An Introduction to Skin Changes At Life's End (SCALE) Protection Status
elderly hands

by Rick Hall, BA, RN, CWON

Series Note: Dying patients experience a variety of skin changes, including pressure ulcers, as part of the natural dying process. While this phenomenon has been recognized in the health care literature for centuries, the explanations and etiologies have yet to be fully elucidated. In this blog series, I will be discussing key concepts related to Skin Changes At Life's End and the Kennedy Terminal Ulcer from the perspective of a hospice wound care nurse. Suggestions for clinical practice and a case series with discussion will also be presented in future posts.

Signs of Skin Change At Life's End

The changes to skin that dying patients experience were recently summarized by an expert panel who termed the phenomenon Skin Changes At Life's End (SCALE).1 For example, the skin often takes on a mottled (bluish fishnet) appearance, which starts on the extremities and progresses toward the trunk of the body. The helix and ear lobes begin to rotate back toward the head and neck as the muscles of the jaw relax.

These changes are typically attributed to hypoperfusion of the skin, resulting in an increased risk for ischemic injury. Other factors contributing to increased risk for skin breakdown near the end-of-life include reduced nutrient and fluid intake, often accompanied by catabolic changes due to an underlying disease process.1

This process results in weight loss and dehydration, both of which increase the risk of cutaneous breakdown. In addition, an altered level of consciousness results in reduced awareness, ischemic discomfort and decreased position changes.

Skin, being the largest organ of the body, can break down during the pre-active and active phases, of dying causing terminal pressure ulcers (end of life ulcers). Because it is the only organ outside the body, it can forewarn people about the changes going on inside the body. When the body begins the dying process, the need for fuel and energy decreases, which is natural. The body's appetite no longer exists. In addition, disorientation, confusion, respiratory changes, restlessness and non-responsiveness all affect the skin.2,3

Catabolism (e.g., the muscle wasting seen in patients with cancer) is another risk factor for tissue breakdown. The cells cannot reproduce and the skin cannot repair the normal loss of cells. Dehydration and protein depletion add to the skin's vulnerability. The skin becomes less tolerant of pressure, friction and shear, resulting in easy injury, infection and pressure ulcers. Other co-morbidities also increase the risk of advanced skin breakdown.2

The Kennedy Terminal Ulcer

A specific type of skin breakdown at the end of life is known as the Kennedy Terminal Ulcer. The KTU is a pear, butterfly or horseshoe shaped wound which is red, yellow, black or purple. (The color purple is not a color first described by Kennedy in her findings.) KTUs can start out as a blister or abrasion and progress. They are typically located on the coccyx or sacrum; but also occur on the heels, elbows, arms and calf muscles.

The earliest reference in the modern medical literature describing a pressure ulcer at life’s end is attributed to Jean-Martin-Charcot in 1877.,4 Charcot labeled the condition “decubitus ominous”, and noted patients who developed these wounds died soon afterward. Charcot also described the ulcer as butterfly shaped and occurring over the sacrum, but he erroneously attributed its etiology as neuropathic in nature.6

In 1989 Karen Lou Kennedy described the KTU based on clinical observation and data from a retrospective chart review.5 More than half of patients who developed a KTU (55.7%) died within two weeks to several months.

These observations were supported by Hanson and colleagues (5) who reported that 62.5% of hospice patients who developed KTU’s died within a 2 week period. Kennedy further noted the skin often tended to deteriorate rapidly, even during the course of a single day.5

In contrast the normal pressure ulcer does not progress this rapidly. For example, a Stage I pressure ulcer over a bony prominence may take 5-7 days before it turns black or blue and non-stageable. It may take several months before it demarcates enough to be stageable.

Skin Failure Assessment

All pressure ulcers (by definition) have pressure as the main causative factor in their etiology. Likewise, the KTU is generally also associated with pressure or shear; however it is theorized pressure is secondary to the primary causative factor, which is skin organ failure. The concept of skin organ failure is not new to the literature and has been reviewed by Langemo and Brown (2006).6

More recently, an expert panel met to discuss the concept of skin failure at end of life and termed the phenomenon Skin Changes At Life’s End (SCALE) This group of experts in wound care suggested that our current assessment of the complex phenomenon is limited. The panel concluded that additional research is necessary to assess the etiology of SCALE, to clinically describe and diagnose the related skin changes and to recommend appropriate pathways of care.

1. Sibbald RG, Krasner DL, Lutz JB, et al. Skin Changes at Life's End (SCALE): Final Consensus Statement. European Pressure Ulcer Advisory Panel. Published October 1, 2009.
2. Langemo DK, Brown G. Skin Fails Too: Acute, Chronic, and End-Stage Skin Failure. Adv Skin Wound Care. 2006;19(4):206-11.
3. Hanson D, Langemo DK, Olson B, et al. The prevalence and incidence of pressure ulcers in the hospice setting: analysis of two methodologies. Am J Hosp Palliat Care. 1991;8(5):18-22.
4. Levine, JM. Historical Perspective on Pressure Ulcers: The Decubitus Ominous of Jean-Martin Charcot – JAM Geriatric Soc. 2005.53(7) 1268-51
5. Kennedy, KL: The Prevalence of Pressure Ulcers in an Intermediate Care Facility. Decubitus 1989:2 (2):44-5.
6. Langemo, DK, Brown. Skin fails too: acute, chronic, and end stage skin failure. Advances Skin Wound Care 2006; 19(4):206-211

About the Author
Rick Hall is a wound and ostomy educator and consultant for Kaiser Permanente and Helping Hands wound consultant.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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For years now knowing that pressure injuries are caused by unrelieved pressure. I place anyone who cannot reposition themselves on a good alternating pressure air mattress. I have not yet seen a pressure injury you must act straight away.

Thank you, Rick, for this important contribution to the SCALE Wound literature.
You can download additional information on SCALE Wounds, including the original SCALE Consensus Statement, Annotated Bibliography and a powerpoint from

Congratulations on this work. It will help so many understand the end stage life experience better. I saw this with my husband's decline and remembered your first presentation to our hospice.. It helped me prepare in many ways. THANK YOU. God bless your work.

Great article. Some of the descriptions related to the Kennedy Terminal Ulcer are not consistent with the description noted on the website . To utilize this description in areas other than the sacrum is a stretch based upon the initial description and subsequent discussions in the literature. Also, the last paragraph describing the 'progression' of a stage I is much too general and potentially provides an inaccurate picture of pressure injuries. Staging is an anatomical description of injury and is not meant to suggest progression.

I realize some of the descriptions are not consistent with what Karen Kennedy described in her literature and website. Over the 7 years I’ve known Karen, I have shared my observations with her and we have had quite a few discussions about what I have observed in my hands on work with wound patients over the last 13 years. Karen has given me much input and help in writing the paper that supports my blog. As you continue to follow the blog, you will see where I am going with it.

As far as staging, some Stage I PrU’s are only the tip of the iceberg. Sometimes the damage begins at the bone and progresses upward to suspected deep tissue injuries or even stageable pressure ulcers. Suspected Deep Tissue Injuries (SDTI) are just that. Damage done to the deep tissues may show later on.

Thank you for writing this article. It helps all of us better understand these skin changes.

I was stunned to come across this completely unqualified statement in a dressing manufacturer's literature. Would you please comment on it? "In situations where offloading is impossible (such as in palliative care) pressure ulcers do not deteriorate further, even without offloading, if dressing is applied correctly."
If I use this dressing in palliative care and the PU DOES deteriorate, can I be sued for not applying it "correctly"? Or, will jurors believe that skin does indeed change at the end of life?

Dr. Linda Benskin,
You are very fortunate you are not seeing deterioration in your patients’ pressure ulcers. In the 13 years I have been doing hands on wound care, I have seen many pressure ulcers deteriorate even with offloading, palliative care and use of proper dressings.

The CMS has recognized Skin Changes at Life’s End (SCALE) in nursing homes and LTACs.

If good, thorough documentation and appropriate care planning with the patient and family on the care they choose is done, then everything should be in order. With the proof that shows everything possible was done for the patient’s comfort, you should not be in fear of losing your case should you find yourself in court.

The National Pressure Ulcer Advisory Panel has devoted about 5 pages to palliative care in their new manual. It is about the patient and family desires during end of life care. If they do not want to be turned but every four hours, it is imperative to care plan it.

I believe in my attempt to be succinct my comment was misunderstood. I agree with Rick Hall that deterioration of the skin is often inevitable in dying patients. However, I was pointing out that not all agree, and this could create legal difficulties for nurses if we are not alert. A new dressing is being marketed that makes very bold claims. Their website states, "In situations where offloading is impossible (such as in palliative care) pressure ulcers do not deteriorate further, even without offloading, if dressing is applied correctly."
(Google the quote to see the context) This manufacturer is claiming that offloading, turning, and even being at the end of life are all IRRELEVANT: if their dressings are applied correctly, the pressure ulcer WILL NOT deteriorate further. I am concerned that if a nurse uses this particular dressing and the wound DOES deteriorate, a jury could be convinced by a lawyer quoting this claim that the damage could only be because the dressing was not applied correctly, which would make the nurse liable. Shouldn't the NPUAP have a discussion with this dressing manufacturer to learn how they substantiated this very bold claim?

This article should certainly make us think about the etiology of wounds rapidly developing at the end of life. Perhaps it is not the caregivers fault, but a natural process as the body's circulation shuts down. Certainly all dying patients should receive good skin care with off-loading, but when ulcers develop in spite of good care, we must be careful where we place the blame.
Thanks Rick for calling this to our attention.

Thank you, Dr. Old, for this endorsement. Working together with you for so many years, taking care of the terminally ill patient and their skin changes at life’s end has been a driving force for me to get the word out about this phenomena which disturbs patients, families, caregivers and the entire medical community. Unfortunately, blame is placed on the caregiver for neglect and abuse. Not only does the caregiver face guilt and shame, but sometimes financial burdens and in one recent case, imprisonment of a family member who was taking care of her aunt. Research must be done to protect caregivers from these undue consequences when they may not be to blame.


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