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

Elizabeth A. Ayello, Jeffrey M. Levine, Diane Langemo, Karen Lou Kennedy-Evans, Mary R. Brennan, R. Gary Sibbald

Research output: Contribution to journalArticlepeer-review

45 Scopus citations


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.

Original languageEnglish
Pages (from-to)109-121
Number of pages13
JournalAdvances in Skin and Wound Care
Issue number3
StatePublished - 1 Mar 2019


  • KTU
  • Kennedy terminal ulcer
  • Skin Changes At Life's End
  • TB-TTI
  • Trombley-Brennan terminal tissue injury
  • acute skin failure
  • avoidable pressure injuries
  • chronic skin failure
  • end-stage skin failure
  • pressure injuries
  • pressure ulcers
  • skin failure
  • terminal ulcers
  • unavoidable pressure injuries


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