Introduction

I was asked to perform a wound consult on a newly admitted resident to a post-acute unit of a nursing home. She rested quietly with a barely touched breakfast on her bedside table. Her aide had tried to feed her, but she accepted only small spoonfuls of oatmeal and a sip of orange juice. She came to our facility after a long hospitalization for COVID-19–related complications, including pneumonia, kidney failure, and septic shock that required pressor agents. While in the ICU on a ventilator, she developed a pressure injury. At 86 years old, her transfer papers revealed feeding tube refusal and a do-not-resuscitate (DNR) order.

Case Study: Unstageable Wound

She could not move on her own and did not have the strength to grasp the side rail. With assistance from the nurse, we positioned her for examination. Gentle removal of the dressing revealed a substantial, unstageable wound over her sacrum and left buttocks that measured 8 x 6 centimeters. The odor of necrosis was readily apparent. Before leaving the room, we ensured the low air loss mattress was properly adjusted, and applied sodium hypochlorite soaked gauze to the wound. After reviewing her chart, I reflected on the elements of her presentation that indicated a limited prognosis for survival and wound healing. These elements included:

• A combination of recent multi-organ system failure with deconditioning
• Poor nutritional status and refusal of a feeding tube
• Advanced age with severely impaired functional status
• A necrotic sacral wound

Other relevant components of history included stroke with vascular dementia, coronary artery disease, congestive heart failure, and laboratory values indicating severe anemia and hypoalbuminemia.

Evaluating the Evidence: Unstageable or Terminal Ulcer?

Given her overall medical condition and prognosis, would it be justified to document the wound as a terminal ulcer? If so, entering this conclusion into the chart and sharing my thoughts with the primary care team could impact the treatment plan by reinforcing expectations of a poor outcome. Even worse, declaring this difficult diagnosis, which includes an intrinsic prognostication of death, could cause emotional distress for the family and diminish hope for recovery. I decided not to use any reference to terminal ulceration in my documentation or team discussions. The daughter was calm and reasonable on the phone as I explained her mother's treatment options. Although the daughter wanted the DNR to stay in place, she expressed a desire for aggressive wound management and consented to excisional bedside debridement.

Treatment: Interdisciplinary Efforts in Action

After 2 weeks, the combination of topical antiseptic and the removal of necrosis transformed the wound into a clean stage 4 that was ready for negative pressure wound therapy (NPWT). The speech therapist designed a dysphagia-friendly diet in conjunction with the dietician. Bedside coaxing by the certified nursing assistant (CNA) and visiting family members helped maximize her caloric intake. The nursing team was diligent in continuing the use of dressings and hygiene implementation.

By 5 weeks, the wound presented as a rich bed of granulation tissue filling the cavity. Soon, the edges contracted, and new epithelium crept across the granulation tissue. Two months into her treatment, NPWT was discontinued and replaced with alginate packing under foam dressings, and she was walking with a walker. In another month, her wound was mostly healed, and she was discharged to home care with visiting nurses and family members who performed wound care.

Wound Care Terminology: The Consequences of Terminal Ulcers

Words matter—particularly when coming from authority figures such as doctors and nurses. Patients and families seek comfort and hope, and caregivers should be cautious about voicing opinions that deny or limit these elements. Terminal ulcer terminology has been in the wound care literature for over 3 decades, but the designation depends on future events that nobody can accurately predict. Many factors alter a dire prognosis. These factors include the system of care within a facility, social support networks, medical technology, or the simple human will to live. As a geriatrician and wound care specialist, I recognized that my patient had a limited prognosis, and given her underlying medical conditions, this wound might not have healed. That said, I resisted the conclusory designation of "terminal ulceration" and constructed a treatment plan with family and facility personnel, including the primary care physician, nurses, nursing assistants, a dietician, and a speech therapist.

Terminal ulcer terminology is firmly embedded within our wound care lexicon, and even appears in regulations governing long-term care (see F-Tag 686). As of this writing, without a diagnosis-related group (DRG) designation, Medicare's reimbursement system has no official recognition. Given the uncertainty of defining the end-of-life period, terminal ulcer terminology should be reserved for situations when the body’s essential functions are shutting down, and both family and the health care team accept a state of impending death.

Conclusion

My patient had just been admitted from the hospital where she suffered multi-organ system failure. Her failed organ systems included skin—the body's largest organ—and resulted in necrosis over her sacrum while critically ill and immobilized with aggressive medical interventions. In determining her guarded prognosis, I considered both patient and family wishes, including DNR and refusal of a feeding tube. With the support of the nursing home staff, she beat the odds and responded to standard wound care interventions as part of her rehabilitation plan. Not every patient is capable of rallying in this manner, but as wound care specialists, we need to provide elements of management as indicated by individualized clinical assessment.

About the Author

Jeffrey M. Levine, MD, AGSF, CWSP, is a geriatrician and wound care specialist in New York City. He enjoys writing about the fascinating history of wound care, and you can see his website and blog here.