Send to

Choose Destination
Adv Skin Wound Care. 2019 Mar;32(3):109-121. doi: 10.1097/01.ASW.0000553112.55505.5f.

Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries.

Author information

Elizabeth A. Ayello, PhD, RN, CWON, ETN, MAPWCA, FAAN • Faculty • Excelsior College School of Nursing • Albany, New York • President • Ayello Harris & Associates, Inc • Copake, New York • President • World Council of Enterostomal Therapists • Co-Editor-in-Chief • Advances in Skin & Wound Care • Philadelphia, Pennsylvania Jeffrey M. Levine, MD, AGSF, CMD • Associate Clinical Professor of Geriatrics and Palliative Care • Icahn School of Medicine at Mount Sinai • New York, New York Diane Langemo, PhD, RN, FAAN • President • Langemo & Associates • Professor Emeritus and Adjunct Professor • University of North Dakota College of Nursing • Grand Forks, North Dakota Karen Lou Kennedy-Evans, RN, FNP, APRN-BC • Wound Consultant • Foothills Rehabilitation Center • Tucson, Arizona Mary R. Brennan, MBA, RN, CWON • Assistant Director for Wound and Ostomy Care • North Shore University Hospital • Manhasset, New York R. Gary Sibbald, MD, DSc (Hons), MEd, FRCPC (Med Derm), ABIM, FAAD, MAPWCA • Professor • Medicine and Public Health • University of Toronto • Toronto, Ontario, Canada • Director • International Interprofessional Wound Care Course and Masters of Science in Community Health (Prevention and Wound Care) • Dalla Lana School of Public Health • University of Toronto • Project Lead • ECHO Ontario, Wound & Skin Care • Previous President • World Union of Wound Healing Societies • co-Editor-in-Chief • Advances in Skin and Wound Care • Philadelphia, Pennsylvania.



To synthesize the literature regarding skin injuries that are found in patients at the end of life and to clarify the terms used to describe these conditions.


This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.


After completing this continuing education activity, you should be better able to:1. Define the terms used to describe pressure injuries and skin changes at the end of life.2. Discuss the concept of skin failure as applied to end-of-life skin injuries and implications for practice.


This article synthesizes the literature regarding the concepts of "terminal" skin injuries that are found in patients at the end of life, including Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, and skin failure. Also included is a discussion of avoidable and unavoidable pressure injuries as defined and differentiated by the Centers for Medicare & Medicaid Services and the National Pressure Ulcer Advisory Panel. To help clarify the controversy among these terms, a unifying concept of "skin failure" that may occur with an acute illness, chronic illness, or as part of the dying process is proposed. This proposed concept of skin failure is etiologically different than a pressure injury, although pressure injury and skin failure can occur concomitantly. These proposed concepts require further research and validated diagnostic criteria. Consensus around appropriate terminology is essential to reduce confusion among stakeholders and ensure appropriate patient care.

[Indexed for MEDLINE]

Supplemental Content

Full text links

Icon for Wolters Kluwer
Loading ...
Support Center