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FEATURES: CLINICAL MANAGEMENT EXTRA

SCALE: Final Consensus Statement: October 1, 2009©

Sibbald, R. Gary BSc, MD, MEd, FRCPC (Med Derm), MACP, FAAD, FAPWCA; Krasner, Diane L. PhD, RN, CWCN, CWS, BCLNC, FAAN; Lutz, James MS, CCRA

Author Information
Advances in Skin & Wound Care: May 2010 - Volume 23 - Issue 5 - p 225-236
doi: 10.1097/01.ASW.0000363537.75328.36

Abstract

INTRODUCTION

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, Illinois. 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 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 internationally 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 as a result of both internal and external insults. The panel concluded that healthcare practitioners' 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 (PrUs) are avoidable. Specific areas requiring research and consensus include (1) the identification of critical etiologic 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 will help the clinician to facilitate the implementation of knowledge-transfer-into-practice techniques for quality patient outcomes. This implementation process should include interprofessional teams (clinicians, laypeople, 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.

BACKGROUND FOR SCALE

Organ dysfunction is a familiar concept in the health sciences and can occur at any time but most often occurs at life's end, during an acute critical illness, or with severe trauma. Body organs, particularly the heart and kidneys, undergo progressive limitation of function as a normal process related to aging and the end of life. End of life is defined as a phase of life when a person is living with an illness that will often worsen and eventually cause death. This period is not limited to the short period when the person is moribund.1 It is well accepted that during the end stages of life, any of a number of vital body systems (eg, the renal, hepatic, cardiac, pulmonary, or nervous systems) can be compromised to varying degrees and will eventually totally cease functioning. The process of organ compromise can have devastating effects, resulting in injury or interference with functioning of other organ systems that may contribute to further deterioration and eventual death.

The panel proposes that the skin, the largest organ of the body, is no different, and also can become dysfunctional with varying degrees of resultant compromise. The skin is essentially a window into the health of the body and, if read correctly, can provide a great deal of insight into what is happening inside the body. Skin compromise, including changes related to decreased cutaneous perfusion and localized hypoxia (blood supply and local tissue factors), can occur at the tissue, cellular, or molecular level. The end result is a reduced availability of oxygen and the body's ability to utilize vital nutrients and other factors required to sustain normal skin function. When this compromised state occurs, the manifestations are termed SCALE. It should be noted that the acronym SCALE is a mnemonic used to describe a group of clinical phenomena and should not be confused with a risk assessment tool. The term applies to all individuals across the continuum of care settings.

Skin organ compromise at life's end is not a new concept in the literature. The first clinical description in modern medical literature appeared in 1989 with the KTU.2 Kennedy described the KTU as a specific subgroup of PrUs that some individuals develop as they are dying. They are usually shaped like a pear, butterfly, or horseshoe and are located predominantly on the coccyx or sacrum (but have been reported in other anatomical areas). The ulcers are a variety of colors, including red, yellow, or black; are sudden in onset; typically deteriorate rapidly; and usually indicate that death is imminent.2 This initial report was based on retrospective chart reviews of individuals with PrUs. It sparked further inquiry into how long these individuals within the facility lived after the occurrence of a PrU. More than half (55.7%) died within 6 weeks of discovery of his/her PrU. The observations were further supported by Hanson et al,3 who reported that 62.5% of PrUs in hospice patients occurred in the 2 weeks prior to death. Further evidence for the existence of the KTU is mostly observational in nature but is consistent with the premise that skin function can become compromised at life's end.

It is noteworthy that although Kennedy independently described the KTU in 1989, a similar condition was actually first described much earlier in the French medical literature by Jean-Martin Charcot (1825-1893).4,5 In a medical textbook written in 1877, Charcot described a specific type of ulcer that is butterfly in shape and occurring over the sacrum. Patients that developed these ulcers usually died shortly thereafter; hence, he termed the ulcer decubitus ominosus. However, Charcot attributed the ulcers to being neuropathic rather than pressure in origin. Charcot's writings of decubitus ominosus were all but forgotten in the medical literature until recently with renewed interest in skin organ compromise.4 The fact that 2 experts in the field of chronic wounds independently reported the same clinical phenomenon, with very similar descriptions, 112 years apart, lends credence to the possible existence of terminal PrUs as a result of end-of-life skin organ compromise.

Also of historical interest is the original work of Dr Alois Alzheimer in Germany. He was on call in 1901 when a 51-year-old woman, Frau Auguste D, was admitted to his asylum for the insane in Frankfurt. Dr Alzheimer followed this patient, studied her symptoms, and presented her case to his colleagues as what came to be known as Alzheimer disease. When Frau Auguste D died on April 8, 1906, her medical record listed the cause of death as "septicemia due to decubitus."6 Alzheimer noted, "at the end, she was confined to bed in a fetal position, was incontinent, and, in spite of all the care and attention given to her, she suffered from decubitus." So, here we have the first identified patient with Alzheimer disease having developed immobility and 2 PrUs with end-stage Alzheimer disease. In our modern times, end-stage Alzheimer disease has become an all-too-frequent scenario with multiple complications including SCALE.

In 2003, Langemo7 proposed a working definition of skin failure: that it is a result of hypoperfusion, creating an extreme inflammatory reaction concomitant with severe dysfunction or failure of multiple organ systems. Three years later, Langemo and Brown8 conducted a comprehensive review of the literature on the concept of skin failure that focused largely on PrU development. They presented a discussion of changes in the skin that can occur with aging, the development of PrUs, multiorgan failure, and "skin failure" (both acute and chronic, as well as end of life).9-15 In the early 1990s, 2 publications by Witkowski and Parish11,16 had presented logical arguments about the mechanism of PrU occurrence at the end of life, suggesting that they may not be preventable in those individuals with multiple organ failure. Although the term skin failure has been introduced, it is not currently a widely accepted term in the dermatologic or the wound literature.

Despite the limited scientific literature, there is consensus from the narrative literature that some PrUs may be unavoidable, including those that are manifestations of SCALE. The panel proposes that, at the end of life, failure of the homeostatic mechanisms that support the skin can occur, resulting in a diminished reserve to handle insults such as minimal pressure. Therefore, contrary to popular myth, not all PrUs are avoidable.17,18 Many members of the SCALE Panel acknowledge the need for systematic study of the phenomenon.

GOALS AND OBJECTIVES OF THE SCALE PANEL

The overall goal of the SCALE Expert Panel was to initiate stakeholder discussion of skin changes at the end of life, a phenomenon the panel has termed SCALE. An objective was to examine the concept of unavoidable PrUs that can occur as a result of SCALE. Although reaching consensus on the various aspects of this topic is an important outcome, this endeavor will require a more rigorous scientific investigative approach that was beyond the scope of this groundbreaking meeting. The purpose of this initial meeting was to generate a series of statements that will serve as a platform for future consensus discussions. The objective of this document is to present these panel statements, disseminate them for public discussion, and to further the development of the body of scientific knowledge on this important topic.

METHODOLOGY

A modified 3-phase Delphi method approach was used to reach consensus on the 10 statements presented in this document. The Delphi method relies on expert panel input to reach consensus on a topic of interest.19 This approach consisted of 3 separate phases of consensus building, involving an international group of 69 noted experts in the field of wound care.

Phase 1

A panel of 18 experts in the field of wound care with expertise in wound and skin care convened in a roundtable format on April 4-6, 2008, in Chicago, Illinois. Audio proceedings and written notes from this roundtable discussion were used to generate a preliminary consensus document (PCD). This PCD was returned to the original panel for review and was modified as necessary to reach panel consensus.

Phase 2

The PCD was presented and distributed at numerous international conferences seeking public comment from September 2008 through June 2009. The document was published20 and also available for public download from the Web site of the panel's sponsor.21 The PCD was further reviewed by a selected international panel of 49 distinguished reviewers with noted expertise in wound care and palliative medicine.

Phase 3

Written input received from the panel of distinguished reviewers and from the various public presentations was used to generate a final consensus document (FCD). This FCD was then returned to the original 18-member expert panel and a 52-member distinguished reviewer panel for voting on each of the 10 statements for consensus. A quorum of 80% who strongly agree or somewhat agree with each statement was used as a predetermined threshold for having achieved consensus on each of the statements. Fifty-two individuals voted on the final consensus process.

In addition to the PCD and FCD documents, an annotated bibliography of literature pertinent to SCALE was generated and is available for download from the Web site of the panel sponsor.21

PANEL STATEMENTS

As a result of the 2-day panel discussion and subsequent panel revisions, and with input from 69 noted wound care experts in a modified Delphi method approach, the following 10 statements are proposed by the SCALE Expert Panel:

Statement 1

Physiological changes that occur as a result of the dying process may affect the skin and soft tissues and may manifest as observable (objective) changes in skin color, turgor, or integrity, or as subjective symptoms such as localized pain. These changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care.

When the dying process compromises the homeostatic mechanisms of the body, a number of vital organs may become compromised. The body may react by shunting blood away from the skin to these vital organs, resulting in decreased skin and soft-tissue perfusion, and a reduction of the normal cutaneous metabolic processes. Minor insults can lead to major complications, such as skin hemorrhage, gangrene, infection, skin tears, and PrUs that may be markers of SCALE. See statement 6 for further discussion.

Statement 2

The plan of care and patient response should be clearly documented and reflected in the entire medical record. Charting by exception is an appropriate method of documentation.

The record should document the patient's clinical condition including comorbidities, PrU risk factors, significant changes, and clinical interventions that are consistent with the patient's wishes and recognized guidelines for care.22 Facility policies and guidelines for record keeping should be followed, and facilities should update these policies and guidelines as appropriate. The impact of the interventions should be assessed and revised as appropriate. This documentation may take many forms. Specific approaches to documentation of care should be consistent with professional, legal, and regulatory guidelines and may involve narrative documentation, the use of flow sheets, or other documentation systems/tools.

If a patient is to be treated as palliative, it should be stated in the medical record, ideally with a reference to a family/caregiver meeting, and that consensus was reached. If specific palliative scales, such as the Palliative Performance Scale,23 or other palliative tools were used,24 they should be included in the medical record. Palliative care must be patient centered, with skin and wound care being only a part of the total plan of care.

It is not reasonable to expect that the medical record will be an all-inclusive account of the individual's care. Charting by exception is an appropriate method of documentation. This form of documentation should allow the recording of unusual findings and pertinent patient risk factors. Some methods of clinical documentation are antiquated in light of today's complexity of patient care and rapidly changing interprofessional healthcare environment; many current documentation systems need to be revised and streamlined.

Statement 3

Patient-centered concerns should be addressed including pain and activities of daily living.

A comprehensive, individualized plan of care should address not only the patient's skin changes and comorbidities, but also any patient concerns that impact quality of life, including psychological and emotional issues. Research suggests that, for wound patients, health-related quality of life is especially impacted by pain, change in body image, odors, and mobility issues. It is not uncommon for these factors to have an effect on aspects of daily living, nutrition, mobility, psychological factors, sleep patterns, and socialization.25,26 Addressing these patient-centered concerns optimizes activities of daily living and enhances a patient's dignity.

Statement 4

Skin Changes At Life's End are a reflection of compromised skin (reduced soft-tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes).

When a patient experiences SCALE, tolerance to external insults (such as pressure) decreases to such an extent that it may become clinically and logistically impossible to prevent skin breakdown and the possible invasion of the skin by microorganisms. Compromised immune response may also play an important role, especially with patients with advanced cancer and with the administration of corticosteroids and other immunosuppressant agents.

Skin changes may develop at life's end despite optimal care, as it may be impossible to protect the skin from environmental insults in its compromised state. These changes are often related to other cofactors including aging, coexisting diseases, and drug adverse events. SCALE, by definition, occurs at life's end, but skin compromise may not be limited to end-of-life situations; it may also occur with acute or chronic illnesses, and in the context of multiple organ failure, it is not limited to the end of life.8,27 However, these situations are beyond the scope of this panel's goals and objectives.

Statement 5

Expectations around the patient's end-of-life goals and concerns should be communicated among the members of the interprofessional team and the patient's circle of care. The discussion should include the potential for SCALE, including other skin changes, skin breakdown, and PrUs.

It is important that the provider(s) communicates and document goals of care, interventions, and outcomes related to specific interventions (statement 2). The patient's circle of care includes the members of the patient unit including family, significant others, caregivers, and other healthcare professionals who may be external to the current interprofessional team. Communication with the interprofessional team and the patient's circle of care should be documented. The education plan should include realistic expectations surrounding end-of-life issues with input from the patient if possible. Communication of what to expect during end of life is important, and this should include changes in skin integrity.

Being mindful of local protected health information disclosure regulations (eg, the Health Insurance Portability and Accountability Act of 1996 [HIPAA]),28 the patient's circle of care needs to be aware that an individual at the end of life may develop skin breakdown, even when care is appropriate. They need to understand that skin function may be compromised to a point where there is diminished reserve to tolerate even minimal pressure or external insult. Educating the patient's circle of care up-front may help reduce the chances of shock and emotional reactions if end-of-life skin conditions occur.

This education includes information that, as one nears end of life, mobility decreases. The individual frequently has a "position of comfort" that the patient may choose to maintain, resulting in a greater potential for skin breakdown. Some patients elect to continue to lie on the PrU, stating that it is the most comfortable position for them. Respecting the coherent patient's wishes is important.

With the recognition that these skin conditions are sometimes a normal part of the dying process, there is less potential for assigning blame and a greater understanding that skin organ compromise may be an unavoidable part of the dying process.

Discussions regarding specific trade-offs in skin care should be documented in the medical record. For example, patients may develop PrUs when they cannot be (or do not want to be) turned because of pain or the existence of other medical conditions. PrUs may also occur in states of critical hypoperfusion because of underlying physical factors, such as severe anemia, hypoxia, hypotension, peripheral arterial disease, or severe malnutrition. Care decisions must be made with the total goals of the patient in mind and may be dependent on the setting of care, trajectory of the illness, and priorities for the patient and family. Comfort may be the overriding and acceptable goal, even though it may be in conflict with best skin care practice. In summary, the patient and family should have a greater understanding that skin organ compromise may be an unavoidable part of the dying process.

Statement 6

Risk factors, symptoms, and signs associated with SCALE have not been fully elucidated, but may include

  • weakness and progressive limitation of mobility;
  • suboptimal nutrition including loss of appetite, weight loss, cachexia and wasting, low serum albumin/prealbumin level, and low hemoglobin, as well as dehydration;
  • diminished tissue perfusion, impaired skin oxygenation, decreased local skin temperature, mottled discoloration, and skin necrosis;
  • loss of skin integrity from any of a number of factors, including equipment or devices, incontinence, chemical irritants, chronic exposure to body fluids, skin tears, pressure, shear, friction, and infections; and
  • impaired immune function.

Diminished tissue perfusion is the most significant risk factor for SCALE and generally occurs in areas of the body with end arteries, such as the fingers, toes, ears, and nose. These areas may exhibit early signs of vascular compromise and ultimately collapse, such as dusky erythema, mottled discoloration, local cooling, and, eventually, infarcts and gangrene.

As the body faces a critical illness or disease state, a normal protective function may be to shunt a larger percentage of cardiac output from the skin to more vital internal organs, thus averting immediate death. Chronic shunting of blood to the vital organs may also occur as a result of limited fluid intake over a long period. Most of the skin has collateral vascular supply, but distal locations, such as the fingers, toes, ears, and nose, have a single vascular route and are more susceptible to a critical decrease in tissue oxygenation because of vasoconstriction. Furthermore, the ability to tolerate pressure is limited in poorly perfused body areas.

Additional literature reviews and clinical research are needed to more thoroughly comprehend and document all of the potential risk factors associated with SCALE and their clinical manifestations.

Statement 7

A total skin assessment should be performed regularly and document all areas of concern consistent with the wishes and condition of the patient. Pay special attention to bony prominences and skin areas with underlying cartilage. Areas of special concern include the sacrum, coccyx, ischial tuberosities, trochanters, scapulae, occiput, heels, digits, nose, and ears. Describe the skin or wound abnormality exactly as assessed.

It is important to assess the whole body because there may be signs that relate to skin compromise. Table 1 provides a limited list of dermatologic terms that may be useful when describing areas of concern. Table 2 provides descriptive terms for lesions based on characteristics and size.

Table 1
Table 1:
USEFUL DERMATOLOGIC TERMS FOR DESCRIBING AREAS OF CONCERN
Table 2
Table 2:
DERMATOLOGIC DESCRIPTIONS OF LESIONS BASED ON CHARACTERISTICS AND SIZE

Statement 8

Consultation with a qualified healthcare professional is recommended for any skin changes associated with increased pain, signs of infection, skin breakdown (when the goal may be healing), and whenever the patient's circle of care expresses a significant concern.

There are very definite descriptive terms for skin changes that can be used to facilitate communication between healthcare professionals (statement 7). Until more is known about SCALE, subjective symptoms need to be reported, and objective skin changes described. This will allow for identification and characterization of potential end-of-life skin changes.

An accurate diagnosis can lead to decisions about the area of concern and whether it is related to end-of-life care and/or other factors. The diagnosis will help determine appropriate treatment and establish realistic outcomes for skin changes. For PrUs, it is important to determine if the ulcer may be (1) healable within an individual's life expectancy, (2) maintained, or (3) nonhealable or palliative.17 The treatment plan will depend on an accurate diagnosis, the individual's life expectancy and wishes, family members' expectations, institutional policies, and the availability of an interprofessional team to optimize care.31 Remember that patient status can change, and appropriate reassessments with determination of likely outcomes may be necessary.

It is important to remember that a maintenance or nonhealable wound classification does not necessarily equate with withholding treatment. For example, the patient may benefit with improved quality of life from surgical debridement and/or the use of advanced support surfaces.

Statement 9

The probable skin change etiology and goals of care should be determined. Consider the 5 P's for determining appropriate intervention strategies:

  • prevention
  • prescription (may heal with appropriate treatment)
  • preservation (maintenance without deterioration)
  • palliation (provide comfort and care)
  • preference (patient desires).

Prevention is important for well-being, enhanced quality of life, and potential reimbursement and to avoid unplanned medical consequences for end-of-life care. The skin becomes fragile when stressed with decreased oxygen availability associated with the end of life. The plan of care needs to address excessive pressure, friction, shear, moisture, suboptimal nutrition, and immobilization.

Prescription refers to the interventions for a treatable lesion. Even with the stress of dying, some lesions are healable after appropriate treatment. Interventions must be aimed at treating the cause and at patient-centered concerns (pain, quality of life) before addressing the components of local wound care as consistent with the patient's goals and wishes.

Preservation refers to situations where the opportunity for wound healing or improvement is limited, so maintenance of the wound in its present clinical state is the desired outcome. A maintenance wound may have the potential to heal, but there may be other overriding medical factors that could direct the interprofessional team to maintain the status quo. For example, there may be limited access to care, or the patient may simply refuse treatment.

Palliation refers to those situations in which the goal of treatment is comfort and care, not healing. A palliative or nonhealable wound may deteriorate because of a general decline in the health of the patient as part of the dying process or because of hypoperfusion associated with noncorrectable critical ischemia.32,33 In some situations, palliative wounds may also benefit from some treatment interventions such as surgical debridement or support surfaces, even when the goal is not to heal the wound.34

Preference includes taking into account the preferences of the patient and the patient's circle of care.

The 5 P's enabler can be used in combination with the SOAPIE (Subjective, Objective, Assessment, Plan, Implement, Evaluate/Educate) mnemonic to help explain the process of translating this recommendation into practice Figure 1.35 Realistic outcomes can be derived from appropriate SOAPIE processes, with the 5 skin P's becoming the guide to the realistic outcomes for each individual.

Figure 1
Figure 1:
THE SOAPIE MNEMONIC WITH THE 5 P's ENABLER

S-Subjective skin & wound assessment. The person at the end of life needs to be assessed by history, including an assessment of the risk for developing a skin change or PrU (Braden Scale or other valid and reliable risk assessment scale).36

O-Objective observation of skin & wound. A physical examination should identify and document skin changes that may be associated with the end of life or other etiologies including any existing PrUs.

A-Assess and document etiology. An assessment should then be made of the general condition of the patient and a care plan.

P-Plan of care. A care plan should be developed that includes a decision on skin care considering the 5 P's as outlined in Figure 1. This plan of care should also consider input and wishes from the patient and the patient's circle of care.

I-Implement appropriate plan of care. For successful implementation, the plan of care must be matched with the healthcare system resources (availability of equipment and personnel) along with appropriate education and feedback from the patient's circle of care and as consistent with the patient's goals and wishes.

E-Evaluate and educate all stakeholders. The interprofessional team also needs to facilitate appropriate education, management, and periodic reevaluation of the care plan as the patient's health status changes.

Statement 10

Patients and concerned individuals should be educated regarding SCALE and the plan of care.

Education needs to be directed not only to the patient, but also to the patient's circle of care. Within the confines allowed by local protected health information regulations (eg, HIPAA),28 the patient's circle of care needs to be included in decision-making processes regarding goals of care and the communication of the meaning and method of accomplishing those decisions. Collaboration and communication should be ongoing with designated representatives from the patient's circle of care and the clinical team connecting at regular intervals. Documentation of decision making, educational efforts, and the patient's circle of care perspective is recommended. If adherence to the plan of care cannot be achieved, this should be documented in the medical record (including the reasons), and alternative plans proposed if available and feasible.

Education also extends beyond the patient's circle of care, to other involved healthcare professionals, healthcare administrators, policy makers, and to the payers. Healthcare professionals need to facilitate communication and collaboration across care settings and disciplines; organizations need to prepare staff to identify and manage SCALE. Ongoing discussions with key stakeholders will additionally provide a stimulus for additional evidence-based research and education regarding all aspects of SCALE.

PRACTICE PEARLS
PRACTICE PEARLS:
PRACTICE PEARLS

RECOMMENDATIONS FOR FUTURE RESEARCH

Conduct and disseminate through publications and presentations:

  • a thorough review of the literature concerning all aspects of SCALE;
  • research to identify the mechanisms for the proposed decreased hypoperfusion and oxygenation of the skin and soft tissues involved with SCALE and resulting outcomes;
  • research to determine the mechanisms for the proposed tissue, cellular, and molecular dysfunctions that occur during SCALE;
  • research that helps to clarify and distinguish skin and soft-tissue damage associated with SCALE from PrUs and other skin disorders not associated with skin organ compromise or the end of life;
  • research into predictive tools for the onset and measurement of SCALE and the timing of life's end (possibly adaptive use of the Palliative Performance Scale [http://palliative.info/resource_material/PPSv2.pdf]);
  • qualitative research to explore the impact of SCALE on the patient, the patient's circle of care, and professional caregivers with regard to healthcare-related quality of life;
  • development of a database of patients (with histories) suspected of exhibiting SCALE to analyze them retrospectively for skin and soft-tissue changes and risk factors that occurred just prior to death. Isolate the skin changes and risk factors involved and determine how important each individual variable is to the occurrence of SCALE;
  • research cataloging patients who do not exhibit SCALE to identify factors that may help prevent the occurrence of SCALE;
  • development of a registry of KTUs to better categorize this phenomenon, including location, clinical description, patient and ulcer outcomes, and the presence of other end-of-life skin changes including lesions in other locations;
  • both prospective and retrospective prevalence research of individuals suspected of exhibiting SCALE, particularly among hospice patients; and
  • research on specific medical and physiological conditions that may contribute to SCALE. These include, but may not be limited to, malignancy, hypotension and hemodynamic instability, administration of potent vasoconstrictors, peripheral arterial and vascular disease, hypoxia, malnutrition, and severe anemia.

CONCLUSIONS

SCALE Panel members are in agreement that there are observable changes in the skin at the end of life. Our current understanding of this complex phenomenon is limited, and the panel concludes 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.

The panel recommends that clinicians, laypeople, and policy makers need to be better educated in the medical, social, legal, and financial ramifications of SCALE. Healthcare organizations need to ensure the provision of resources that enable healthcare professionals to identify and care for SCALE, while maintaining the dignity of the patient, family, and circle of care to the end of life.

Although more research is needed regarding SCALE, clinicians will be better able to assess skin changes at life's end and more accurately diagnose these changes, rather than assume a diagnosis, after reading this article. Clinicians will also realize that some skin changes, including PrUs, at the end of life are unpreventable.

Glossary of Terms
Glossary of Terms:
Glossary of Terms
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                                CONTINUING MEDICAL EDUCATION INFORMATION FOR PHYSICIANS

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