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Patient Education - Skin Changes At Life's End

The skin is the body's largest organ. Like other organs, the skin may not function properly and may begin to fail near life's end. Even with proper care, the skin may still develop problems, such as pressure ulcers.

Often the changes to the skin can't be prevented or healed when someone is dying. These skin changes are referred to as Skin Changes at Life's End, or SCALE. However, there are some ways to manage or care for sore areas to keep a patient comfortable.

This reference summary will help you better understand the changes the skin undergoes at life's end, including risk factors and treatment options.

SCALE

End of life is a time when, because of worsening illness or disease, a patient's condition will worsen and ultimately lead to death. During this time, many different organs and organ systems may begin to function at less than optimal levels. Eventually they will stop working. The skin is one of the organs that can weaken and break down at life's end. There are many reasons for the skin to lose its function during this time.

Near the end of life, the skin has less blood supply. This is because the blood is directed to more vital organs, like the heart and the brain. Decreased blood supply also means less oxygen reaches the skin. This makes the skin unable to use important nutrients that would keep it strong and healthy. The skin loses function and can't protect the body like it once could.

Once the skin function begins to decline, even simple external forces can cause problems. Minor cuts could result in infections, skin tears, or pressure ulcers. Also, certain types of pressure ulcers may develop as some people approach death. These can be caused by just a small amount of pressure since the skin isn't working properly.

Pressure ulcers that develop at life's end get worse quickly and often don't heal. They are usually located on the lowest part of the back, directly above the buttocks. This area is called the sacrococcygeal area. Also, these ulcers are often shaped like a pear, butterfly, or horseshoe.

The skin may also change color, feel cool in certain areas, and become less flexible. Pain may be felt in certain areas due to pressure ulcers, skin tears, or infection. The fingers, toes, ears, and nose are the areas most likely to be affected in this way.

Risk Factors

There are some risk factors that increase a person's chances of developing skin changes at life's end. These include:

  1. Incontinence. Incontinence is the inability to control the flow of urine from the bladder or the escape of stool from the rectum.
  2. Weakness and decreased movement.
  3. Impaired immune system.
  4. Low blood pressure.
  5. Malnutrition, including weight loss and dehydration.

Other risk factors for skin changes at life's end include:

  1. Having other diseases, such as cancer.
  2. Exposure to pressure, shear or friction forces.
  3. Taking certain medications.
  4. Use of certain equipment or devices that may affect the skin.

Shear forces may cause skin to be pulled in the opposite direction of muscle or bone. This can cause a pressure ulcer.

Prevention

Changes to the skin, such as pressure ulcers, may not be preventable at life's end. If many organ systems are already losing function, they may be unavoidable.

Skin changes may develop even if the best care possible is given. Since the skin is not working properly, it can't be protected as easily. Also, the immune system may not be working properly at the end of life. This system is important in preventing infections and other diseases. This leads to an increased likelihood of skin infection.

Immune System

Mobility usually decreases when a person is near the end of life. This can cause further breakdown of the skin. Usually a person has a certain position in which they feel most comfortable. A patient's wishes should be respected, even if it results in the skin's condition worsening.

Treatment

A treatment plan should be chosen by the patient, if possible, as well as their health care provider and family. Care decisions should be made with the patient in mind. Keeping the patient comfortable may be more important than caring for the skin in the best way possible.

Certain changes to the skin at life's end may be reversible with treatment. However, this is not common. A patient's pain level and quality of life should be considered before deciding if an affected area on the skin should be treated aggressively. Since healing is not usually an option, treating a patient's skin injuries may include preservation or palliative care. Preservation is an attempt to maintain the current level of injury. Palliative care focuses on the patient's comfort.

A decision to preserve a wound may be made for many reasons. A wound could have the potential to heal, but the patient may refuse treatment. Preservation may also be a good treatment plan if the patient has another medical condition, such as diabetes, which makes it harder to treat the wound. The goal of palliative care is to keep the patient comfortable rather than aggressively treating the wound and causing more pain and suffering.

It is important to recognize that a treatment plan may change as the patient's condition changes. You should talk to a healthcare provider if you think the treatment plan needs to be changed.

Summary

The skin is the body's largest organ. Like other organs, the skin may not function properly and begin to fail near life's end. Despite proper care, the skin may still develop problems, such as pressure ulcers. Often the changes to the skin can't be prevented or healed when someone is dying. However, there are some ways to manage or care for sore areas to keep a patient comfortable. Becoming aware of the process of skin breakdown at life's end is important in helping deal with the emotions and shock that may be felt during this time.


All information provided on this website is for information purposes only. Every patient's case is unique and each patient should follow his or her doctor's specific instructions. Please discuss nutrition, medication and treatment options with your doctor to make sure you are getting the proper care for your particular situation. If you are seeking this information in an emergency situation, please call 911 and seek emergency help.

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