Five FAQs about SCALE

At a glance…

The Skin Changes at Life’s End panel has compiled a consensus statement. Ten statements were issued concerning geriatric skin meant to be a guide for those caring for people with older skin.

FAQ1: What is SCALE?

Dr. Diane Krasner

SCALE is an acronym that stands for Skin Changes at Life’s End. In April 2008, a panel of experts in skin and wound care met to discuss aspects of skin conditions, including pressure ulcers, that affect dying patients. The SCALE Panel included physicians, nurses, hospice and palliative care practitioners, legal experts, and a medical writer. The panel came from across the United States and Canada representing the continuum of care. The result of the panel’s work and participation by numerous international stakeholders is the SCALE Final Consensus Statement, a 19-page document with 10 statements (see sidebar).

FAQ2: How was the SCALE consensus statement developed?

Following the initial panel meeting, a preliminary consensus document (PCD) was drafted from the audio proceeding and written notes by the medical writer. The panel reviewed and modified the PCD. During Phase 2 the PCD was presented and distributed at conferences and in publications and was available for download and comment from the Web site of the panel sponsor, Gaymar Industries, Inc. ( The PCD was also reviewed by a selected international panel of 49 distinguished reviewers with noted expertise in wound and/or palliative care. Written input received from all of these sources was used to generate a final consensus document (FCD).

FAQ3: How was consensus on the SCALE document reached?

In Phase 3 of the process, the FCD was returned to the original 18-member expert panel and a 52-member distinguished reviewer panel for online voting on the 10 statements using a modified Delphi approach. A quorum of 80% that 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 in the final consensus process.

FAQ4: How should a facility used the SCALE document?

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 policymakers) concerned with the care of individual’s at life’s end to adequately address the medical, social, legal, and financial ramifications of SCALE.

FAQ5: How can you get more information on SCALE?

The SCALE Final Consensus Statement and a SCALE Abstract (in PDF format) can be downloaded from the Gaymar Web site On the home page, click on Clinical Support and Education and follow the link to SCALE Consensus Documents. In addition, an annotated bibliography of literature pertinent to SCALE was generated and is available to download.

SCALE Final Consensus Statements

Statement 1: Physiologic 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.

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.

Statement 3: Patient-centered concerns should be addressed including pain and activities of daily living.

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).

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 pressure ulcers.

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/pre-albumin, 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.

  • Impaired immune function.

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.

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.

Statement 9: The probable skin change etiology and goals of care should be determined. Consider the 5Ps for determining appropriate intervention strategies:

  • Prevention

  • Prescription (may heal with appropriate treatment)

  • Preservation (maintenance without deterioration)

  • Palliation (provide comfort and care)

  • Preference (patient desires)

Statement 10: Patients and concerned individuals should be educated regarding SCALE and the plan of care.

Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, is the WOCN/Special Projects Nurse at Rest Haven-York, a 158-bed facility in York, Pennsylvania, and the SCALE corresponding author. She also serves as a consultant in wound and skin care and as an expert witness in legal cases. Dr. Krasner is the lead co-author of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 4th Edition (, and the clinical editor of WoundSource ( She can be reached at 212 East Market Street, York, PA, 17403; or e-mail

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Long-Term Living 2010 February;59(2):26-27

Topics: Articles , Clinical