An expert panel was convened (2008) to initiate discussion and ultimately, to formulate a consensus statement on Skin Changes At Life’s End (SCALE) (Sibbald, Krasner & Lutz, 2010). I can speak to this first hand, because I was the convener and had the honor of bringing this distinguished group together in Chicago. The Panel consisted of 18 internationally recognized key opinion leaders including clinicians, caregivers, medical researchers, legal experts, academicians, a medical writer, and leaders of professional organizations. The Panel discussed the nature of SCALE, including the proposed concepts of the Kennedy terminal ulcer (KTU) and skin failure along with other end-of-life skin changes. The consensus document and statements were edited and reviewed by the panel following the meeting, while subsequently, the document and statements were externally reviewed by 49 internationally distinguished reviewers. A modified Delphi approach was used to determine the final statements, and 52 internationally distinguished reviewers reached consensus on the final ten statements.
The skin, as the body’s largest organ, like any other organ, is subject to failure and a loss of integrity. It has an increased risk for injury as a result of both internal and external insults. The Panel concluded that healthcare practitioners’ comprehension of skin changes that can occur at life’s end may be limited, that SCALE process is insidious, difficult to prospectively determine, additional research and expert consensus is necessary, and, perhaps most critical, not all pressure injuries are avoidable.
In the intervening years, the ten statements from this consensus document have helped clinicians to facilitate the transfer of knowledge into practice for quality patient outcomes, which are ideally driven by interprofessional teams involved with the care of individuals at life’s end. They highlight the need for additional education and research to better understand skin changes at the end of life.
The consensus statements on Skin Changes At Life’s End (SCALE) are important for legal nurse consultants (LNCs) reviewing wound care cases for several reasons. SCALE are unique because due to the life circumstances and the physiologic changes in the integumentary system during this period, the goal of care is different. The objectives of the individualized care plan may no longer be wound healing, but rather, overall quality of life, avoidance of complications and enhancement of comfort. Individualizing the plan of care to focus on the needs and wishes of the “circle of care” is the primary goal (Sibbald, Krasner, & Lutz, 2010). The LNC should be aware that not all pressure injuries are avoidable and that clinical and diagnostic criteria for SCALE conditions need to be considered.
SCALE Panel members agreed that there are observable changes in the skin at the end of life. The Panel recommends that clinicians, laypeople, and policy makers be better educated in the medical, social, legal, and financial implications of SCALE. Healthcare organizations need to recognize and provide resources that enable healthcare professionals to identify and care for SCALE, while maintaining the dignity of the patient, family, and “circle of care” at end of life. By raising awareness of SCALE, clinicians have been better able to assess skin changes at life’s end and more accurately diagnose these changes, rather than assume a diagnosis. Clinicians will also realize that some skin changes, including pressure injuries at the end of life are unavoidable.
The legal ramifications of SCALE may include liability for healthcare providers if they fail to identify and appropriately treat SCALE in their patients. In cases where patients develop skin changes associated with SCALE, families may file lawsuits alleging negligence or malpractice on the part of healthcare providers for not providing adequate care.
LNCs may play a crucial role in identifying and evaluating the care provided to patients with SCALE and assessing whether healthcare providers met the standard of care in preventing, identifying, and treating SCALE. They may also provide expert testimony in legal proceedings related to SCALE. It is important for healthcare providers to be aware of the potential legal implications of SCALE and to take steps to prevent and treat these skin changes appropriately.
Most recently, one of the co-chairs of the SCALE Consensus Event, has authored an update and review of seven strategies for end of life skin and wound Care (Krasner, 2022). Her work describes a practical approach to maximize the quality of life for individuals with SCALE and lays the practical groundwork for clinical practice. The LNC who is versed in and knowledgeable about SCALE will have a deeper understanding of wound cases during the final stage of life.
Krasner, Diane L. “Seven Strategies for Optimizing End-of-Life Skin and Wound Care.” Advances in Skin & Wound Care 35, no. 9 (2022): 515–19.
Sibbald, R. Gary, L. Diane Krasner, and Lutz, J. “SCALE: Skin Changes At Life’s End: Final Consensus Statement; October 1, 2009.” Advances in Skin & Wound Care 23 (2010): 225–36.
Cynthia Sylvia, legal nurse consultant, is a Certified Wound Care Nurse with 42 years of clinical expertise. With a Doctorate in Nursing and an MSc in Wound Healing, Cindy is a former VP of Clinical Affairs, an honorary lecturer at Cardiff University and a published author and international speaker.