SCALE: Skin Changes at Life’s End

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Editor’s note: This version of the SCALE consensus document has been condensed from its original version. To access the full SCALE document, please visit www.woundsresearch.com or
www.gaymar.com.

The content of this document is based on the results of a 2-day roundtable discussion held on April 4–6, 2008 in Chicago, IL, and was made possible by an unrestricted educational grant from Gaymar Industries, Inc. Additional input was received from international panels of 49 and 52 distinguished reviewers using a modified Delphi Method process. The information contained herein does not necessarily
represent the opinions of all panel members, distinguished reviewers, or Gaymar Industries, Inc.

Copyright 2009 Skin Changes At Life’s End (SCALE) Expert Panel. All rights reserved. Used with permission.

Disclaimer: The content of this document is intended for general information purposes and is not intended to be a substitute for medical or legal advice. Do not rely on information in this article in place of medical or legal advice.



Abstract: An expert panel was established to formulate a consensus statement on Skin Changes At Life’s End (SCALE). The panel consists of 18 internationally recognized key opinion leaders including clinicians, caregivers, medical researchers, legal experts, academicians, a medical writer, and leaders of professional organizations. The inaugural forum was held on April 4–6, 2008 in Chicago, IL, and was made possible by an unrestricted educational grant from Gaymar Industries, Inc. The panel discussed the nature of SCALE, including the proposed concepts of skin failure along with other end of life skin changes. The final consensus document and statements were edited and reviewed by the panel after the meeting. The document and statements were initially externally reviewed by 49 international distinguished reviewers. A modified Delphi process was used to determine the final statements and 52 international distinguished reviewers reached consensus on the final statements.





     The skin is the body’s largest organ and like any other organ is subject to a loss of integrity. It has an increased risk for injury due to both internal and external insults. The panel concluded that: our current comprehension of skin changes that can occur at life’s end is limited; that SCALE process is insidious and difficult to prospectively determine; additional research and expert consensus is necessary; and contrary to popular myth, not all pressure ulcers are avoidable.

     Specific areas requiring research and consensus include: 1) the identification of critical etiological and pathophysiological factors involved in SCALE, 2) clinical and diagnostic criteria for describing conditions identified with SCALE, and 3) recommendations for evidence-informed pathways of care.

     The statements from this consensus document are designed to facilitate the implementation of knowledge-transfer-into-practice techniques for quality patient outcomes. This implementation process should include interprofessional teams (clinicians, lay people, and policy makers) concerned with the care of individuals at life’s end to adequately address the medical, social, legal, and financial ramifications of SCALE.

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