The skin is the largest organ of the body and vulnerable to the physiological changes that occur as a result of the dying process.
Skin changes at the end of life are the result of reduced skin and soft tissue blood perfusion, a decreased resistance to external pressure and the skin’s reduced ability to remove metabolic waste. These changes can, but may not, manifest as wounds or ulcers. In the following we consider skin failure and pressure ulcers as separate but related issues.
describes the skin’s capacity to stay intact and act as a barrier to organisms and toxins, help regulate body temperature, and provide sensory input.
describes the state of compromised skin integrity where the skin as an organ fails. Skin failure increases the risk for pressure and/or shear-related injury and is often an indicator of other body system failures.
Pressure injury (pressure ulcer)
is a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction; the blood supply is restricted and the skin becomes necrotic.
Kennedy terminal ulcers (KTU)
are wounds that suddenly develop over bony prominences in the days preceding death. These ulcers are typically in the sacro-coccyx area; have a butterfly or pear shape with irregular borders; are purple, red, blue, or black colour (often variegated).
Trombley-Brennan terminal tissue injury (TB-TTI)
is a unique, irreversible phenomenon associated with end-of-life organ failure and can be predictive of impending death (commonly within 3 days). It presents as a pink, purple, or maroon discoloration of the skin. The skin remains intact.
KTUs and TB-TTIs are skin injuries that occur in the pre-active or active phases of dying and are considered terminal injuries.
For more on wound development with advanced cancer see the section on malignant wounds.
Nurses have an important role in recognising, assessing, and managing symptoms related to skin care. As skin changes are easily noticed, they may be of concern to the person and their family. Nurses can also help with sensitive and culturally appropriate education and support.
Risk factors, symptoms, and signs associated with skin changes at the end of life include loss of appetite, weight loss, cachexia and wasting, low haemoglobin, and dehydration.
Physiological changes that occur as part of the dying process may affect the skin and soft tissues and be observable as changes in skin colour, elasticity, or integrity or as symptoms such as localised pain.
Pruritis (skin itchiness) may also develop as an adverse reaction to opioid medicines, or as a symptom of cancer or end stage liver or kidney disease.
Ageing, smoking, diabetes, peripheral neuropathy, COPD, kidney disease, anaemia and other vascular conditions all lead to decreased circulation, increasing risk for skin breakdown. In advanced disease this can lead to skin damage and wounds including:
Care of the skin is primarily prevention of injury and monitoring for changes that accompany advanced illness. Management of a skin issue will depend on what it is and the likelihood for it to heal.
Pressure ulcers can be caused by lying or sitting for long periods of time without changing position. In palliative care patients, pressure ulcers can develop very easily and quickly and once present, they are difficult to heal. It is important to understand that in the terminal phase of illness, despite the best care, it may be difficult to prevent the development of a pressure ulcer.
Nurses should regularly check the skin when the following risk factors associated with skin breakdown and pressure ulceration are present:
When assessing skin look for:
Pay particular attention to areas prone to skin breakdown due to pressure such as the sacrum, coccyx, ischium, trochanters, scapula, occiput, heels, elbows and ears.
When assessing pressure ulcers look for:
The Braden Scale, Waterlow Scale or Norton Scale may be used to assess risk for pressure injury. These scales have been shown to have adequate to good predictive validity (the degree to which the test accurately predicts a measurable outcome) but most research has not been conducted in a palliative care context.
It is important to determine the impact of the wound on the person and if the wound has the potential to heal.
Management includes prevention, and treatment to heal or treatment to limit the impact on the person’s quality of life.
Use the concerns identified by the person (e.g. pain, mobility, aesthetics) to guide the way you manage skin and wound care.
Nurses can care for the skin and prevent skin wounds through:
Management of pressure ulcers includes the preventive measures above and
Practical considerations when attending to pressure ulcers and wounds include:
This information was drawn from the following resources:
Read Skin failure in patients with a terminal illness (609kb pdf)
Go to Pressure ulcers on the Marie Curie website
Access more Skin Changes resources
Page created 25 August 2022