Terminal ulcers in end-of-life care: a scoping review

Background In the final stage of life, the skin may fail, leading to the development of terminal ulcers. These ulcers are considered unavoidable, since they occur despite all pressure-relieving interventions being implemented and the best quality of care being provided. However, they are often misdiagnosed as pressure injuries, since healthcare professionals are not always adequately prepared for this topic. Thus, effective palliative care and palliative wound care is not provided and prevalence data is missed, despite it being considered a solid indicator of the quality of nursing care. Since the goals of palliative and standard care differ, failing to correctly identify the underlying cause of the ulcer may result in the skin injury being treated inappropriately, and the overall needs of the patient and their family not being accurately addressed. While palliative care settings are probably more accustomed to this type of assessment, recognising and accepting this situation could be more challenging in other clinical settings. The aim of this work is to summarise the current knowledge regarding terminal ulcers. Specifically, the researchers seek to provide a comprehensive overview of the concept of unavoidability, the terminology employed in relation to terminal ulcers, the diagnostic criteria and assessment tools, the prevention and management of such ulcers, their aetiology, and the understanding clinicians have regarding this topic. Methods To achieve this goal a scoping review was performed. Following Arksey and O'Malley's framework and Joanna Briggs Institute guidelines, we systematically searched the PubMed, Scopus, CINAHL, Embase, Google Scholar, ProQuest databases, up to March 2025, without time or methodological limitations. The review incorporated studies that explicitly referenced terminal injuries occurring at the end of life, written in English. The study encompasses all patients in all healthcare settings. A narrative synthesis was performed. Results Twenty-six studies were included in the analysis. The review summarises the huge amount of terminology applied to terminal ulcers and identifies multiple potential aetiologies. Diagnostic criteria were outlined, and considerations regarding the prevention, management, and professional education were discussed. The need for validation of assessment tools and clearer diagnostic criteria was highlighted. Conclusions This review maps current evidence on terminal ulcers and identifies significant gaps. Future research should focus on healthcare professionals' training, communication skills, and the early recognition and prevention of these lesions to promote dignity in end-of-life care. Nurses are responsible for the proper identification and management of terminal wounds, which raises ethical concerns about the quality of care and the principles of beneficence and non-maleficence. Although correct identification may affect reimbursement, ensuring the best possible care and a dignified end-of-life process remains the priority.