Defining and Describing Terminal Ulcers in Dying Adults: An Integrative Review

Abstract

OBJECTIVE: To identify and synthesize the published primary literature on unavoidable skin breakdown and end-of-life wounds known as terminal ulcers. DATA SOURCES: Sources were identified through a systematic search of the Cochrane Library, Medline, ProQuest, Embase, CINAHL complete, and PubMed databases. STUDY SELECTION: The date limiters were set between 1984 and 2020 to locate primary qualitative, quantitative, and/or mixed methods studies on terminal ulcers. DATA EXTRACTION: Investigators examined 180 sources, and ultimately four quantitative studies were included in this review. All were conducted in the US and published between 1989 and 2019. Retrospective chart audits of deceased patients' medical files were undertaken in three of the studies, and prospective observations were used in the fourth. DATA SYNTHESIS: Descriptive and inductive content analyses were conducted. Three categories emerged: (1) distinguishing the ulcer development patterns, (2) identifying the ulcer characteristics, and (3) delivering specialized and individualized end-of-life care. CONCLUSIONS: There is limited primary evidence published on terminal ulcers. Pressure injuries and terminal ulcers have a similar appearance, but their development differs significantly. The lack of a specific terminal ulcer assessment tool and staging system increases the risk of these unavoidable end-of-life wounds being incorrectly assessed and managed as pressure injuries. Further research on terminal ulcers is needed to inform clinical practice and ensure specialized care is delivered to patients at end of life who develop these wounds.