Kennedy Terminal Ulcer: the “Ah-Ha!” Moment and Diagnosis

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Joy E. Schank, RN, MSN, ANP, CWOCN

Abstract: The Kennedy Terminal Ulcer (KTU) is an unavoidable skin breakdown or skin failure that occurs as part of the dying process. Research is limited but the literature suggests that KTUs are typically pear-shaped, red/yellow/black, similar in appearance to an abrasion, and tend to occur suddenly in the sacral/coccygeal region not long before death. In this case study, one resident of a long-term care facility suddenly developed a full-thickness ulcer. The ulcer did not respond to treatment and the resident died 6 weeks following ulcer development. Another resident, admitted with a full-thickness ulcer, also did not respond to standard measures of care and general skin failure was observed. She died after 5 months. Research about end-of-life phenomena such as skin failure is needed to help clinicians, caregivers, and patients understand what is occurring and facilitate the provision of optimal and appropriate end-of-life care.

Key Words: pressure ulcer, end-of-life care, Kennedy Terminal Ulcer

Please address correspondence to Joy E. Schank, RN, MSN, ANP, CWOCN, 3013 Wood Road, Himrod, NY 14842; email: joyschank@yahoo.com.

     Patients nearing death may experience a phenomenon known as the Kennedy Terminal Ulcer (KTU). The skin breakdown in the sacral/coccygeal area was first noted by Karen Lou Kennedy and other healthcare workers at the Byron Health Center, an intermediate care facility in Fort Wayne, IN, in 1983. The ulcer occurred despite preventive measures. Skin deterioration progressed rapidly, even in the course of a single day. Caregivers and family members were surprised at the sudden onset; Byron staff noted this type of ulcer heralded impending death. This case study describes two extended care facility residents whose skin changes in general, and the development of a KTU in particular, were associated with end of life.

Literature Review

     The KTU is described as a pear-, butterfly-, horseshoe-, or sometimes irregular-shaped red/yellow/black ulcer, similar in appearance to an abrasion or blister, that may occur suddenly.1 The blister roof may be very fragile and even gentle cleansing may change the skin surface from intact to a fairly large open wound. The ulcer may darken quickly before demarcating within days; it has the characteristics of early deep tissue injury and can progress rapidly to a Stage II, Stage III, or Stage IV ulcer (see Figure 1). Sometimes the surrounding tissue is soft or loose beneath the surface. Time is a key factor. Pressure ulcers in general can develop within 24 hours of skin insult and take as long as 5 days to present.2 According to Kennedy1 and others, KTUs come on quickly and progress rapidly, often within hours.

     Initially, the KTU was thought to be located exclusively in the sacral/coccygeal area; this was later amended to be described as its usual location.

References: 

1. Kennedy KL. The prevalence of pressure ulcer in an intermediate care facility. Decubitus. 1989;2(2):44–45.
2. Bryant RA. Pressure ulcer prevention summit: Minnesota’s response to adverse health events. Available at: www.mnpatientsafety.org/files/tools/PU_Summit. Accessed September 8, 2009.
3. Langemo DK, Brown G, Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 19(4);206–211.
4. Kennedy KL. Kennedy Terminal Ulcer. In: Milne C, Corbett L, Dubec D, eds. Wound, Ostomy and Continence Nursing Secrets. Philadelphia, PA: Hanley & Belfus, Inc;2003:198–199.
5. Ayello EA, Schank JE. Ulcerative lesions. In: Kuebler KK, Heidrich DE, Esper P. Palliative & End-of-Life Care Clinical Practice Guidelines, 2nd ed. St. Louis, MO: Saunders-Elsevier;2006:519–536.
6. Hanson D, Langemo DK, Olson B, et al. The prevalence and incidence of pressure ulcers in the hospice setting: analysis of two methodologies. Am J Hosp Palliat Care. 1991;8(5):18–22.
7. Sibbald RG, Krasner DL, Lutz JB, et al. Skin changes at life’s end (SCALE). J WOCN. 2009;36(3S):S33.
8. Medline Industries. The wound care handbook. Available at: www.medline.com/compass. Accessed September 8, 2009.
9. Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206–211.
10. Thomas DR. Are all pressure ulcers avoidable? JAMDA. 2003:4(2suppl):S43–S48.
11. Jones KR, Fennie K. Factors influencing pressure ulcer healing in adults over 50: an exploratory study. J Am Med Dir Assoc. 2007;8:378–387.
12. American Medical Directors Association. Pressure Ulcers in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD:AMDA;2008.
13. Black J, Baharestani M, Cuddigan J, et al. National Pressure Ulcer Advisory Panel's updated pressure ulcer staging system. Dermatol Nurs. 2007;19(4):343–350.
14. Hogue EH. Key legal issues for wound care practitioners in 2005. The Remington Report. 2005.May/June:14–16.














Anonymoussays: June 25.2012 at 19:36 pm

In response to Kenneth Olshansky, M.D., my husband has been given 24 hour/ round-the-clock care at home. We have 2 family members at all times. We are 2 BSN, 1 Occupational Therapist, 1 Chiropractor, and our resource is a cousin M.D. who specializes in geriatric renal diseases.
He is bedridden secondary to stage IV metastatic RCC and sudden onset lower extremity paralysis. It is 5.3 months since the initial dx. He is positioned several times daily to relieve pressure off of the sacral area. Additionally, he had a cath. inserted recently to avoid unnecessary rubbing of the area during toilet transfers and also because of the tumors in the ribs and spine which made transfers extremely painful. On a Friday as I sponged his sacral area I noticed 4 small abrasion spots (looked like a scraped knee would look after a fall). I applied skin protectant and dressing. Sat. during sponge I washed the area and it looked no different. Same with Sun. However, Mon. morning the sacral area was blackened, 3 inch by 2.5 inch area. It was oozing in one small spot, and reddened around his whole buttock area which was hot to the touch, but with no fever. He had been positioned correctly, cleansed, dressed and he still had a sudden onset necrosis of the sacral area. It surfaced very quickly. He has a special air mattress due to the tumors on the spine, ribs, and hips. I called Hospice and the nurse came and verified my suspicion. Perhaps it is skin failure, but is that not what KTU is? Skin failure? And trust me...it happens very, very quickly, even with the best of care.
Rebecca

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Anonymoussays: September 28.2009 at 23:58 pm

This article helps to bring awareness to the health care arena about skin failure and the importanceof education and research. As a nurse, a wound care specialist and as a legal nurse consultant I have long recognized skin failure when multiple co-morbidities, a significant health care event, protein catabolism, weight loss,and multisystem organ failure occur together. These patient's often live for several months with multisytem organ failure, sepsis, protein malnutrition etc. because of the medical modalities we now provide these dying patients. Even with the best prevention and treatment of these pressure ulcers, these wounds do not heal. Education of healthcare professionals, patients, and families is imperative. Thank you Ms. Shank for writing this article.
Sandra Higelin, MSN, RN, CNS, CWCN, CLNC

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Anonymoussays: May 11.2011 at 21:06 pm

I just learned of this type of wound last week. I have a patient who has dealt with this for over a year. He would go into renal failure, the wound would appear, the body would rebound and we were able to get the wound to heal.This time, however, he has gone from a Stage II to a Stage IV in 10 days. I have never seen a more aggressive decube. Wow. Thank goodness for the Hospice wound nurse that alerted us to this type of wound.

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Anonymoussays: September 27.2009 at 15:01 pm

This is a good article and also raises several issues which have perplexed all of us taking care of ill patients. I totally agree that more research is needed. First,is there really an entity of a Kennedy Terminal Ulcer(KTU). We hear alot about KTU's and "Skin Failure" but why is it that the "skin failure" and KTU's are almost always on a bony prominence. Until we can do 24 hour surveillance and other research to show that the patients received adequate round the clock pressure relief, it will be hard to validate a KTU or true skin failure ,in my opinion. Again,nice article. Kenneth Olshansky,M.D.

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