Q: What is terminal ulceration?

A: It has long been recognized that certain wounds can herald death. But there is profound lack of agreement on terminology and identification of these wounds.

The Kennedy Terminal Ulcer, originally described in 1989, made its way into the current Guidance to Surveyors for Long Term Care Facilities, but this lesion has not achieved universal acceptance. Other terms exist, leaving caregivers, coders and regulators confused when discussing the topic.

There is a need to understand the limits of terminal ulcer terminology while building a modern classification system.  Skin is the largest organ of the body and, therefore, subject to failure like any other organ system. Given its large surface area, as well as regional variations of anatomy and mechanical stress, it may fail regionally as well as systemically, and failure can be acute or chronic.

“Skin failure” can apply to skin breakdown in ICU patients or in debilitated persons with multiple comorbidities in the nursing home.  It also can account for unavoidable pressure injury in patients across the healthcare continuum with irremediable risk factors. 

The designation of a wound as “terminal” confuses diagnosis and prognosis, as it is unclear whether the wound predicts death, results from the dying process or both. This period is complex, often prolonged and  difficult to define.

Terminal ulceration should be recognized as a component of the spectrum of skin failure and used in situations where patients are recognized as actively dying by the healthcare team including providers, patient and family.

Reframing terminal ulceration within the concept of skin failure will result in improved interdisciplinary communication, better understanding of wound pathology and physiology, and creation of a sensible path to the future by allowing a comprehensive model for injury.