With regard to Schank JE. Special report: Terminating the Kennedy Terminal Ulcer. Wound Manag Prev. 2019;65(4):18–22: The article explored the origins of the Kennedy Terminal Ulcer (KTU), practitioner and payer acceptance of the concept, and some of the challenges involved in the diagnosis of KTU and related conditions that affect the skin at the end of life. The terms Kennedy Terminal Ulcer, Skin Changes at Life’s End (SCALE), and Trombley-Brennan Terminal Tissue Injury (TB-TTI) all address the changes that occur at the end of life, and I believe they could be classified under the term skin failure.
The term skin failure and its associated descriptors was first documented by Jean Martin Charcot1 in the 1800s. He described his observations: “There appear on many points of the skin one or more erythematous patches, variable in extent and irregular in shape. The skin has a rosy hue, sometimes violet in color.” This description is commonly used in clinical practice today and also can be applied to KTU, SCALE, and TB-TTI. Basically, these different terminologies describe the same phenomena.
Although I agree with many of the points in the Schank article, I have one major concern. The author states KTU should continue to be used, and the wound care community should continue to research and evaluate skin failure terminology. I am of the opinion that KTU, SCALE, and TB-TTI all should be rolled into the diagnosis of skin failure using the qualifiers acute, chronic, and end of life. Charcot laid the foundation for this diagnosis centuries ago. Now that his work has been revived, it should not be left out of the conversation. Similarly, the research and evidence that Kennedy and others have brought to bear over the years should be viewed as building on the foundation that was already established by Charcot. There should be no confusion among clinicians as to the changes in terms. In medicine and health care (including wound care), our practice should evolve as knowledge evolves.
As a practicing wound care nurse, I all-too-often have seen the confusion among clinicians and the resistance to the terms skin failure, Kennedy Terminal Ulcer, and others in the acute care setting. This usually stems from lack of knowledge of skin conditions in general and the skin changes that occur with various metabolic processes in particular. A consensus needs to be established on the terminology, followed by an effort to educate health care professionals to help overcome many of the challenges currently faced when terminology impedes care.
Nekisha Hyman, BSN, RN, CWS
1. Levine JM. Historical perspective on pressure ulcers: the decubitus ominosus of Jean-Martin Charcot. J Am Geriatr Soc. 2005;53(7):1248-1251.