Objectives. Wisconsin Case Facts. Wounds: The Criminalization of Skin Failure. Lived with aunt for 8 years Aunt s wishes

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1 Wounds: The Criminalization of Skin Failure Joyce Schank, RN, MSN, ANP, CWOCN, Penn Yan NY Objectives Discuss methods to protect caretakers and clinicians from civil/criminal charges for unavoidable skin breakdown. Determine the tragic consequences of skin failure, including caretakers facing criminal charges. Describe skin changes at life s end, including the Kennedy Terminal Ulcer and SCALE. Wisconsin Case Facts Lived with aunt for 8 years Aunt s wishes No doctors No hospitals Advanced Alzheimer s Developed KTU

2 Wisconsin Case Facts Patient wanted to die at home and niece agreed Cause of death: sepsis due to infected decubitus ulcers/ physical neglect No blood cultures WBC normal Photos - no sign of infection 4 Wisconsin Case Facts Felony charge 3 year prison sentence 7 year s probation 25 years maximum Jury believed deceased should have been taken to hospital despite wishes Arrest in Gloucester woman's death mirrors trend of elder neglect Elderly victim dies of neglect as state reports rise in abuse of older victims September 16, 2010 By Matt Sabo, msabo@dailypress.com

3 Virginia Case Facts Aunt essentially homeless Nephew transported her to VA Advanced Alzheimer s LTC placement Escaped from LTC Home care Family physician Virginia Case Facts PEG placement Stage I noted by nephew Praise from Home Health Continued to pull out PEG Family physician Deemed hospice candidate Virginia Case Facts Discharged from Home Health Wanted family physician No hospice Developed pneumonia Developed KTU

4 Virginia Case Facts Transported to hospital Adult protective services Police at home Virginia Case Facts Felony charges 2-10 years Up to $100,000 fine

5 Virginia Case Facts Plea deal offered to one Plead guilty Testify against other No time but $10,000 fine Charges dropped against Gloucester elder neglect suspect Judge rules sores unavoidable so near 87-year-old's death July 12, 2011 By Dan Parsons, Reasonable doubt? I doubt it Tamara Dietrich DAILY PRESS July 19, 2011 ET Let me get this straight. An ex-felon with a conviction for preying on a vulnerable elderly widow was able to get access to another vulnerable elderly widow. He took over her $2,300-a-month Social Security checks. Then months later, after the woman had shrunk down to a virtual death camp inmate emaciated, dehydrated, riddled with bedsores to the bone, insensible from Alzheimer's he drove 70 miles to leave her at a hospital where staff were so alarmed they reported the case to adult social services. Weeks later, the woman died.

6 To this laywoman, it sounds like a KTU diagnosis can cover a multitude of sins. Virginia Case Facts Night before 2 nd trial Offered plead guilty No time $10,000 fine Family said take deal Another Case Professional overseeing mother s care To ER for increased bruising Protective services involved Elder abuse suspected Coumadin!

7 Yet Another Case Professional overseeing aunt s care Aunt wants to live alone Stage I pressure ulcer ER nurse suspicious Abuse suspected Authorities notified What Did Go Right? Police Adult protective services What Went Wrong? Lack of knowledge Family physician not contacted

8 Elder Abuse/Neglect OR Skin Failure/KTU Skin Failure An event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care 2006;19(4): Kennedy Terminal Ulcer End of life ulcer Skin failure Pressure ulcer

9 Kennedy Terminal Ulcer 1983 first described 1989 in literature 1877 in literature Decubitus Ominosus Dr. Jean-Martin Charcot Dr. Charcot s research not known to Kennedy nor reported in modern literature Kennedy Terminal Ulcer May occur at end-of-life Usually on the sacrum, but not always Onset is sudden Pear-shaped with irregular borders Characteristic colors of red, yellow, and black Courtesy of Karen Kennedy-Evans, FNP Kennedy Terminal Ulcer Can progress rapidly Can come on within a few hours Courtesy of Karen Kennedy-Evans, FNP

10 Kennedy Terminal Ulcer How do you know it s a KTU? Facts Patient history Medical records Family history Pictures or wound description Healthcare providers/caretakers CMS recognizes the Kennedy Terminal Ulcer in Long-Term Care Hospitals unavoidable-kennedy-ulcer-in-longterm-care-hospitals/ CMS recognizes the Kennedy Terminal Ulcer in Long-Term Care Hospitals The KTU can now be used to avoid reporting a pressure ulcer as a quality measure in Long-Term Care Hospitals (LTCHs).

11 CMS recognizes the Kennedy Terminal Ulcer in Long-Term Care Hospitals This step goes a long way in legitimizing the concept that certain medical conditions can lead to unavoidable pressure ulcers that are not indicative of inadequate quality of care. SCALE PANEL Skin Changes at Life s End Consensus panel Recognized internationally Occurs also with overwhelming illness (illness aspect not published) STOP PANEL STOP: Shifting The Original Paradigm: Pressure Ulcer Staging

12 STOP PANEL Most Stage III and Stage IV pressure ulcers do not go through the progression of, or development from, Stage I or Stage II pressure ulcers. They begin de novo in the deeper tissue and present initially as Deep Tissue Injury (DTI) or as Stage III or Stage IV pressure ulcers. STOP PANEL In some instances, the ulcers may have had their origins as DTI (Deep Tissue Injury) as presently defined by the National Pressure Ulcer Advisory Panel. However, in many instances they defy detection as DTI and present as closed/covered ulcers that present very quickly as Stage III or Stage IV ulcers, confounding the ability for early detection. STOP PANEL Conlusion of STOP Panel Our surveillance methods, prevention regimes, timeframes for intervention, theories about support surface performance, topical treatments, and approaches to the entire clinical course, may need to be restated.

13 What s in the Chart When wound appeared Type Cause Description Treatment Diagnosis Medical history Pressure Ulcers Hot topic Surveys Never events Quality indicator Avoidable/Unavoidable Litigation Plaintiff Attorney Perception of Pressure Ulcers Preventable Should heal Proof of bad care Proof of neglect Ischemic leg ulcers are pressure ulcers

14 Pressure Ulcers Needlessly KILLING Patients Most pressure sores are preventable and are caused by faulty care Courtesy of Caroline Fife, MD 40 Pressure Sores are Entirely Preventable Courtesy of Caroline Fife, MD 41 Pressure sores are entirely preventable The criminalization of end-of-life care and the emergence of clinical forensic medicine James Campbell/John Fullerton Disturbing trend of criminal charges (family) Elders with dementia Campbell J, Fullerton J. The criminalization of end-of-life care and the emergence of clinical forensic medicine. National Association of Criminal Defense Lawyers, Inc. The Champion. November 2010; 34 Champion 12.

15 The criminalization of end-of-life care and the emergence of clinical forensic medicine In a case involving the end stages of a disease (e.g., terminal cancer or multiple, advanced chronic diseases causing multi-system organ failure), the skin breaks down, even with meticulous care, and creates Terminal Skin Failure, as another organ system predictably fails. Campbell J, Fullerton J. The criminalization of end-of-life care and the emergence of clinical forensic medicine. National Association of Criminal Defense Lawyers, Inc. The Champion. November 2010; 34 Champion 12. The criminalization of end-of-life care and the emergence of clinical forensic medicine In fact, the Kennedy Ulcer, classically a butterfly-like pressure type ulcer on the lower back, may be used as a marker and a prognosticator of terminal disease, classically forming only during the last 48 hours of life. Kennedy s research noted the ulcer could occur 2-3 months prior to death Campbell J, Fullerton J. The criminalization of end-of-life care and the emergence of clinical forensic medicine. National Association of Criminal Defense Lawyers, Inc. The Champion. November 2010; 34 Champion 12. Kennedy KL. The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 1989;2(2): Who Else can be charged?: Hawaiian nursing home operator convicted of manslaughter after resident dies of infection caused by pressure ulcers Courtesy of Caroline Fife, MD

16 Who can be charged: Nursing home operators With the introduction of criminal prosecution for gross neglect, a new weapon against poor nursing care has appeared. Courtesy of Caroline Fife, MD Pitfalls Healthcare circles the wagon Blame game Lack of documentation Various departments document differently Strategies Unavoidable/SCALE/KTU Document Educate

17 Strategies Initial and interval assessments Document any skin problem Watch the words Pressure Staging Purulent Strategies Consider flow sheets BUT Document in notes as needed Document when patient refuses treatment Document discussions with family Be aware of what is said in public places Check the boxes Fill out forms Do everything first Strategies

18 Anatomical Locations Wound Classification by Depth Partial Thickness Friction Injury Skin Tear Stage II Pressure Ulcer Partial- Thickness Burn Wound Classification by Depth Full Thickness

19 Type/Etiology Skin Tear Perineal Dermatitis Pressure Ulcer Venous Ulcer Diabetic Ulcer Arterial Ulcer Surgical Wound Burn Moisture Associated Skin Damage (MASD) Wound Etiology Origin VERY important Wound may have started due to moisture May later become pressure ulcer

20 NPUAP Pressure Ulcer Staging Suspected Deep Tissue Injury Stage I Stage II Stage III Stage IV Unstageable Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons (a heralding sign of risk). Stage II Definition Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury Shiny Ulcer Blister Shallow Ulcer

21 Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Stage IV Full thickness tissue loss with exposed Definition bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Bone Joint Capsule Tendon Unstageable Pressure Ulcer Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body s natural (biological) cover and should not be removed.

22 Suspected Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Blood-filled Blister Dark Skin Tones NPUAP Pressure Ulcer Staging Complicated Inter-rater reliability Some organizations want it changed to partial and full thickness NPUAP Pressure Ulcer Staging Not necessarily a progression Can start as full thickness meaning a Stage III or IV

23 Unavoidable Pressure Ulcers Federal government recognizes unavoidable pressure ulcers in the long term care setting Federal government does not recognize unavoidable in acute care National Pressure Ulcer Advisory Panel (NPUAP) Consensus conference Feb 2010 Not all pressure ulcers are avoidable Backed away from most pressure ulcers are avoidable Agreed on definition of unavoidable Adapted long term care s definition for acute care National Pressure Ulcer Advisory Panel (NPUAP) Unavoidable - means that the individual developed a pressure ulcer even though the provider had evaluated the individual s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with individual goals and recognized standards of practice; monitored and evaluated the impact of the intervention; and revised the approaches as appropriate

24 Take a deep breath Be calm Tell the truth Plaintiff Attorneys Deposition/Trial References American Medical Directors Association. Pressure Ulcers in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD:AMDA;2008. Black JM et al. Pressure ulcers: Avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy/Wound Management 2011; 57(2): Campbell J, Fullerton J. The criminalization of endof-life care and the emergence of clinical forensic medicine. National Association of Criminal Defense Lawyers, Inc. The Champion. November 2010; 34 Champion 12. References Kennedy KL. The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 1989;2(2): Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care 2006;19(4): Levine, Jeffery M. Historical perspective on pressure ulcers: The Decubitus Ominosis of Jean-Martin Charcot. Journal of the American Geriatrics Society (JAGS) 53: , 2005

25 References Sibbald RG, Krasner DL, Lutz, et al. The SCALE Expert Panel: Skin Changes At Life s End. Final Consensus Document. AdvSkin Wound Care., Oct 23:225-36; quiz Schank, J. (2009). Kennedy Terminal Ulcer: The Ah-Ha! moment and diagnosis. Ostomy Wound Management, 15;55(9): Thomas DR. Are all pressure ulcers avoidable? JAMDA. 2003:4(2suppl):S43 S48. References Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospitalacquired pressure ulcers and risk of death. J Am Geriatr Soc. 1996;44(12): Yankowsky,K. Preventative Legal Care: A Practitioner s Guide to Medical-Legal Fitness. Best Publishing Company, 2015.

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