Got this from Medscape: http://www.medscape.com/viewarticle/715497

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, IL, and was made possible by an unrestricted educational grant from Gaymar Industries, Inc. The panel discussed the nature of SCALE, including the proposed concepts of 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 international 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 due to both internal and external insults. The panel concluded that: our 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 are avoidable.

Specific areas requiring research and consensus include: 1) the identification of critical etiological 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 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 policy makers) concerned with the care of individuals at life's end to adequately address the medical, social, legal, and financial ramifications of SCALE.

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: 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.

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 pressure ulcers 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, pressure ulcer risk factors, significant changes, and clinical interventions that are consistent with the patient's wishes and recognized guidelines for care.[1] 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,[2] or other palliative tools were utilized,[3] 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 not only address the patient's skin changes and comorbidities, but 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.[4,5] Addressing these patient-centered concerns optimizes activities of daily living and enhance 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 advanced cancer patients 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 that is not limited to the end of life.
[6,7] 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 pressure ulcers.

It is important that the provider(s) communicate and document goals of care, interventions, and outcomes related to specific interventions (See Statement 2). The patient's circle of care includes the members of the patient unit including family, significant others, caregivers, and other healthcare professionals that 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.