SCALE Wounds: Unavoidable Pressure Injury

Diane L. Krasner, PhD, RN; Thomas P. Stewart, PhD


Wounds. 2015;27(4):92-94. 

In This Article

Abstract and Introduction


Skin Changes at Life's End (SCALE) wounds include wounds of many underlying etiologies that accompany the dying process. These wounds occur due to unmodifiable intrinsic and extrinsic factors unique to each individual. This article describes the case of a dying patient who sustained a skin tear that deteriorated into a SCALE wound that meets the criteria for a National Pressure Ulcer Advisory Panel unavoidable pressure injury.


Skin Changes at Life's End (SCALE) is a concept that was introduced in 2009 to describe a group of unusual wounds that can occur at the end of life.[1] These wounds may present as classic pressure ulcers, deep tissue injury, unavoidable pressure injury, ischemic wounds, mottling, or tumors—essentially a whole range of wound types that appear in people who are in the dying process. The first documented connection between pressure ulcers and dying patients in modern health care literature was made by Jean-Martin Charcot who described the decubitus ominosis in his 1877 text Lecture on Diseases of the Nervous System.[2,3] Charcot described 3 types of decubitus and identified the decubitus ominosis as the one that presaged death.

Some SCALE wounds are examples of unavoidable pressure injuries, as discussed by Edsberg and colleagues.[4] In dying patients, SCALE pressure injuries occur due to a combination of nonmodifiable intrinsic and extrinsic risk factors unique to each individual that make him or her susceptible to pressure, friction, shear, deformation (eg, stress and strain), hemodynamic instability, critical ischemia, and/or reperfusion injury. A combination of these mechanisms, unique to each patient, are the underlying cause of SCALE pressure injury that accompanies the dying process. The 2014 National Pressure Ulcer Advisory Panel Consensus Statement #11 states, "Terminally ill individuals who become immobile are at increased risk for unavoidable pressure ulcers."[4]