Management and Education of Skin Care Changes at Life's End (SCALE) Protection Status
Patient Care

by Rick Hall, BA, RN, CWON
Part 2 in a series on Skin Care Changes at Life's End (SCALE) and Kennedy Terminal Ulcers (KTUs).
For part 1, click here.

Treatment of Skin Changes at Life's End (SCALE) and Kennedy Terminal Ulcers (KTUs) is the same as any other ulcer: moist wound therapy if the skin is open, protect and offload the area if the skin is closed. Continue to turn the patient for comfort and alleviate any undue pressure on the already compromised skin. When the patient is in the active phase of dying, caregivers have a tendency not to turn the patient because it may be painful.

Palliative Wound Care

The Pressure Ulcer Treatment Quick Reference Guide from the EPUAP/NPUAP devotes five pages to those receiving palliative care, which help both the patient and caregiver. In section Pressure Redistribution number: 1.4 it states "comfort is of primary importance and may supersede prevention and wound care for individuals who are actively dying or have conditions causing them to have a single position of comfort." In section 1:7, it says to individualize the turning and repositioning schedule, ensuring that it is consistent with the individual’s goals and wishes, current conditions, as medically feasible. In section 1:1.8, it says to document turning and repositioning as well as the factors influencing these decisions (e.g. individual’s wishes or medical needs).

Under pressure ulcer care, the panel says to set a goal to enhance quality of life, even if the pressure ulcer cannot be healed or treatment does not lend to closure/healing.

In reference 3:3.2 the statement made is to use dressings which can remain in place for longer periods of time to promote comfort to the ulcer care.

Reflections of a Hospice Nurse

Although palliative care is often recommended for the management of patients with SCALE/KTUs, the health care worker is sometimes faced with the challenge of providing palliative care when the patient or family desires the continuation of more aggressive care, despite accumulating evidence of the onset of the dying process. The dialogue with the patient and family is essential in these complex situations.

For example, I encountered a nursing home patient whose condition deteriorated, followed by development of a KTU. The facility managed the KTU using appropriate clinical measures. They turned the patient more often, and a dietary consultant assessed the patient’s nutritional needs and made recommendations which were implemented. However, the family expressed distress with the rapid decline of their loved one and wanted the patient sent to the hospital for aggressive treatment. As a result, the patient was started on intravenous therapy and a gastrostomy tube was inserted.

The nursing home Administrator requested a chart audit to make certain everything was done for the patient that could have been done. An independent consultant reviewed the case and concluded the facility had implemented appropriate care under the circumstances. In addition, the patient’s attending physician concurred in writing with the conclusions of the consultant. Ultimately, the patient returned to the facility and died a few days later. A state surveyor became involved in the case in response to a complaint by the family. However, after a careful review of the patient’s medical records and an independent chart audit, the surveyor also concluded this was indeed a KTU, unavoidable, and no deficiencies were cited.

Education for Patients and Family Members

It is unfortunate that families often first learn about the KTU when it happens to their loved one. Because of the dramatic appearance, patients and or families may conclude that the lesion or lesions occurred because of a lack of preventive care. Therefore I recommend that patient and family teaching begin upon admission to the hospice and include teaching about SCALE and KTUs and the fact these wounds may signal the active phase of dying. Anticipatory education of families may alleviate anxiety and fear and prevent litigation.

Educating families early may avoid penalties, lawsuits or imprisonment. The guilty feelings that caregivers have when this skin breakdown happens may be avoided. Education gives the family and caregivers a chance to understand and work through this difficult situation.

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Available at

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.


I am at the end of my nursing career. Just so dissapointed to hear patients are still getting pressure injuries with what we know. If some one is at risk ie. they cannot reposition themselves they need to be provided with a good alternating pressure air mattress asap. We still need to turn our patients 4 hourly. If you do this with all your ' At Risk' patients as soon as they cannot turn or lift themselvea you will not see pressure injuries. This also takes the pressure of our over worked nurses. Nursing has changed I feel those doing the guidelines should put a uniform back on work in a hospital or facility. Guidelines need to be kept simpler and achievable. Happy to discuss further

Well stated! End of life wounds require that we communicate carefully with patients (if appropriate) and families, with honesty and integrity. Diane Krasner PhD RN CWCN CWS MAPWCA FAAN

It is very difficult to educate people who are in a state of extreme emotional distress. For this reason, it is important to educate patients and families about topics such as g-tubes (which do not decrease the incidence of aspiration pneumonia), KTUs, skin failure, and the likely outcomes of the dying patient gradually eating and drinking less early, so that by the time they confront these decisions they already know what they really want to do.

In choosing dressings for palliative care, keep in mind that polymeric membrane dressings are unique in their proven ability to subdue and focus inflammation when placed on wounds or on intact skin. This can lead to dramatic pain relief for many of our palliative care patients. The Feb 2010 NPUAP White Paper on PUs in Palliative Care patients states, "Polymeric membrane foam dressings are very absorptive, have a surfactant to help cleanse the wound, and have been shown to decrease pain." Polymeric membrane dressings also contain glycerol. Coupled with the continuous wound cleansing system within the dressings, the glycerin can often keep wound odor completely contained. Odor management is essential because in their last days patients should be able to focus on their visitors, rather than their visitors being forced to focus on their wound.

Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA
Clinical Research & Education Liaison, and Charity Liaison
Ferris Mfg. Corp (makers of PolyMem)

Rick, Thank you for continuing to raise awareness about SCALE. Your participation in the consensus initiative was and continues to be appreciated. It was an honor to be able to facilitate SCALE and I am personally pleased that end of life care is becoming increasingly a focus within the wound care community.

Thank you for the kind words and it was a pleasure to be on the SCALE panel and meeting so many of my heroes in wound care. Unfortunately, there is so much more education to be presented. I am disappointed there have been no studies to help prove SCALE and specifically the KTU. The public needs to be educated more about what happens to the body as we begin the dying process. One of my installments should reveal where I'm going with this. Thanks again.

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