By Kimberly Marselas, McKnights
While acceptance of end-of-life wounds has risen over the last three decades, a lack of consensus around what actually causes them and how to categorize them clinically continues to leave providers vulnerable to lawsuits and other risks.
Two noted long-term wound experts are calling for key research that could lead to a universally accepted definition of and diagnosis criteria for skin failure. They also want the development of related ICD-10 coding.
Such changes could improve care and lower liability risks for well-intentioned providers who meet new standards.
“There is currently no way to appropriately classify the development of a necrotic wound in a pressure area of a nursing home resident in a trajectory toward death, or a full-thickness skin injury in a critically ill patient in intensive care,” Dan Berlowitz, MD, chair of the Department of Public Health at the University of Massachusetts Lowell, and Jeffrey Levine, MD, clinical Professor in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, wrote in a viewpoint for JAMA Internal Medicine.
“As the aging demographic has expanded and medical technology has progressed, it has been realized that not all ‘pressure injuries’ may be pressure injuries,” they added in their Jan. 13 piece. “While relief of pressure injuries should be part of standard care, hospitals and healthcare professionals should not be penalized for skin failure that is not preventable.”
Norris Cunningham, an Indianapolis-based attorney who commonly represents nursing homes in pressure injury cases, said they actually often involve misunderstood end-of-life wounds.
No amount of educating patients and families about skin failure that occurs with or without pressure — and often regardless of how often or how well a patient has been repositioned — has been foolproof in preventing lawsuits and citations, Cunningham told McKnight’s Long-Term Care News.
Education can be quickly undone by a plaintiff’s attorney well-versed in preventable pressure injuries. Often, they come equipped with gruesome photos and eager to secure a victory. And failure to document even just a single turn could be detrimental to a defense, added Cunnigham, a member of Stoll Keenon Ogden.
“We’re always going to be looking at taking the blame here if there are no distinguishing characteristics between what could essentially be termed skin failure versus some external force like pressure,” he said. “We are always going to find ourselves in a position of being sort of behind the 8-ball, trying to show that no, this was about the person’s comorbidities. It was about these issues, and not a function of external pressure.”
Tools to address the toll on skin
But research that pinpoints specific bodily mechanisms or conditions associated with unavoidable skin failure, a consensus statement or other tools would make it easier for nursing homes to defend themselves, he said.
Such tools would also help build the confidence of frontline staff, who currently might be unsure of how to document skin failure such as a hallmark Kennedy Terminal Ulcer. Better guidance could help determine when not to label a wound as a pressure injury in the Minimum Data Set, which became an option in late 2022 but sparked confusion since end-of-life wounds can look the same as other wounds.
“There is no way to distinguish, based on appearance, a pressure injury from an ulcer developing as a result of skin failure,” Berlowitz and Levine wrote. “Their appearances are similar, and biopsy results are unlikely to reveal any specific markers. The only distinguishing characteristics are the clinical scenario in which an injury develops and whether recommended preventative measures were followed.”
Even though the Centers for Medicare & Medicaid Services has begun to recognize the presence of end-of-life skin failure among nursing home patients, it hasn’t extended the same interpretation to hospitals. There, both Cunningham and the researchers noted, such wounds would still be considered “never events” and bring on intense regulatory scrutiny and financial penalties.
That may be partly because patients’ risks are expected to be managed over a short stay, Cunnigham said. But end-of-life wounds can develop quickly if skin, an organ like any other in the body, begins to shut down. In some cases, especially if a patient, the skin may be so unable to bear pressure that turning a patient every 10 minutes wouldn’t stave off breakdown, Cunningham said.
More clarity needed
Among long-stay nursing home residents, failure to assess and address risk factors to surveyors’ standards still puts providers at risk. Reviewers and juries alike need more ways to help understand what happens to skin at the end of life and why little intervention is possible.
“We are essentially still in the position of doing what we always have to do in these cases, which is trying to take the jury to medical school and explain this science to them in a way that at least gives them to understand this may not be their [the nursing home’s] fault,” Cunningham said. “We have SCALES [Skin Changes at Life’s End] or this concept of skin failure that exists, but then we say, but we can’t tell you what causes that. It happens, but we can’t tell you exactly why.”
Levine and Berlowitz hope the next frontier in skin failure research will identify a clinical syndrome that makes the issue clearer for all parties and spurs ICD-10 diagnostic codes for multiple skin failure scenarios.
“Establishing skin failure as an entity by understanding contributing factors will enable clinicians to recognize and address it effectively, develop new prevention and treatment methodologies, assist regulators in modifying quality measures and avoid unwarranted penalties,” they argued.
