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Skin Failure: Identifying and Managing an Underrecognized Condition
Key words: Long-term care, pressure ulcers, skin failure, skin integrity.
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Pressure ulcers in long-term care (LTC) facilities and other settings are largely, but certainly not always, preventable. Since late 2008 in the United States, the Centers for Medicare & Medicaid Services (CMS) has considered a hospital-acquired stage III or stage IV pressure ulcer to be a serious reportable event. Therefore, it will no longer reimburse providers for the treatment of these conditions, according to a letter from Herb B. Kuhn, acting deputy administrator, CMS, and director, Center for Medicaid and State Operations, to state Medicaid directors.1 As of 2011, the National Quality Forum was assembling a technical advisory panel to consider expanding the scope of serious reportable events to include those occurring in LTC and skilled nursing facilities.2 Although these efforts to ensure quality care should be applauded, considerations must be made for an aging population and for sustaining life beyond the norm, which is a phenomenon we are increasingly seeing.
The baby boomer generation is turning 65 years old, and as that population ages, it will represent the “oldest-old” group (age >85 years) by 2030.3 It is anticipated that the baby boomer population will grow from 5.7 million in 2008 to 19.0 million in 2050.3 Some research suggests that the death rate will continue to decline,3 which is not surprising given the influx of medical advances that are continuing to prolong life, enabling more people to reach ages beyond which the skin can maintain its integrity.4 Organ failure is often seen with advanced age and in the setting of a critical illness, and the skin is no exception. In view of an aging and growing critically ill population, skin failure and pressure ulcers will likely be an increasing occurrence. This article reviews skin failure and how it differs from pressure ulcers, outlines tools that can be used to predict the occurrence of skin failure, and reviews plans of care for patients with skin failure.
Discussion
Consisting of about 10% to 15% of a person’s body weight, the skin is the largest organ of the body. Intrinsic aging makes the skin particularly susceptible to insult in older adults. Difficulties with thermoregulation, tensile strength, immunity, and vascularity worsen during the aging process. Clinically, these problems cause the skin to become more dry, thin, and prone to shear, leading to prolonged healing times.5 When these conditions are compounded by an acute illness, one can appreciate how skin can fail in frail older adults and critically ill individuals. Nevertheless, few studies have addressed skin failure. Instead, currently available data mainly focus on whether certain pressure ulcers are avoidable,6,7 and the relationship between skin failure and pressure ulcers has yet to be properly defined.
Skin Failure Versus Pressure Ulcers
Pressure ulcers and skin failure are not the same. The National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) define a pressure ulcer as “localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear.”8 Skin failure occurs without the presence of pressure and/or shear, whereas pressure, shear, or both are responsible for pressure ulcer development. A pressure ulcer and skin failure can and often do occur together, as an area of skin failure exposed to pressure and/or shear would have greater vulnerability to breakdown. This is not uncommon in an individual with hemodynamic instability, whose position cannot be changed or can only be changed minimally. A pressure ulcer would understandably develop more quickly in an area where the skin has failed. The key difference is that pressure alone or in combination with shear must be present for the development of a pressure ulcer. Researchers’ understanding of pressure ulcers versus skin failure has evolved over the past decade.
In 2006, Langemo and Brown4 had defined 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.” In 2009, an interdisciplinary panel of 18 experts in wound healing convened to develop SCALE (Skin Changes at Life’s End), a consensus statement on the changes that occur to the skin at the end of life.9 The panel adopted the 2006 definition of skin failure by Langemo and Brown,4 thus identifying skin failure as a real condition that can occur in the last days or weeks of life. The panel reported that our knowledge of this condition is limited and requires further research, and they also acknowledged that skin failure can occur in both acute and chronic illnesses. Another point of discussion for the panel was the Kennedy Terminal Ulcer, which was first described in 1989 and is now often explained by researchers as an unavoidable skin breakdown that occurs during the dying process.10,11 The ulcer often presents as a red, yellow, or purple pear-shaped lesion on the coccyx or sacrum. Afterward, the lesion will darken deeply and may deteriorate into a full-thickness ulcer in a matter of days. According to the NPUAP and EPUAP pressure ulcer staging criteria,8 this lesion would be considered a suspected deep-tissue injury before the full-thickness ulcer becomes evident. Despite the assertions that skin failure does exist, there has been little investigation into the pathophysiology of such an ulcer, and the topic therefore remains controversial.12
In 2011, the NPUAP stated that not all pressure ulcers are avoidable.13 This position was the outcome of a consensus conference involving a wide array of wound care professionals. The panelists asserted that there are clinical conditions that lead to the unavoidable nature of some pressure ulcers, and they emphasized that skin failure and pressure ulcers are two separate conditions that can occur concomitantly. Any further attempts to define skin failure were beyond the scope of the NPUAP.13
Based on statements from the SCALE panel and the NPUAP, there are two conditions necessary for establishing skin failure: skin hypoperfusion and severe organ dysfunction or failure. For the frail older adult living in an LTC facility, these conditions are easily met; however, not all LTC residents experience skin failure at the end of life. There may be an as yet undefined predisposition to this type of organ failure.
Pathophysiology of Skin Failure
Researchers have theorized that when multiorgan failure occurs with the resultant conservation of blood for the vital organs, the skin will become hypoperfused and ischemic, leading to difficulty with metabolite management and, ultimately, to necrosis.14 Observational studies show that skin failure will often begin as a stage II pressure ulcer or suspected deep-tissue injury and progress rapidly to necrosis.10,11 Animal models suggest that there is an ischemia-reperfusion cycle at work when deep-tissue injury occurs. During reperfusion, instead of restoring oxygen and washing out waste products, there may be an activation of free radicals, resulting in swelling and inflammation. These animal models may indicate that repeated ischemia-reperfusion cycles cause more damage to tissues than one long ischemic episode.15-17 More studies are needed to delineate the pathophysiology of skin failure.
Prediction Tools
As pressure ulcers and skin failure are not the same, there is a need to develop tools that can predict skin failure. With a pressure ulcer, it is only after the ulcer develops that quality assurance initiatives determine avoidability.13 Two European studies aimed to develop pressure ulcer risk assessment scales in palliative care settings.18,19 Of these tools, the most promising was the Hospice Pressure Ulcer Risk Assessment (HoRT) scale,19 which includes physical activity, mobility, and age in its assessment. In a study of 85 subjects in a palliative care ward, the HoRT scale had a 100% sensitivity (100% negative predictive value) and 75% specificity (50% positive predictive value) for predicting a pressure ulcer. The scale remains to be validated in other settings, including in frail older adults in LTC.10
Another palliative care study showed that factors such as male sex, an inability to lie flat, catheter use, ostomy care, and an inability to perform activities of daily living are associated with pressure ulcers in home care residents with terminal cancer.20 For those LTC residents who are frail or have chosen a palliative pathway of care, a more sophisticated tool for the prediction of skin failure is needed. Presumably, such a tool would help staff educate residents’ families about the realistic expectations of skin changes during end-of-life care.
Comorbidities and Skin Failure in LTC
Langemo and Brown4 described three types of skin failure: acute, chronic, and end-stage. They reported that most episodes of skin failure in LTC settings are either chronic or end-stage. In chronic skin failure, the resident must have a chronic disease and exhibit a steady decline associated with aging or the progression of his or her disease. Dementia is a common chronic illness in LTC.21 Advanced dementia is frequently associated with complications in its last stages, such as impairment in nutritional status, loss of fat and muscle, pneumonia, and febrile episodes.22,23 As this and other chronic diseases cause slow organ failure, blood is shunted away from the skin, which eventually fails. In end-stage skin failure, the resident experiences more rapid skin failure that is concurrent with the end of life. As in chronic skin failure, blood is diverted to the vital organs as the final effort to preserve internal organ function. The resulting skin breakdown can be shocking to both staff and family members. Honest, open communication about the prognosis is therefore important at this time.
Prior to starting interventions, staff caregivers should be fully aware of residents’ comorbid conditions that may hamper efforts to maintain nutrition and hydration. In the last months of Alzheimer’s dementia, a terminal illness, eating problems will begin.24 Those patients with dementia and skin failure will require a family discussion regarding the use of a feeding tube. No data show, however, that feeding tubes improve nutritional status or resolve pressure ulcers in the setting of end-stage dementia.25 Despite the lack of data, families may find it challenging to watch their loved ones “waste away” with failing skin. Providers and dietary and speech therapists must continue to support families in the decision-making process. Nursing staff, including certified nursing assistants, can educate families about the pleasures of hand-feeding their loved ones.26
Managing Skin Failure in LTC
Similar to other chronic wound conditions, skin failure necessitates an interdisciplinary approach. In the LTC setting, these specialists should be readily available. Providers, nursing staff, dietitians, rehabilitative therapists, and the resident and caregivers all play a role in the resident’s care (Figure). Whereas pressure ulcer care is aimed at reversing the underlying condition, skin failure care should be focused on resident-centered and caregiver-centered concerns.9
Providers need to have frank discussions with the resident and his or her family, significant other, or caregivers regarding the resident’s prognosis, treatment of symptoms, and goals of care. In turn, residents and caregivers must be willing to clarify the goals of care. Several discussions may be necessary to help them through this process.27 A palliative care or hospice team, if available, can be invaluable in establishing a prognosis, educating the resident and his or her family, and treating the resident’s symptoms.
Skin failure, like other wounds, will produce significant pain for the resident. Pressure ulcer pain is thought to have both nociceptive and neuropathic mechanisms.28 The provider must assess whether the pain is noncyclic acute (eg, associated with debridement), cyclic acute (eg, associated with hygiene, turning regimens, dressing changes), or chronic.29 Both pharmacologic and nonpharmacologic means should be used to alleviate the pain, depending on its type and duration. The certified nursing assistant can alert the team to any changes in the resident’s pain experience, such as grimacing or moaning that occurs during the resident’s hygiene or turning regimen. Rehabilitative specialists can educate the team about repositioning the resident as well as recommend off-loading devices to help relieve pressure and pain.
A pressure ulcer will push a resident into a catabolic state, thereby increasing his or her nutritional and hydration needs.30 A dietitian can calculate the necessary amount of calories and fluid that the resident would require for healing, if healing is considered possible. Adequate calories, in addition to protein, are needed to promote collagen and connective tissue synthesis.31 If only protein is supplied without adequate calories, then the protein will be used as an energy fuel.
The mainstay of chronic wound management is moist wound healing. In the case of skin failure, where healing may not be possible, moist wound healing may increase the bacterial burden and risk of infection.32,33 In these situations, povidone-iodine and other antiseptics may be beneficial in preventing wound deterioration or worsening, but these agents have been prohibited in healthcare facilities because of their reported cytotoxic effects. Two systematic reviews, however, have suggested that there is still a role for antiseptics in the treatment of nonhealable wounds.34,35 The resident’s prognosis, goals of care, and ability of the wound to heal must be continuously documented to enable the use of such a controversial product. When antiseptics are used, care must be taken to prevent the wound from overdrying, which can cause increased pain with dressing changes. Wet-to-dry dressings are not recommended,8 as they are especially problematic in patients with skin failure, leading to increased nursing burden and worsening pain for the resident, while providing no bacterial balance.36,37 The recommended dressings are those that are nonadhesive, absorptive, and odor-controlling; prevent desiccation of the wound bed; protect the periwound from maceration; and can be left in place for longer periods. Examples of these dressings include hydrogels, foams, polymeric membrane foams, silicones, and alginates. Odor can be counteracted by removing necrotic debris and using antimicrobials, activated charcoals, and a variety of external odor absorbers.8,38
Conclusion
Because of the dearth of clinical data regarding skin failure, it can be difficult to determine the difference between a pressure ulcer and skin failure. This can be problematic when LTC facilities face increasing liability along with an increasing incidence of pressure ulcers.Skin failure is not a “permissible” pressure ulcer,and research efforts must therefore be focused on a better understanding of this phenomenon.
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Disclosures:
The authors report no relevant financial relationships.
Address correspondence to:
Elizabeth Foy White-Chu, MD
Hebrew SeniorLife
Department of Medicine
1200 Centre Street
Roslindale, MA 02131
foywhitechu@hsl.harvard.edu
