All About Nursing · CNE review · Hospice & Palliative Care

Skin failure near the end of life (Reading & Sharing)

Considered to be the largest organ system in the human body, our skin protects our internal organs and structures. The skin layers include the epidermis, dermis, and subcutaneous tissue. Although skin is only 1 to 2 mm thick, it contains 15% of the total weight for an adult and acts as the first line of defense against invading microorganisms.

Skin functions:

  • Providing protection for the underlying tissues and organs.
  • Receptors in the skin sense pain, pressure, and temperature changes.
  • Skin also plays a role in fluid balance, temperature regulation, and the synthesis of vitamin D.
  • The subcutaneous fatty layer acts as a cushion and stores fat for energy.

Alteration in skin integrity:

  • Age – As a person ages, physiological changes inherent to the aging process occur, such as reduced elasticity, loss of skin turgor, and decreased vascularity. Changes also occur in the cells at the junction of the dermis and epidermis, which may result in skin tearing more easily in elderly. Patients with a terminal illness pose a unique risk of alternations in skin integrity, and one aspect gaining attention includes the concept that skin injuries for these patient may be unavoidable and related to dying process.

Skin failure in now being used to describe 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, such as the heart, lungs, and kidneys. Skin failure is associated with multiorgan failure and end stage illness and can occur despite the provision of quality skin care.

Skin failure categories: acute, chronic, and end stage. Acute skin failure happens during an acute, critical illness and is associated with impaired nutrition, multisystem organ failure, decreased tissue perfusion, anemia, sepsis, prolonged mechanical ventilation, and surgery lasting longer than 3 hours. Chronis skin failure is thought to happen in conjunction with a chronic illness and is a slow, gradual process. End stage skin failure happens in the final days or weeks of life, with skin breakdown occurring rapidly within days or even hours. Patients at greatest risk for developing skin breakdown include those who are entering the final stage of the dying process.

Pressure Injury:

  • An injury to skin and /or underlying soft tissue that occurs as the result of unrelieved pressure.
  • A pressure injury usually occurs over a bony prominence and the degree of tissue damage is directly related to the intensity and duration of the pressure.
  • More than 2.5 million people in the US develop pressure injuries each year.
  • Pressure injuries that occur in the precative or active phases of dying are considered terminal injuries. (The unavoidable nature of terminal pressure injuries has been recognized by the CMS, and it’s recommended that wounds associated with the end of life be clearly documented to avoid being considered as part of a facility’s quality measures.
  • The Kennedy terminal ulcer (KTU)
    • is the skin alteration most commonly associated with patients who are terminally ill.
    • most commonly presents on the sacrum or coccyx as an irregularly shaped wound (like a butterfly or pear) that may be red, yellow, black, or purple. (initially erythematous and /or purpuric)
    • one of the most distinguishing features of a KTU is how quickly it can appear, seemingly overnight (sudden in development). It’s also much larger at the onset than other pressure injuries, initially beginning very superficially and rapidly progressing.
    • noted within 2 weeks or several months before a patient’s death (a KTU can occur despite diligent efforts to relieve pressure).
  • 3:30 Syndrome
    • A variation of KTU is known as 3:30 syndrome, which develops more rapidly than a KTU and may initially appears as small black specks on the patient’s skin.
    • The spots can look like tiny deep tissue injuries and they very quickly increase in size.
    • This syndrome 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 may patients who develop it have a very short life expectancy, approximately 8-24 hours.
  • Trombley- Brennan terminal tissue injury
    • 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.
    • can occur in areas not considered to be pressure points and may appear as linear striations.
    • a unique, irreversible phenomenon associated with end-of-life organ failure and can be predictive of impending death.

Atopic dermatitis (another skin issue):

  • An extremely common skin disorder described as superficial inflammatory, erythematous, pruritic, and eruptive
  • In adults, it is usually localized and chronic
  • It is in many ways a cyclic disorder, starting as a constant pruritis causing scratching, which in turns causes a rash that causes of atopic dermatitis are unclear, although there is often intolerance to environmental irritants’.
  • Exacerbation of atopic dermatitis may be caused by conditions that are common to patients near the end of life, including emotional stress, temperature changes, and bacterial skin infections, and for this reason it is important to consider these factors as a potential etiology of dermatitis in these patients.
  • Therapy involves avoidance of rubbing on the skin, minimization of scratching, and decreasing exposure to triggering stimuli in the environment. The skin should be kept well lubricated. Medications that are useful in reducing symptoms are similar to those used for pruritis and include hydroxyzine, diphenhydramine, and topical steroids. If lesions are resistant to this therapy then superimposed infection may be present. For such patients, antibiotic treatment directed against S. aureus may be of benefit.


Juilan, M. K. (2020) Skin Failure in Patients with a Terminal Illness

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