Kennedy Terminal Ulcer: the “Ah-Ha!” Moment and Diagnosis
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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: email@example.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.
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. KTUs have been known to appear on the heels, posterior calf muscles, arms, and elbows.3 Early descriptions compare the look of the buttocks in some cases to being dragged over a black-topped road.4
The ulcer also is addressed in literature5 on providing evidence-based treatment options for patients needing palliative or end-of-life care. The primary care provider or wound consultant customarily makes the diagnosis and prescribes/recommends treatment for this skin failure/KTU. These actions often are based on the recommendations or suggestions from the nurses working with the patient and his/her family.
A KTU has been found to be a pressure ulcer that heralds the end of life.
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