Skin Changes At Life's End (SCALE)

This article reviews SCALE, a topic that is just beginning to be researched. A common manifestation of SCALE is the Kennedy Terminal Ulcer. Not all pressure ulcers are avoidable at end-of-life, especially the Kennedy Terminal Ulcer. Specialties Hospice Article

Published Jul 13, 2012

The skin is the largest organ of the body and can become dysfunctional at life's end, with loss of integrity, just like any other vital body system, with reduced ability to utilize nutrients and other factors necessary to sustain normal skin function.

The manifestations of this dysfunctional state are called skin changes at life's end (scale).

These end-of-life skin changes stem from ineffective skin and underlying soft tissue perfusion, increased vulnerability to external insults (such as minimal pressure), build up of metabolic wastes, and local tissue factors. At end-of-life, a person may develop skin breakdown, despite multiple appropriate interventions and optimal care, as it may be impossible to shield the skin from insult and injury in its compromised state.

The acronym scale describes clinical phenomena in skin and soft tissues that occur when the dying process compromises homeostasis, resulting in skin failure. Skin failure is defined as the localized death of skin and its underlying tissues due to decreased blood flow secondary to dysfunction of other body systems, often multiple system organ failure. This failure of the largest organ can be classified as acute, chronic, or end-stage. Clinicians need to have a realistic understanding of what can be achieved, in terms of prevention and treatment of wounds, due to the declining health status of individuals with multiple comorbid conditions and/or terminal illness, as they approach end of life.

As stated earlier, not all pressure ulcers at end-of-life are avoidable. A common manifestation of scale is a phenomenon known as the kennedy terminal ulcer (ktu), which is a special type of pressure ulcer that forms suddenly in dying individuals. A pressure ulcer, also termed a bedsore or a decubitis ulcer, is a lesion that develops as a result of unrelieved pressure, shearing force, or friction or a combination of these factors. It usually develops over bony prominences.

The damage consists of areas of tissue ischemic hypoxia, necrosis and ulceration. Pressure ulcers are most often seen in elderly, immobilized, or emaciated patients. The sores are graded by stages of severity, from stage i through stage iv.

Research is limited, but the ktu is an unavoidable pressure ulcer that develops in some individuals as they are dying, usually within 2 weeks of death and in conjunction with impaired skin perfusion. This unique type of skin failure or skin breakdown is typically found on the sacrum or coccyx, occurs suddenly (usually within hours), and is shaped like a pear, butterfly, or horseshoe. The ulcers may be red, yellow, black, or purple in color, and tend to progress rapidly to stage iii/ iv. The treatment for the ktu is the same as for any other pressure ulcer of the same stage.

This has been an overview of scale, a topic that is just beginning to be researched. Not all pressure ulcers are avoidable at end-of-life, especially the kennedy terminal ulcer.

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About VickyRN, MSN, DNP, RN

VickyRN, PhD, RN, is a certified nurse educator (NLN) and certified gerontology nurse (ANCC). Her research interests include: the special health and social needs of the vulnerable older adult population; registered nurse staffing and resident outcomes in intermediate care nursing facilities; and, innovations in avoiding institutionalization of frail elderly clients by providing long-term care services and supports in the community. She is a Professor in a large baccalaureate nursing program in North Carolina.

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Skin Changes At Life's End (SCALE)

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