u003c/p\u003e \u003cp\u003eAlmost exclusively in the sacro-coccygeal area and heel, but it is also been seen on calves, arms, elbows.\u003c/p\u003e \u003cp\u003eIt emerges in a few hours, that\u0026rsquo;s why it\u0026rsquo;s been called a \u0026ldquo;ah ah ulcer\u0026rdquo;.\u003c/p\u003e \u003cp\u003eKTU is the most observed and known lesion and it requires specific attention since it is constantly mistaken for a pressure injury.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e32\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Death of the Kennedy Terminal Ulcer.\u003c/p\u003e \u003cp\u003eMiller, 2016.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe name is based on observations in which the a.m. evaluation did not identify any skin issues but at 3:30 p.m. the skin showed evidence of injury, which progressed. Life expectancy was found to be 8\u0026ndash;24 hours.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMiller Pressure Equivalent Injuries (MPEI): terminal status becomes a systemic stressor instead of a definitive cause for pressure-based tissue injuries.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e34\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Kennedy Terminal Ulcer \u0026ndash; Alive and Well\u003c/p\u003e \u003cp\u003eSchank, 2016.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1989: Kennedy presented her research on KTU, not being aware of Charcot\u0026rsquo;s previous work.\u003c/p\u003e \u003cp\u003eIt often appears on the sacrum or coccyx, but also elsewhere. Two presentations: bilateral (death within 2 weeks to several months) or unilateral (onset to death of 24\u0026ndash;48 hours).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1877: Charcot described the phenomenon of Decubitus Ominosus.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e35\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePressure ulcers at the end of life.\u003c/p\u003e \u003cp\u003eMitchell, 2022.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKennedy (1989) described these as pressure ulcers that developed during the dying process. Usually pear, butterfly\u003c/p\u003e \u003cp\u003eor horseshoe shaped and primarily located on the coccyx or\u003c/p\u003e \u003cp\u003esacrum, these ulcers were described to appear suddenly and\u003c/p\u003e \u003cp\u003edeteriorate rapidly.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIt should be noted that this\u003c/p\u003e \u003cp\u003emnemonic is to describe the phenomenon and is not a risk assessment tool.\u003c/p\u003e \u003cp\u003eSCALE is used to describe cellular or molecular\u003c/p\u003e \u003cp\u003edysfunction leading to tissue hypoxia.\u003c/p\u003e \u003cp\u003eThe main difference between SCALE and pressure ulcers is\u003c/p\u003e \u003cp\u003ein aetiology.\u003c/p\u003e \u003cp\u003eSCALE is associated with hypoperfusion due to multiorgan failure that leads to skin\u003c/p\u003e \u003cp\u003efailure.\u003c/p\u003e \u003cp\u003eSCALE is\u003c/p\u003e \u003cp\u003einfluenced more by intrinsic than extrinsic factors.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lsquo;Skin failure\u0026rsquo; described by La Puma (1991)\u003c/p\u003e \u003cp\u003ewas identified as a component of multiorgan failure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1877, Charcot described a specific type of ulcer\u003c/p\u003e \u003cp\u003ein a butterfly shape occurring over the sacrum. He termed these ulcers \u0026ldquo;debcubitus ominosus\u0026rdquo;, as patients tended to die\u003c/p\u003e \u003cp\u003eshortly after the appearance of these ulcers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe first table collects the following information, according to the studies included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTitle of the study, first author and year of publication\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMethodology used\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDefinition of the concept of unavoidability\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTerminology regarding terminal ulcers\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDiagnostic criteria and assessment tools\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePrevention and management of these ulcers\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAetiology or risk factors identified for terminal ulcers\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHealthcare professional\u0026rsquo;s awareness and education\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTo facilitate the process of data extraction in the fourth area, a specific table about terminology was developed. This form was used only for the studies that provided a detailed description of different types of terminal ulcer. In this case, the information collected was as follow:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTitle of the study, first author and year of publication\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eKennedy Terminal Ulcer (KTU)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e3:30 Syndrome\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTrombley-Brennan Terminal Tissue Injury (TB-TTI)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSCALE\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSkin Failure\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDecubitus ominosus\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMiller pressure equivalent injury (MPEI)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe first author performed the initial data extraction. Other authors verified the data charting approach and that all the process was in line with the aims of the scoping review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Data synthesis and Analysis\u003c/h2\u003e \u003cp\u003eThe findings were collated and synthesised narratively in relation to the scope of the review.\u003c/p\u003e \u003cp\u003eThe data collected have been organised thematically in order to present an effective overview of the studies included (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003e[Insert\u003c/em\u003e Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cem\u003e]\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 1 734 sources were initially identified from databases and grey literature.\u003c/p\u003e\n\u003cp\u003eFollowing the inclusion and exclusion criteria, 19 studies were included through the screening and 7 were added from reference lists. The total number of studies included in this scoping review is 26.\u003c/p\u003e\n\u003cp\u003eThe process for selecting sources of evidence is described in \u003cem\u003eFig.\u0026nbsp;1.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[Insert Fig.\u0026nbsp;1 here]\u003c/em\u003e Fig. 1: PRISMA diagram demonstrating selection process (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Characteristics of the included studies\u003c/h2\u003e\n \u003cp\u003eThe 26 articles included in the scoping review were published between 2009 (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) and 2025 (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe methodologies employed in the studies were as follows:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eCase study or case series (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eNarrative review (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eModified Delphi study (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eRetrospective study (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eCommentary or editorial or letter to the editor (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eContinuing education article (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eScoping review (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eIntegrative review (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eObservational study (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eRetrospective case-control study (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eDespite the search strings used, most of the studies focused on Kennedy Terminal Ulcers (KTUs). The studies that focused exclusively on this type of lesion are listed thereafter: (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eOf the studies considered, only one focused on pediatric patients (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe care settings in which this type of injury has been most frequently studied include palliative care (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e), intensive care units (ICU) (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e) and primary care (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 The concept of unavoidability for terminal ulcers\u003c/h2\u003e\n \u003cp\u003eThe differential diagnosis between avoidable and unavoidable wounds is not merely a matter of words: this classification is the basis on which to plan achievable goals. If an injury is unavoidable, the purpose of completely healing it will probably be unrealistic (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eNowadays, there is a broad consensus in literature that terminal ulcers are unavoidable (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e), (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e), unlike pressure injuries, thus they cannot be prevented even through the best quality of care, and they are not attributable to substandard care (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eHowever, this concept deserves further elucidation for at least two reasons: on one side, not all end-of-life patients develop a terminal ulcer but only a proportion of them do so (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e); on the other side, it\u0026rsquo;s not fully clarified how terminal ulcers are different from pressure-related injuries, since both of them commonly occur over bony prominences (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Terminology related to terminal ulcers\u003c/h2\u003e\n \u003cp\u003eMultiple types of skin changes may occur in patients at the end of life. These patients are prone to develop terminal ulcers during the preactive and active stages of dying (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e). Although it doesn\u0026rsquo;t exist only one accepted definition, end-of-life is considered as a time frame of six or less months of estimated life, while it should last even less, such as days or hours (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e). According to the fact that dying is a process, patients entering this period, from months until few hours before death, are at great risk of terminal ulcers, which are considered unavoidable (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eA synopsis of the terminology regarding terminal ulcers is outlined below:\u003c/p\u003e\n \u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003eDecubitus Ominosus\u003c/u\u003e: in 1877, Jean-Martin Charcot described a specific butterfly-shaped lesion which appeared on the buttocks of patients, shortly before dying and he termed it \u003cem\u003edecubitus ominosus\u003c/em\u003e (7), (27), (30), (25), (34). In Latin language, \u0026ldquo;\u003cem\u003eominosus\u003c/em\u003e\u0026rdquo; refers to something that brings misfortune, according to the observation that patients tended to die shortly after the occurrence of this ulcer. His observations have been basically forgotten until Kennedy raised the interest on this topic, describing the same kind of terminal wounds (27), not being aware of Charcot\u0026rsquo;s previous work (34).\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eKennedy Terminal Ulcer\u003c/u\u003e (KTU) is a term that was firstly coined in 1983 by Karen Lou Kennedy and that was presented for the first time at NPUAP in 1989 (24), (33). She, along with her team, noticed that some patients used to suddenly develop a specific kind of pressure injury, typically on sacrum or coccyx, just few weeks before dying and started measuring this phenomenon. After 5 years of data examination, they noticed that 55,7% of patients died within 6 weeks from the ulcer\u0026rsquo;s occurrence (42), leading to the conclusion that these skin changes were part of the dying process.\u0026nbsp;\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eIn 2023, she started referring to this ulcer as \u0026ldquo;Kennedy lesion\u0026rdquo; (KL), since the term \u0026ldquo;terminal\u0026rdquo; was not suitable any longer, considering how long life could be prolonged with new technologies (38).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTo avoid confusion, this scoping review will refer to this kind of wound as KTU, since the majority of papers still use this terminology.\u003c/p\u003e\n \u003cp\u003eKTUs are considered a subset of pressure injuries (PI) (27), (12), (18), that\u0026rsquo;s why they are also known as \u0026ldquo;terminal pressure injuries\u0026rdquo; (25) or \u0026ldquo;end-stage skin failure\u0026rdquo; (28): indeed, this kind of ulcer is defined as \u0026ldquo;a pressure ulcer that some people develop as they are dying\u0026rdquo; (7).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThese ulcers are reported in adults as well as in pediatric patients, in the final weeks of life (31).\u003c/p\u003e\n \u003cp\u003eThey are indicators of imminent death (19), (7), (28), (37) thus, their proper identification may help clinicians in shift goals of care towards palliative care as soon as possible (19). Death is estimated in days to weeks since the occurrence of the ulcer (28), (30).\u003c/p\u003e\n \u003cp\u003eHowever, they are often mistaken for pressure injuries, leading not only to missed care but also to lack of prevalence data (12), (31), (22), (23).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIt seems that, at the moment, no validated assessment tools for KTUs are available (12), (37).\u003c/p\u003e\n \u003cp\u003eKTUs usually develop in a matter of hours and for this reason they are also called \u0026ldquo;ah ah ulcer\u0026rdquo; (23): this is the most peculiar characteristic, which may facilitate a proper diagnosis (36), (31).\u003c/p\u003e\n \u003cp\u003eKTUs may have bilateral or unilateral presentations (12), (37): in the first case, they are observed in the sacral and gluteal regions, as well as on calves, arms and elbows (23), and have a pear, butterfly or horseshoe shape with irregular borders; they appear suddenly with rapid and progressive deterioration (19), (28), (27), (20), (36), (30), (25), (21), (22), (35); color of the skin may vary from yellow, to purple, to black (27), (30), (25), (31).\u003c/p\u003e\n \u003cp\u003eThe unilateral presentation is known as a 3:30 syndrome (12), which will be detailed later.\u003c/p\u003e\n \u003cp\u003eAll the papers included assessed KTU according to the NPUAP nomenclature (43), reporting that KTUs often turn very quickly into a Stage 3 or 4 or deep tissue injury (DTI) (25), (21), (22).\u003c/p\u003e\n \u003cp\u003eNowadays, it has been reached a large consensus on the unavoidable nature of these lesions (12), (21) thus on the fact that they may occur despite the best preventative measures (31). On the other hand, some authors consider pressure as a contributing factor, along with other physiological changes, such as hypoperfusion, that could eventually increase the effects of pressure (36).\u003c/p\u003e\n \u003col start=\"3\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003e3:30 Syndrome\u003c/u\u003e is considered a variant of KTU (7), (36), with unilateral presentation (12).\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eThe name is due to the rapid onset (31): clinicians usually reported not to have identified any skin issue during the morning evaluation; instead, at 3:30 p.m., they used to note some evidence of skin injury, which would have progressed in the next hours (32).\u003c/p\u003e\n \u003cp\u003eThese lesions appear as small black spots that look like \u0026ldquo;specks of dirt\u0026rdquo;, rapidly turning into flat black blisters (36), (31) or macular lesions of less than 1 cm\u003csup\u003e2\u003c/sup\u003e, with purpuric or black irregular margins, without epidermal erosion (12).\u003c/p\u003e\n \u003cp\u003eLife expectancy after the occurrence of these lesions is from 8 to 24 hours (7), (36), (12): prompt modification of the treatment plan would be possible with a correct diagnosis.\u003c/p\u003e\n \u003cp\u003eThis kind of ulcer seems to develop despite any pressure-relieving measures (20).\u003c/p\u003e\n \u003col start=\"4\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003eTrombley-Brennan Terminal Tissue Injuries (TB-TTI)\u003c/u\u003e were introduced in 2012 by a team of palliative care nurses who recognized a type of injury different from KTU, but still occurring at the end of life and despite any evidence-based interventions (36).\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eTogether with KTUs, TB-TTIs are counted as part of terminal ulcers, thus are considered unavoidable (26), (28), prognosticators of death and not related to pressure (28), (20), (12).\u003c/p\u003e\n \u003cp\u003eLife expectancy from identification of the injury is 36 hours, with the 75% of patients who died within 72 hours of these skin changes noticed (7), (36), or from 20 minutes to several days (28).\u003c/p\u003e\n \u003cp\u003eThey have been reported in patients aged from 35 to 95 years old (28).\u003c/p\u003e\n \u003cp\u003eClinical characteristics of TB-TTIs are similar to those of KTUs regarding colors and sudden onset; in particular, they appear as pink, purple, or maroon discoloration (36).\u003c/p\u003e\n \u003cp\u003eHowever, TB-TTIs develop in a shorter time to death after first discoloration and skin remains intact. Compared to KTU, an additional location where the ulcers may occur is the extremities, with linear discoloration patterns, similar to linear striations (28),(36), (30), (38).\u003c/p\u003e\n \u003cp\u003eThese lesions could be confused with a DTI (7) since the skin remains intact and they never turn into a deep wound (28), (12), (37). It has been hypothesized that TB-TTIs don\u0026rsquo;t ulcerate because of the patient\u0026rsquo;s rapid death (30).\u003c/p\u003e\n \u003col start=\"5\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003eSkin Failure\u003c/u\u003e is a broad concept that includes many multiple similar phenomena, such as KTU, TB-TTI, SCALE and others (7), (12), (39). This term unifies all kinds of breakdowns that skin, as an organ, may go through, although the best quality of care is provided (31).\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eTalking about failure, multi-organ failure is described as the \u0026ldquo;presence of altered organ function in acutely ill patients such that homeostasis cannot be maintained without interventions. It usually involves two or more organs\u0026rdquo; (7). As all the other organs, skin can fail as well.\u003c/p\u003e\n \u003cp\u003eThere are two subsequent definitions of skin failure that deserve to be mentioned: in 2006, Langemo described skin failure as \u0026ldquo;an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems\u0026rdquo; (44). Later, Levine defined it as \u0026ldquo;the state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiologic impairment such as hypoxia, local mechanical stresses, impaired delivery of nutrients and buildup of toxic metabolic byproducts\u0026rdquo; (11).\u003c/p\u003e\n \u003cp\u003eLiterature reports that pressure is not a necessary component of skin failure (7).\u003c/p\u003e\n \u003cp\u003eThree types of skin failure are listed in literature (7), (28), (36): acute (associated with acute illness) (24), chronic (associated with a chronic condition) and end stage, that occurs during the last period of life, such as days or weeks (7), (36).\u003c/p\u003e\n \u003cp\u003eWhile for other organs biomarkers or screening tools are disposable, for the diagnosis of \u0026ldquo;skin failure\u0026rdquo; it doesn\u0026rsquo;t exist any classification system, as well as diagnostic tools for clinical signs (27) or biomarkers diagnostic nor blood test (11), (36), (39).\u003c/p\u003e\n \u003col start=\"6\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003eSCALE:\u003c/u\u003e In 2008, an international panel of experts met to define a set of ten statements called Skin Changes At Life\u0026rsquo;s End, known with the mnemonic of SCALE; its aim is to describe a group of clinical manifestations and it\u0026rsquo;s not to be considered as a risk assessment tool (27), (35).\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eSCALE is a broad term that includes \u0026ldquo;all the physiological changes that occur as a result of a dying process and affect the skin color, turgor or integrity, or as subjective symptoms such as localized pain, regardless of whether they are avoidable\u0026rdquo; (24), (37).\u003c/p\u003e\n \u003cp\u003eThe term SCALE doesn\u0026rsquo;t only include KTUs and TB-TTIs, but it also encompasses fungating wounds, ischemic wounds, pressure injuries, skin tears and many more (36).\u003c/p\u003e\n \u003cp\u003eTo sum up, it\u0026rsquo;s possible to claim that SCALE could be considered as a consequence of skin failure, according to the previous seen definition by Levine (37). However, it should be considered that not everyone with SCALE has skin failure or multi-organ failure, since the death process affects skin with different degrees (7). Likewise, we still miss detailed diagnostic criteria to fully understand the extent of skin failure (7) which would have been very useful for a deeper understanding of this issue.\u003c/p\u003e\n \u003cp\u003eSigns and symptoms of SCALE are recognized as follows (24):\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMuscle weakness and mobility impairment\u003c/li\u003e\n \u003cli\u003eLoss of appetite, loss of weight, sarcopenia, dehydration\u003c/li\u003e\n \u003cli\u003eReduced skin perfusion\u003c/li\u003e\n \u003cli\u003eLoss of skin integrity (due to incontinence, devices\u0026hellip;)\u003c/li\u003e\n \u003cli\u003eReduced immunity, leading to an increased risk of infection\u003c/li\u003e\n \u003cli\u003eLoss of vascular supply to extremities\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eSCALEs are encompassed in the unavoidable skin ulcers and are often the result of multiorgan failure (40), (12). For this reason, pressure-relieving interventions could not be effective in maintaining skin integrity (12).\u003c/p\u003e\n \u003cp\u003eThe most significant risk factor for SCALE is the diminished tissue perfusion, thus in some cases, pressure ulcer can be markers of SCALE (27), (37), (35).\u003c/p\u003e\n \u003col start=\"7\" type=\"1\"\u003e\n \u003cli\u003e\u003cu\u003eMiller Pressure Equivalent Injuries (MPEI)\u003c/u\u003e: In 2016, Miller proposed the concept of MPEI, assuming that multiorgan failure due to systemic disease should have an equal effect on all the body (12), (32).\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eMiller argued that if it is true that systemic diseases have systemic effects (as a cardiac disease affects the entire body, for instance) and that if it is true that pressure is equally distributed (since patients are regularly positioned), then the presumption that the terminal status itself will result in a pressure-related injury cannot be considered valid, mostly if the injury develops only in one area, usually in the sacrum (32).\u003c/p\u003e\n \u003cp\u003eThus, he considered the terminal status as a systemic stressor, instead of a definitive cause for pressure-based tissue injuries (12), (32). There\u0026rsquo;s not a unique consensus on Miller\u0026rsquo;s assumptions (7).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4 Diagnostic criteria and assessment tools\u003c/h2\u003e\n \u003cp\u003eWhen an ulcer occurs, especially in vulnerable patients at the end of life, nurses and health care professionals may experience a sense of guilt or may feel blamed, since the wound is often attributed to poor quality of care and it will probably lead to financial or legal issues (29).\u003c/p\u003e\n \u003cp\u003eHowever, at the best of our knowledge, we miss a unified classification system for terminal ulcers, with clinical signs and symptoms, that could be useful for reporting these wounds differently from other kinds of ulcers (20). This classification is even more complicated by the fact that end-of-life wounds may occur together with PIs (29), and we still miss standardized diagnostic criteria to differentiate between the two (20).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAs clinicians, who spend most of our time at the bedside, it\u0026rsquo;s true that the first diagnostic criterion for assess a terminal ulcer is the recognition that the patient is dying (11): we must always recall that, before evaluating wounds, we are taking care of people, so we have to consider the overall health conditions in order to perform a correct differential diagnosis (37).\u003c/p\u003e\n \u003cp\u003eResearch, although still limited, is mainly focused on the validation of an assessment tool (26), (39) and diagnostic criteria (19), (38).\u003c/p\u003e\n \u003cp\u003eAs an assessment tool, in 2023, a Delphi panel of 16 international experts in terminal ulcers found a consensus around the \u0026ldquo;End-of-life wound assessment tool\u0026rdquo;. The aim of this tool is to gain a better identification of terminal ulcers but also to decrease legal controversy and improve wound care and palliative care for these patients (26). The tool doesn\u0026rsquo;t discriminate between end-of-life wounds and PIs, but it should be used if the health care professional suspects that the ulcer is indeed a terminal one. At the moment, a moderate interrater reliability of this tool has been achieved and a larger study is needed (45).\u003c/p\u003e\n \u003cp\u003eA \u0026ldquo;Skin failure indicator scale\u0026rdquo; has also been proposed, which considers the serum albumin level, a diagnosis related to impaired blood flow, the presence of sepsis or multiple organ dysfunction syndrome, the use of vasopressor or inotrope medication and the mechanical ventilation as predictors of skin failure; the tool still needs to be validated but it may represent an effective way to predict skin failure (39).\u003c/p\u003e\n \u003cp\u003eConcerning diagnostic criteria that can be used to assess a terminal ulcer, a case study published in 2025 reported the use of ultrasound as a complement to the clinical examination done by nurses (19): it was observed a mild oedema in the subcutaneous tissue of the perilesional skin and a cobblestone-like tissue in the lesion bed; both sites showed absence of blood flow. For the future, it is possible to figure out that the use of ultrasound will become more frequent and that this will help in assessing the wounds, differentiating between terminal and pressure injuries.\u003c/p\u003e\n \u003cp\u003eAnother new diagnostic criterion proposed in literature consists in skin temperature changes, since it\u0026rsquo;s known that, for PIs, areas of inflammation or hyperemia are warmer than the surrounding skin and areas of ischemia are cooler. Only one of the studies included in this scoping review reported assessing this parameter (38): skin temperature was evaluated within 24 hours from a newly identified area of discoloration. The study stated that the Relative Temperature Differential (RTD) between the discolored area and a control point of intact skin was not normal if it was \u0026gt; +1.2\u0026deg;C or \u0026lt; -1.2\u0026deg;C, based on previous literature. While for PIs skin temperature used to decrease or increase compared to the control point, for KTUs it doesn\u0026rsquo;t seem to happen.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMore research on this topic is needed to fully understand the pathophysiology of KTUs and thus to explain why the early skin temperature doesn\u0026rsquo;t change in the first 24 hours, but it could be an interesting starting point, since it could help in differentiating PIs from terminal ones.\u003c/p\u003e\n \u003ch3 id=\"_Toc213341790\"\u003e3.5 Aetiology\u003c/h3\u003e\n \u003cp\u003eThe main point to be considered when talking about SCALE is that these kinds of ulcers don\u0026rsquo;t stem from external stressors but, instead, from internal factors (20): it\u0026rsquo;s often the result of hypoperfusion and multi-organ failure, rather than pressure and shear, and thus it should be considered an unavoidable phenomenon, as said (40).\u003c/p\u003e\n \u003cp\u003eThe most widely accepted aetiology for the onset of these lesions is related to the concept of hypoperfusion linked to multiple organ failure: in crisis situations, the body reacts by diverting blood flow from the skin to vital organs, thereby reducing skin perfusion. The consequence of this is that hypoxia and a slowdown in normal metabolic processes will occur at the skin and subcutaneous levels (27), (20), (24), (29), (37), (30), (25), (21), (33), (34), (35).\u003c/p\u003e\n \u003cp\u003eHowever, starting from this assumption, the question remains as to why only some people develop terminal lesions, despite hypoperfusion being associated with the end-of-life period in almost all patients (30). Furthermore, as seen, in 2016 Miller levelled significant criticism at this line of thinking, asserting that the terminal condition alone could not explain the onset of such lesions. From his perspective, if the skin fails as an organ, lesions should be found everywhere and not just in specific areas (32).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eConsequently, other contributing causal factors have been proposed, and alternative hypotheses have been advanced.\u003c/p\u003e\n \u003cp\u003eSince the validation of predictive criteria to identify which patients may develop a pressure ulcer or a SCALE ulcer is currently not possible (24), literature describes the following factors as contributing causes:\u003c/p\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eUse of vasopressors or inotropes (19), (40), (37), (30), (38), (21), (35), (39): in order to remain viable, the skin requires from 25% to 33% of cardiac output (21); since vasopressors divert the blood flow to vital organs, skin becomes more prone to breakdown and death. This type of medication is often used in ICUs or for cardiological patients.\u003c/li\u003e\n \u003cli\u003eRespiratory, renal or circulatory insufficiency (40), (37), (35)\u003c/li\u003e\n \u003cli\u003eInsufficiency of two or more organs (40), (38), (21), (39)\u003c/li\u003e\n \u003cli\u003eCo-morbid conditions, such as cardiovascular diseases, smoking, sepsis or pneumonia, diabetes (38), (21), (39)\u003c/li\u003e\n \u003cli\u003eHypoalbuminemia (40), (37), (21), (35), (39): serum albumin level less than 3,5 g/dl (39)\u003c/li\u003e\n \u003cli\u003eHypoxemia (40), (37), (21), (35)\u003c/li\u003e\n \u003cli\u003eHypotension (30), (38)\u003c/li\u003e\n \u003cli\u003eAlteration of elimination of toxic metabolites (40), (37), (35)\u003c/li\u003e\n \u003cli\u003eDecreased defensive capacity of the skin (40), (37), (38), (35): in particular, aging could be considered associated with altered immune responses and changes in vascular structure (38)\u003c/li\u003e\n \u003cli\u003eLoss weight, loss appetite, cachexia, poor nutrition (40), (37), (38), (35)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eReduced mobility or immobility (40), (38), (35)\u003c/li\u003e\n \u003cli\u003eAnatomic arterial aberrancies (30): the researchers\u0026rsquo; observations moved from the fact that many patient characteristics don\u0026rsquo;t explain why just some of them manifest terminal ulcers. However, they wanted to find out the peculiar feature that could explain why someone, and not everyone, develops terminal injury. Looking at the anatomy of the human body, they speculated that changes or agenesis of specific arteries (median sacral artery, lateral sacral artery and sciatic artery, that may be persistent, instead of regressing by the third month of embryonic development) could lead to the occurrence of ulcers, but only in case of hypotension, since otherwise a collateral circulation would prevent it.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eAt the same time, the authors refused the \u0026ldquo;angiosomal hypothesis\u0026rdquo;: an angiosome is a vascular territory that is supplied by a specific blood vessel. The human body has 40 angiosomes. Considering the most frequent locations where terminal ulcers usually appear (sacrum, coccyx\u0026hellip;), the authors considered that the angiosomal hypothesis could not explain it (30).\u003c/p\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eReperfusion, in cases of recurrent hypotension (30): in case of recurrent hypoperfusion, the skin can go through different alterations, that are linked to the typical manifestations of terminal ulcers. It may move into a whitish change, indicating ischemic necrosis, or it can move into a purplish discoloration, due to the accumulation of red blood cells caused by damaged blood vessels. The process of the reperfusion injury may vary based on factors such as the degree and duration of the hypotension, the size of the blood vessel involved, the characteristic of the vessel itself, the existence of a collateral arterial supply (30).\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eIt is known that commonly, capillary refill is a good way to assess skin perfusion: it has to be considered that the capillary refill could appear for the first 12 hours after skin death, because of the blood remaining in the area for the capillary collapse; for this reason it could be difficult to evaluate skin failure exactly at the moment of its occurrence (25)\u003c/p\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eUse of mechanical ventilation (38), (39)\u003c/li\u003e\n \u003cli\u003eAbnormal white cell counts (38)\u003c/li\u003e\n \u003cli\u003eAnemia (38)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eAlternative hypotheses that have been advanced are the existence of some catabolic patterns that may have something in common with other systems\u0026rsquo; failure or there may be some genetic factors at the basis of vascular responses to ischemia. These factors, if studied and understood, could lead to personalized therapies for both preventing and managing this kind of ulcer (11).\u003c/p\u003e\n \u003cp\u003eIt could be interesting to note that age, Braden score and Body Mass Index were found not to be significant predictors of skin failure (39).\u003c/p\u003e\n \u003ch3 id=\"_Toc213341791\"\u003e3.6 Prevention and management\u003c/h3\u003e\n \u003cp\u003eSince terminal ulcers are considered solid prognosticators of imminent death, the goals of care need to shift from curative to palliative care, in order to avoid therapeutic obstinacy (19), dismiss aggressive interventions and tests (28), (37) and to guarantee comfort and a dignified dying process (20), (12), (37), (22). Thus, the main objective of the new treatment plan isn\u0026rsquo;t wound healing any longer (40), while it should be providing the patient with the best quality of life (36), managing wound symptoms and psychological issues (25).\u003c/p\u003e\n \u003cp\u003eEven if terminal ulcers are considered unavoidable, prevention interventions need to be implemented not to exacerbate existing ones. The literature agrees on the fact that prevention of terminal ulcers is similar to the one for pressure ulcers (31), (22). Strategies to mitigate the risk may include optimizing nutritional support, using appropriate pressure redistribution surfaces, effectively managing moisture and frequent repositioning (21).\u003c/p\u003e\n \u003cp\u003eAlthough pressure is not a causative factor for terminal ulcers (29), pressure-relieving support surfaces could be useful for a conservative approach (24), (31), (21), (35), as well as regular repositioning (20), (36), (21). However, pressure-relieving support surfaces are not always comfortable for patients, and they could even worsen pain and nausea or reduce the ability of independent movement, if still present (24). Furthermore, frequent repositioning may cause unnecessary pain (36). Before their implementation, these interventions should be accurately evaluated and discussed with patients and families, in order to establish the best treatment according to patients\u0026rsquo; preferences and wishes (36), (24), (40), (33).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThe decision regarding whether and how often to reposition such a vulnerable person should be taken under individual judgement, considering the patient\u0026rsquo;s clinical conditions, and the need of premedication with an analgesic before the procedure (31).\u003c/p\u003e\n \u003cp\u003eJakobsen et al. (2020) did not find a significant correlation between the incidence of SCALE and the use of pressure redistribution equipment (46).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGreat importance is given to the communication with patients and family members, as well as caregivers (20), (40), (12), in order to help them cope better with the situation (22). Emotional support and education concerning terminal ulcers are often needed to better understand the situation, to get awareness of the terminality and to know how to assist the person (24), (37), (31), having realistic expectations for wound healing (36). Especially in this phase of life, patients\u0026rsquo; cultural preferences and families\u0026rsquo; expectations should be taken into account and respected (35). Caregivers should be involved in the care plan (33).\u003c/p\u003e\n \u003cp\u003eSince it\u0026rsquo;s not always simple to properly diagnose terminal ulcers, and they are often misdiagnosed as pressure injuries, it is important to clearly document all the interventions, providing evidence of the quality of care administered (20), (24), (31).\u003c/p\u003e\n \u003cp\u003eFrom the perspective of the law, even a correct diagnosis of a terminal lesion, if possible, doesn\u0026rsquo;t fully protect against legal disputes. Therefore, it becomes mandatory to provide proper evidence for every single choice, for example, the decision of reducing mobilizations to avoid unnecessary pain. If possible, it would be useful an informed consent, possibly signed by the patient (23) or considering a written Advance Care Planning.\u003c/p\u003e\n \u003cp\u003eCharting by exception has been proposed as a good method of documentation (27). This type of charting assumes that the patient manifests normal responses to all the interventions performed. The only responses that are documented are the ones that deviate from the standard or from what it is expected (47).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWound care nurses should be involved in the care team as soon as an ulcer is recognized as a terminal one (24), (12). It is recommended that only advanced clinical specialists undertake the assessment of terminal lesions so that an appropriate individual care plan could be set (12).\u003c/p\u003e\n \u003cp\u003eThe SCALE Statement (27) has proposed a list of five P\u0026rsquo;s for determining appropriate intervention strategies. The five P\u0026rsquo;s mnemonic consists of:\u003c/p\u003e\n \u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003ePrevention: since the skin goes through decreased oxygen availability during the last part of the life, it\u0026rsquo;s important to consider reducing pressure, moisture and other risk factors, as well as ameliorating nutrition and mobility, according to the patient\u0026rsquo;s clinical conditions. The aim of prevention is to improve well-being and quality of life.\u003c/li\u003e\n \u003cli\u003ePrescription: this point comprehends all the interventions that are considered appropriate for the treatment of wounds that are considered healable, even in this phase of life.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePreservation: this point refers to the interventions suitable when maintenance is considered a proper goal, despite limited possibilities of gaining complete healing.\u003c/li\u003e\n \u003cli\u003ePalliation: this section involves the interventions to be implemented when the goal of the treatment is managing symptoms, such as pain or odor, and achieving the best quality of life possible, rather than healing or maintenance of the wound.\u003c/li\u003e\n \u003cli\u003ePreference: this last P reminds clinicians to always include patient\u0026rsquo;s preferences and wishes in the decision-making process; the document gives importance to patient\u0026rsquo;s circle of care\u0026rsquo;s opinion as well.\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eA more detailed overview of the interventions suggested by literature is provided in \u003cem\u003eFigure 2\u003c/em\u003e.\u003c/p\u003e\n \u003cp\u003e[Insert Figure 2 about here]\u0026nbsp;Figure 2: Management of terminal ulcers.\u003c/p\u003e\n \u003ch3 id=\"_Toc213341792\"\u003e3.7 Health professionals\u0026rsquo; education\u003c/h3\u003e\n \u003cp\u003eLiterature reveals that there\u0026rsquo;s an issue of misclassification of terminal ulcers that are often reported as pressure injuries (29). This leads to wrong treatment, bad quality of life for the dying person, that probably won\u0026rsquo;t receive the proper palliative care, emotional and practical burden for caregivers.\u003c/p\u003e\n \u003cp\u003eIn this field, nurses are responsible for the correct management and treatment of terminal lesions, together with the avoidance of possible complications (23). But how could it be possible if nurses don\u0026rsquo;t even know how to recognize them? This matter involves ethical issues, concerning quality of care and the principles of beneficence and non-maleficence; moreover, the proper identification of a terminal ulcers can have a potential impact on reimbursement (21).\u003c/p\u003e\n \u003cp\u003eHealthcare professionals are the ones expected to facilitate communication and collaboration, both across care settings and disciplines (27), and towards patients and their circle of care: however, they often show a limited awareness of the skin changes that happen at life\u0026rsquo;s end (27), (29), (12).\u003c/p\u003e\n \u003cp\u003eMoreover, it is possible that in certain settings such as ICUs, clinicians are not so prone to accept the terminology \u0026ldquo;terminal ulcer\u0026rdquo; for a cultural issue based on seeing death as something that must be overcome at all costs (11).\u003c/p\u003e\n \u003cp\u003eOn the other hand, it is paramount that clinicians are educated about terminal ulcers: this will help them to support dying patients and their families and to have open discussions not only regarding the ulcer itself, but also on the impending death, which is quite a difficult topic, if not well-prepared (12).\u003c/p\u003e\n \u003cp\u003eAs many of the studies included in this scoping review involve the settings of palliative care or long stay units, it should be considered that maybe this professional\u0026rsquo;s lack of awareness means that terminal ulcers are completely underdiagnosed outside of these settings (37).\u003c/p\u003e\n \u003cp\u003eOne of the main problems that could explain this difficult situation is having so many terms to describe this kind of ulcer: it can be confusing and it may impede a good communication, even among clinicians (7).\u003c/p\u003e\n \u003cp\u003eEducational topics that deserve to be implemented in order to better recognize terminal ulcers concern the skin prevention and wound treatment (19), and training of healthcare professionals in the management of ulcers that are different from pressure ulcers (22).\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003cbr\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe prevalence of pressure injuries is considered a solid indicator of the quality of nursing care, thus the nursing staff should be able to recognize this kind of ulcer and to distinguish it from all the others (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Moreover, the occurrence of pressure ulcers is seen as patient safety incidences and is linked with the concept of \u0026ldquo;inadequate care\u0026rdquo; (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). That\u0026rsquo;s why it appears of paramount importance that nurses can correctly recognize, report and manage terminal ulcers.\u003c/p\u003e \u003cp\u003eThis kind of ulcer involves people at the end of their life, at any age, affected by many different clinical conditions: as said, the onset is often very rapid so that both patients and families could feel unprepared and hopeless facing this new reality. We, as health care professionals, cannot consider merely the theme of reimbursement or legal disputes when referring to this topic, but we have to focus on providing our patients and their circle of care with the best possible care, trying to achieve the goal of a dignified dying process.\u003c/p\u003e \u003cp\u003eThere still exists a big concern around the real prevalence and incidence of this phenomenon, mostly because it is often misdiagnosed as pressure injury: an Italian multicentric study found an incidence of 2.7% in palliative settings (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), while other studies noted that a differentiation between KTUs and PIs was missing in intensive care units (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs long as we miss detailed diagnostic criteria, we won\u0026rsquo;t be able to understand the real dimension of the issue. As seen, new technologies, like ultrasound (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), are reaching out as important milestones for assessing this kind of ulcer, along with the clinical examination. On the other hand, we still miss a specific and validated terminal ulcer assessment tool and a proper staging system (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e): actually, while an assessment tool has been proposed in the last few years, literature demonstrates that all the terminal ulcers are documented with the same classification system used for pressure injuries.\u003c/p\u003e \u003cp\u003eThe aetiology is the main difference between pressure injuries and SCALE: the first ones are due to external factors such as pressure and shear and the latter are associated to hypoperfusion and multi-organ failure, thus we can say that the root cause is completely different (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The differential diagnosis is further complicated by the fact that the two of them may occur at the same time (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, the bilateral presentation of KTU could eventually be misdiagnosed with Moisture-Associated Skin Damage (MASD), especially if the patient has incontinence or some other risk factors (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) or if the lesions begin as numerous superficial spots, that are going to merge in a larger ulcer in a brief period of time (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThus, the correct identification of terminal ulcers is complicated by the similar manifestations, the classification system equal to the one used for PIs but also by the available terminology.\u003c/p\u003e \u003cp\u003eIn 2019, Levine introduced the concept of potential defensive bias for the terminal ulcer terminology: since the incidence of PIs is considered as an indicator of the quality of nursing care, with thousands of lawsuits each year, talking about \u0026ldquo;terminal ulcers\u0026rdquo; relies on the unavoidability of death and, in some way, seems to relieve caregivers from the responsibility of providing quality care. Levine proposes to replace this terminal ulcer terminology with a more prognosis-neutral nomenclature, in line with the one concerning other organs, such as \u0026ldquo;skin failure\u0026rdquo; (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitations\u003c/h2\u003e \u003cp\u003eSince the literature review is updated by March 2025, we are aware that relevant literature may have been published later.\u003c/p\u003e \u003cp\u003eWe also recognize that it has been difficult to accurately choose the sources of evidence, since the studies were very often focused only on the topic of KTU and, moreover, because information regarding terminal ulcers were strictly embedded in the larger topic of pressure ulcers.\u003c/p\u003e \u003cp\u003eA large part of the studies included in this scoping review have been conducted with a poor methodological quality, as many of them are editorials or are based on the opinion of experts. Furthermore, according to the methodology used, a critical appraisal of the included studies wasn\u0026rsquo;t performed. Therefore, we suggest using these evidences with caution and awareness.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eSome patients, during the end-of-life period, experience a specific kind of wound that is related to hypoperfusion and multi-organ failure: these terminal ulcers, which include a broad number of injuries, usually develop very quickly, with typical patterns. They are considered unavoidable, since they occur despite all pressure-relieving interventions are implemented and the best quality of care is provided.\u003c/p\u003e \u003cp\u003eHowever, these ulcers are often misdiagnosed as pressure injuries, since nurses and health care professionals are often found to be not so well-prepared on this topic: thus, we miss prevalence data and, even more important, we avoid providing effective palliative care and palliative wound care.\u003c/p\u003e \u003cp\u003eThe goals of end-of-life wound management should be focused on comfort care, for the patient, which includes pain relief and conservative management of all the wound\u0026rsquo;s symptoms such as odour or exudate; moreover, other goals for both patients and their circle of care include communication and emotional support regarding the imminent death.\u003c/p\u003e \u003cp\u003eThis scoping review has highlighted several points that warrant further investigation, including the role of pressure in the occurrence of these lesions, some hypotheses regarding their aetiology, the validation of effective assessment tools as well as the definition of solid diagnostic criteria and the issue of healthcare professionals\u0026rsquo; education. The authors hope that more research will address all these topics in order to further improve the quality of care for dying people and for their families.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eKTU: Kennedy Terminal Ulcer\u003c/p\u003e\n\u003cp\u003eKL: Kennedy Lesion\u003c/p\u003e\n\u003cp\u003eTB-TTI: Trombley-Brennan Terminal Tissue Injury\u003c/p\u003e\n\u003cp\u003ePI: Pressure Injury\u003c/p\u003e\n\u003cp\u003eSCALE: Skin Changes At Life\u0026rsquo;s End\u003c/p\u003e\n\u003cp\u003eMASD: Moisture-Associated Skin Damage\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDTI: Deep Tissue Injury\u003c/p\u003e\n\u003cp\u003eMPEI: Miller pressure equivalent injury\u003c/p\u003e\n\u003cp\u003eNPUAP: National Pressure Ulcer Advisory Panel\u003c/p\u003e\n\u003cp\u003eRTD: Relative Temperature Differential\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthical Approval\u003c/h3\u003e\n\u003cp\u003eNot applicable. This article is a review of previously published literature and does not involve any new studies with human participants or animals performed by the author.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of data materials\u003c/h3\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eThe conception and design of the study were undertaken by IS, RB and PF\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIS, RB and PF developed the search strategy and conducted the literature search.\u003c/p\u003e\n\u003cp\u003eThe screening of the articles was conducted by IS, DC and DC, with the supervision of PF.\u003c/p\u003e\n\u003cp\u003eIS, DC and DC completed data charting, followed by data synthesis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe initial draft of the manuscript was prepared by IS.\u003c/p\u003e\n\u003cp\u003eAll authors contributed to successive iterations of the manuscript, and the final version was approved by all.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe authors would like to express their gratitude to Dr. Carmela Palazzi, the university librarian at University of Modena and Reggio Emilia (Italy), for her invaluable assistance in formulating a comprehensive search strategy and in conducting literature searches.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eRadbruch L, De Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. Redefining Palliative Care\u0026mdash;A New Consensus-Based Definition. J Pain Symptom Manage. 2020;60(4):754\u0026ndash;64.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKwan Z, Han WH, Yong SS, Faheem NAA, Choong RKJ, Zainuddin SI, et al. Dermatological Issues Among Individuals Receiving Palliative Care - A Review. Am J Hosp Palliat Care. 2024;41(8):952\u0026ndash;64.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEmmons KR, Lachman VD. Palliative Wound Care: A Concept Analysis. J Wound Ostomy Continence Nurs. 2010;37(6):639\u0026ndash;44.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYousef H, Alhajj M, Fakoya AO, Sharma S. Anatomy, Skin (Integument), Epidermis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2025. http://www.ncbi.nlm.nih.gov/books/NBK470464/. Accessed 21 August 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLa Puma J. The ethics of pressure ulcers. Decubitus. 1991;4(2):43\u0026ndash;4.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBlack JM, Edsberg LE, Baharestani MM, 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\u0026ndash;37.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAyello EA, Levine JM, Langemo D, Kennedy-Evans KL, Brennan MR, Gary Sibbald R. Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries. Adv Skin Wound Care. 2019;32(3):109\u0026ndash;21.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSamuriwo R. End of life skin care - Research informing theory to traverse between Scylla and Charybdis? Palliat Med. 2021;35(6):986\u0026ndash;7.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFerris A, Price A, Harding K. Pressure ulcers in patients receiving palliative care: A systematic review. Palliat Med. 2019;33(7):770\u0026ndash;82.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYardley I, Yardley S, Williams H, Carson-Stevens A, Donaldson LJ. Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents. Palliat Med. 2018;32(8):1353\u0026ndash;62.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLevine JM. Unavoidable Pressure Injuries, Terminal Ulceration, and Skin Failure: In Search of a Unifying Classification System. Adv Skin Wound Care. 2017;30(5):200\u0026ndash;2.\u0026nbsp;\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\u0026ndash;63.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePeters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141\u0026ndash;6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eArksey H, O\u0026rsquo;Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19\u0026ndash;32.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTricco AC, Lillie E, Zarin W, O\u0026rsquo;Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467\u0026ndash;73.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePeters MD, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scoping reviews. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, curatori. JBI Manual for Evidence Synthesis [Internet]. JBI, 2024. https://jbi-global-wiki.refined.site/space/MANUAL/355862497/10.+Scoping+reviews.\u0026nbsp;Accessed 21 August 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;n71.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKennedy-Evans K. Understanding the Kennedy terminal ulcer. Ostomy Wound Manage. 2009;55(9):6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGomes ET, Penna AB, Braga GT, Carioca AC, Renna CR, Rios ACC. Ultrasound evaluation of Kennedy terminal ulcer: case study. Br J Community Nurs. 2025;30(Sup3):S22\u0026ndash;6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eChan CJ, Chuang YH, Huang TW, Gautama MSN. Use of Electronic Health Records to Identify Factors Related to Skin Changes in Terminal Patients. Adv Skin Wound Care. 2025;38(4):204\u0026ndash;9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eReitz M, Schindler CA. Pediatric Kennedy Terminal Ulcer. J Pediatr Health Care. 2016;30(3):274\u0026ndash;8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAlarc\u0026oacute;n-Alfonso CM. Nursing care plan for the Kennedy terminal ulcer patient. Case report. Enferm Cl\u0026iacute;nica Engl Ed. 2022;32(4):284\u0026ndash;90.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGarcea R, Savelli P. Kennedy\u0026rsquo;s terminal ulcer and pressure injury: two different aspects of medical liability related to the same injury. Ital J Wound Care [Internet]. 2023;7(2). https://www.ijwc.it/site/article/view/101. Accessed 21 August 2025.\u003c/li\u003e\n \u003cli\u003eBeldon P. Skin changes at life\u0026rsquo;s end: SCALE ulcer or pressure ulcer? Br J Community Nurs. 2011;16(10):491\u0026ndash;4.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLepak V. Avoidable \u0026amp; Inevitable? Skin Failure: The Kennedy Terminal Lesion. J Leg Nurse Consult. 2012;23(1):24\u0026ndash;7.\u0026nbsp;\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\u0026ndash;50.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSibbald RG, Krasner DL, Lutz J. SCALE: Skin Changes at Life\u0026rsquo;s End Final Consensus Statement: October 1, 2009\u0026copy;. Adv Skin Wound Care. 2010;23(5):225\u0026ndash;36.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBrennan MR, 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\u0026ndash;9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLatimer S, Walker RM, Gillespie BM. End-of-life wounds and pressure injuries in dying adults: distinguishing the difference. InScope. 2022;51.\u0026nbsp;\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\u0026ndash;7.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBateman J. Kennedy Terminal Ulcer #383. J Palliat Med. 2019;22(12):1612\u0026ndash;3.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMiller MS. The Death of the Kennedy Terminal Ulcer. J Am Coll Clin Wound Spec. 2016;8(1\u0026ndash;3):44\u0026ndash;6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSarabia-Cobo C. Poly Ulceration Patient Terminal: Kennedy Terminal Ulcer (KTU). J Palliat Care Med [Internet]. 2017;7(01). https://www.omicsgroup.org/journals/poly-ulceration-patient-terminal-kennedy-terminal-ulcer-ktu-2165-7386-1000297.php?aid=85087. Accessed 20 August 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSchank JE. The Kennedy Terminal Ulcer \u0026ndash; Alive and Well. J Am Coll Clin Wound Spec. 2016;8(1\u0026ndash;3):54\u0026ndash;5.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMitchell A, Elbourne S. Pressure ulcers at the end of life. Community Wound Care. 2022;27(Sup3):S14\u0026ndash;8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJulian MK. Skin failure in patients with a terminal illness. Nurs. Made Incred. Easy. 2020; 18(4): 28-35.\u003c/li\u003e\n \u003cli\u003eRoca-Biosca A, Rubio-Rico L, De molina-Fern\u0026aacute;ndez MI, Martinez-Castillo JF, Pancorbo-Hidalgo PL, Garc\u0026iacute;a-Fern\u0026aacute;ndez FP. Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review. J Tissue Viability. 2021;30(2):178\u0026ndash;82.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKennedy-Evans K, Vargo D, Ritter L, Adams D, Koerner S, Duell E. Early Skin Temperature Characteristics of the Kennedy Lesion (Kennedy Terminal Ulcer). Wound Manag Prev. 2023;69(1):14\u0026ndash;24.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHill R, Petersen A. Skin Failure Clinical Indicator Scale: Proposal of a Tool for Distinguishing Skin Failure From a Pressure Injury. Wounds Compend Clin Res Pract. 2020;32(10):272\u0026ndash;8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eElbourne S. Pressure ulcers at the end of life. Br J Community Nurs. 2022;27(Sup6):S5\u0026ndash;6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHuffman JL, Harmer B. End-of-Life Care. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2025. http://www.ncbi.nlm.nih.gov/books/NBK544276/. Accessed 21 August 2025.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKennedy KL. The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 1989;2(2):44\u0026ndash;5.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEdsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Cont Nurs Off Publ Wound Ostomy Cont Nurses Soc. 2016;43(6):585\u0026ndash;97.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLangemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206\u0026ndash;11.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLatimer S, Walker RM, Hewitt J, Ray-Barruel G, Shaw J, Hunt T, et al. Testing the study protocol and interrater reliability of a new end-of-life wound assessment tool: a feasibility study. BMC Palliat Care. 2025;24(1):216.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJakobsen TBT, 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\u0026ndash;9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMurphy EK. Charting by exception. AORN J. 2003;78(5):821\u0026ndash;3.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eStrazzieri-Pulido KC, S Gonz\u0026aacute;lez CV, Nogueira PC, Padilha KG, G Santos VLC. Pressure injuries in critical patients: Incidence, patient-associated factors, and nursing workload. J Nurs Manag. 2019;27(2):301\u0026ndash;10.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLevine JM. Terminal Ulcer Terminology: A Critical Reappraisal. Wound Manag Prev. 2019;65(8):44\u0026ndash;7.\u0026nbsp;\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":"Scoping review, Palliative care, End-of-life care, Terminal ulcer, End-of-life wound, Palliative wound care, Skin failure","lastPublishedDoi":"10.21203/rs.3.rs-8344060/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8344060/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIn the final stage of life, the skin may fail, leading to the development of terminal ulcers. These ulcers are considered unavoidable, since they occur despite all pressure-relieving interventions being implemented and the best quality of care being provided. However, they are often misdiagnosed as pressure injuries, since healthcare professionals are not always adequately prepared for this topic. Thus, effective palliative care and palliative wound care is not provided and prevalence data is missed, despite it being considered a solid indicator of the quality of nursing care.\u003c/p\u003e\n\u003cp\u003eThis work aims to clarify the concept of the unavoidability of these wounds, understand the terminology used and describe what is currently known about diagnostic criteria and assessment tools, prevention, management and aetiology of these wounds as well as clinicians’ understanding of the phenomenon.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e To achieve this goal a scoping review was performed. Following Arksey and O’Malley’s framework and Joanna Briggs Institute guidelines, we systematically searched the PubMed, Scopus, CINAHL, Embase, Google Scholar, ProQuest databases, up to March 2025, without time or methodological limitations. The review incorporated studies that explicitly referenced terminal injuries occurring at the end of life, written in English. The study encompasses all patients in all healthcare settings. A narrative synthesis was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Twenty-six studies were included in the analysis. The review summarises the huge amount of terminology applied to terminal ulcers and identifies multiple potential aetiologies. Diagnostic criteria were outlined, and considerations regarding the prevention, management, and professional education were discussed. The need for validation of assessment tools and clearer diagnostic criteria was highlighted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This review maps current evidence on terminal ulcers and identifies significant gaps. Future research should focus on healthcare professionals’ training, communication skills, and the early recognition and prevention of these lesions to promote dignity in end-of-life care. Nurses are responsible for the proper identification and management of terminal wounds, which raises ethical concerns about the quality of care and the principles of beneficence and non-maleficence. Although correct identification may affect reimbursement, ensuring the best possible care and a dignified end-of-life process remains the priority.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Terminal ulcers in end-of-life care: a scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 17:16:26","doi":"10.21203/rs.3.rs-8344060/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-02T10:10:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-28T16:29:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-27T04:46:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-25T18:20:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310968847562519052430898673077349309775","date":"2025-12-19T13:51:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106361427852066062609589342860547369455","date":"2025-12-18T21:29:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100367379346111824465655229486473810896","date":"2025-12-18T19:11:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-18T06:01:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-16T12:43:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-15T00:09:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-15T00:09:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-12-12T09:00:10+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":"ebebfe9b-9bcf-499c-8342-c01b05d68955","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:00:26+00:00","versionOfRecord":{"articleIdentity":"rs-8344060","link":"https://doi.org/10.1186/s12904-026-02000-8","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2026-01-30 15:58:15","publishedOnDateReadable":"January 30th, 2026"},"versionCreatedAt":"2025-12-22 17:16:26","video":"","vorDoi":"10.1186/s12904-026-02000-8","vorDoiUrl":"https://doi.org/10.1186/s12904-026-02000-8","workflowStages":[]},"version":"v1","identity":"rs-8344060","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8344060","identity":"rs-8344060","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}