Response

Dear Dr. Olshansky:

I thank you for your thought provoking and challenging comments regarding this article. I believe that a pressure ulcer is a diagnosis of exclusion, not the other way around. For way too many years medical professionals and plaintiff's attorneys have tended to label all breaks in skin integrity as bed sores, decubitus ulcers, or pressure ulcers. I have often observed that nursing staff is considered negligent in performing pressure redistribution maneuvers and held accountable for these wounds. Yet, there is no scientific research that qualifies any time specific schedule for turning and positioning. Care must be individualized.

I respectfully disagree with your assertion that a study must be conducted with 24/7 monitoring to " [horizontal ellipsis]be sure that it wasn't because we fell down on our care." The skin is not only the largest organ but also the only visible one, which alerts the professional of impaired blood flow. A thorough history and physical exam of the individual, along with laboratory analysis, medication review, and nutritional status is a necessity in order to rule out other causative factors such as ischemic, vascular disease, catabolic states, or diabetes mellitus. The body is a dynamic system that cannot be separated into its parts. If there are multiple comorbidities involving the demise of other organs then I question why a similar process cannot be applied to the skin? What about the ischemic events of the heart and the brain? Did we miss something? Why are limbs amputated even after bypass procedures? Should blame be found? Medicine can keep alive or maintain the heart, lungs, and kidneys but has not yet found a way to stop the destructive deterioration of the skin during end-of-life.

The KTU is primarily noted on the coccyx with subsequent involvement of the sacrum and ischiums. Yet if proper pressure redistribution was not done why were other pressure points over the other bony prominences not involved?

My clinical experience overwhelmingly suggests that the KTU is a real phenomenon. I have consistently observed that its course from development to the patient's death is not like that of a pressure ulcer; and I have further observed that its appearance is consistently indicative of hypoperfusion. Finally, I can attest to the diligence of investigative techniques in long-term care facilities. All skin impairments are evaluated and interventions are put into place to prevent the preventable and manage those which develop from a natural course of events.

Diane J. Yastrub, MSN, MSc, FNP-BC, CWCN,. DAPWCA, CDE, CHCQM