The Phenomenon of Skin Failure

5 days ago

4 min read

Alterations to the skin’s integrity for a person nearing death are commonly misdiagnosed and minimally researched. The concept of skin failure was first described in 1991 by Dr. Irvine. Since then, skin failure has been deemed a collective term to describe Skin Changes At Life’s End (SCALE), the Kennedy Terminal Ulcer (KTU), Acute Skin Failure (ASF) and Trombley-Brennan terminal tissue injuries (Ayello et al., 2019). The phenomenon of skin failure is under recognized and often mismanaged, warranting further examination.

Skin failure is unavoidable, and frequently difficult to detect, diagnose, code, and treat. Some contributing factors include having different terminology to describe the occurrence, its relatively new recognition and therefore lack of formal education regarding it, and finally, unfamiliarity with its variable presentation. Even correct coding proves to be challenging for some providers since there is no specific code for skin failure. Current recommendations suggest using ICD-10 code L98. 9 Disorder of the skin and subcutaneous tissue.

The occurrence of skin failure is an observable phenomenon that can present unpredictably when end of life nears and evolves variably depending on comorbidities, location, and terminal illness. Few predictors have been identified in studies to assist in the early detection of impending skin failure. Acute skin failure commonly presents as a centrally located area of tissue damage, usually on the sacrum, coccyx, or buttocks, but may appear elsewhere. This is due to the integumentary systems compromise secondary to hemodynamic instability and/or another organ systems failure. Poor perfusion, even in the absence of pressure, creates a rapidly enlarging discolored lesion that is often mistaken for a deep tissue or unstageable pressure injury. It may resemble to outline of a pear, butterfly, or another irregular shape (Ayello et al., 2019).

This phenomenon only occurs in the terminally ill population. With modern medicine, people are living longer with aggressive interventions. The use of vasoconstrictors, having low mean arterial pressure, immobility, malnutrition, smoking, and comorbidities that have chronic effects on the vasculature are risk factors (Bain et al., 2020). Skin failure has been identified in all settings that involve terminally ill persons, though it is most researched and documented in the inpatient, hospice, and long-term care environments. The population skin failure can present in is most commonly the elderly, however, patients as young as neonates have also experienced this phenomenon (Jacob & Grabher, 2020).

For the clinician working in a wound care specialty, it is essential to be able to detect a skin failure. Differentiating skin failure from a Hospital Acquired Pressure Injury (HAPI) has significant monetary repercussions and potential legal ramifications. According to the Healthcare Financial Management Association, the cost of treatment for a single HAPI can reach an estimated $70,000, however some exceed this (2021). HAPI’s affect 2.5 million patients annually in the United States and are the second most common lawsuit claim made towards hospitals. Lastly, the cost associated with treating a HAPI is not reimbursed by the Centers for Medicaid and Medicare Services (CMS) nor most insurances, and the hospital is usually penalized in addition for its occurrence (Vitale et al., 2021).

HAPI’s are a key quality indicator, and correlate to higher morbidity and mortality nationally (Aningalan & Gannon, 2023). A patient developing a HAPI is classified as a “never event” by the CMS, signifying this is a devastating yet preventable occurrence (Agency for Healthcare Research and Quality, 2019). It is important to note, however, that CMS does acknowledge skin changes at end of life are unavoidable, even with preventative measures that exceed the standards or care. For this reason, skin failure is not due to negligence, if the patient’s clinical presentation supports the etiology and appropriate evaluation, intervention, monitoring, and evaluations were performed (Ayello et al., 2019). This distinction highlights the significance of distinguishing a HAPI from skin failure. The limited number of studies and varying inclusion criteria results in the incidence rate yet to be established in the U.S healthcare system.

Skin failure nearly always occurs near the time of death. A more patient centered, continental approach must be taken considering the goals of care are not to heal or provide palliative measures. A comfort-based goal is commonly pursued. This would include measures to relieve anxiety, minimize dressing changes, avoid in depth wound assessments and above all, prevent and treat pain. Caring for the patients’ spiritual needs and helping them reflect on their life meaning, purpose and come to terms with any internal despair that may be present is priority (Roca-Biosca et al., 2021; Sibbald & Ayello, 2020).

photo credit https://woundreference.com/app/topic?id=is-it-really-skin-failure.

References

Agency for Healthcare Research and Quality. (2019). Never events. https://psnet.ahrq.gov/primer/never-events

Aningalan, A. M., & Gannon, B. (2023). Driving hospital-acquired pressure injuries to zero: A quality improvement project. Advances in Skin & Wound Care, 36(11), 1–6. https://doi.org/10.1097/asw.0000000000000056

Ayello, E. A., Levine, J. M., Langemo, D., Kennedy-Evans, K., Brennan, M. R., & Gary Sibbald, R. (2019). Reexamining the literature on terminal ulcers, scale, skin failure, and unavoidable pressure injuries. Advances in Skin & Wound Care, 32(3), 109–121. https://doi.org/10.1097/01.asw.0000553112.55505.5f

Bain, M., Hara, J., & Carter, M. (2020). The pathophysiology of skin failure vs. pressure injury: Conditions that cause integument destruction and their associated implications. Wounds : a compendium of clinical research and practice, 32(11), 319–327. https://www.hmpgloballearningnetwork.com/site/wounds/article/pathophysiology-skin-failure-vs-pressure-injury-conditions-cause-integument-destruction-and

Irvine, C. (1991). 'skin failure'–a real entity: Discussion paper. Journal of the Royal Society of Medicine, 84(7), 412–413. https://doi.org/10.1177/014107689108400711

Jacob, A., & Grabher, D. (2020). The phenomenon of trombley-brennan terminal tissue injury in a neonate. Advances in Neonatal Care, 20(2), 171–175. https://doi.org/10.1097/anc.0000000000000688

Roca-Biosca, A., Rubio-Rico, L., De molina-Fernández, M., Martinez-Castillo, J., Pancorbo-Hidalgo, P., & García-Fernández, F. (2021). Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review. Journal of Tissue Viability, 30(2), 178–182. https://doi.org/10.1016/j.jtv.2021.02.006

Sibbald, R., & Ayello, E. A. (2020). Terminal ulcers, scale, skin failure, and unavoidable pressure injuries: Results of the 2019 terminology survey. Advances in Skin & Wound Care, 33(3), 137–145. https://doi.org/10.1097/01.asw.0000653148.28858.50 Song, E. & Costa, I.(2024). "Skin Failure - Introduction and Assessment"[photo]. In Milne C, Robinson S, (Eds.) , WoundReference. Available from: https://woundreference.com/app/topic?id=is-it-really-skin-failure. Retrieved on 11/16/24.