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Terminating the Kennedy Terminal Ulcer

Letter to the Editor

Terminating the Kennedy Terminal Ulcer

Index: Wound Management & Prevention 2019;65(11):8


With regard to Schank JE. Special report: Terminating the Kennedy Terminal Ulcer. Wound Manag Prev. 2019;65(4):18–22: The article explored the origins of the Kennedy Terminal Ulcer (KTU), practitioner and payer acceptance of the concept, and some of the challenges involved in the diagnosis of KTU and related conditions that affect the skin at the end of life. The terms Kennedy Terminal Ulcer, Skin Changes at Life’s End (SCALE), and Trombley-Brennan Terminal Tissue Injury (TB-TTI) all address the changes that occur at the end of life, and I believe they could be classified under the term skin failure.

The term skin failure and its associated descriptors was first documented by Jean Martin Charcot1 in the 1800s. He described his observations: “There appear on many points of the skin one or more erythematous patches, variable in extent and irregular in shape. The skin has a rosy hue, sometimes violet in color.” This description is commonly used in clinical practice today and also can be applied to KTU, SCALE, and TB-TTI. Basically, these different terminologies describe the same phenomena.

Although I agree with many of the points in the Schank article, I have one major concern. The author states KTU should continue to be used, and the wound care community should continue to research and evaluate skin failure terminology. I am of the opinion that KTU, SCALE, and TB-TTI all should be rolled into the diagnosis of skin failure using the qualifiers acute, chronic, and end of life. Charcot laid the foundation for this diagnosis centuries ago. Now that his work has been revived, it should not be left out of the conversation. Similarly, the research and evidence that Kennedy and others have brought to bear over the years should be viewed as building on the foundation that was already established by Charcot. There should be no confusion among clinicians as to the changes in terms. In medicine and health care (including wound care), our practice should evolve as knowledge evolves.

As a practicing wound care nurse, I all-too-often have seen the confusion among clinicians and the resistance to the terms skin failure, Kennedy Terminal Ulcer, and others in the acute care setting. This usually stems from lack of knowledge of skin conditions in general and the skin changes that occur with various metabolic processes in particular. A consensus needs to be established on the terminology, followed by an effort to educate health care professionals to help overcome many of the challenges currently faced when terminology impedes care.

Nekisha Hyman, BSN, RN, CWS

1.    Levine JM. Historical perspective on pressure ulcers: the decubitus ominosus of Jean-Martin Charcot. J Am Geriatr Soc. 2005;53(7):1248-1251.



One of the main reasons I respectfully disagree with Ms. Hyman is the lack of agreement regarding the definition of skin failure. We both made reference to Langemo and Brown,1,2 who defined skin failure as “an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems.” Skin failure was further described as acute, chronic, or end-stage. Acute is defined as “an event in which skin and underlying tissue die due to hypoperfusion concurrent with a critical illness.” Chronic is defined as “an event in which skin and underlying tissue die due to hypoperfusion concurrent with an ongoing, chronic disease state.” End-stage skin failure is described as “an event in which skin and underlying tissue die due to hypoperfusion concurrent with the end of life.” Using this definition, the subcategories of end-stage skin failure are the KTU, SCALE, and TB-TTI. There are distinct differences among these 3 terms. I liken Ms. Hyman’s reasoning to deleting the terms basal cell, squamous cell, and melanoma and referring to them all as skin cancer.

The terms skin failure, Kennedy Terminal Ulcer, Skin Changes at Life’s End, and Trombley-Brennan Terminal Tissue Injury are important in legal, as well as clinical, settings. I need to underscore my trepidation regarding the trend to criminalize unavoidable skin breakdown, especially that which occurs at life’s end. The following excerpt from the original article summarizes my concerns2:  “Where is all this headed? I predict the National Pressure Ulcer Advisory Panel (NPUAP) will hold a conference regarding skin failure; my hope is that participants will weigh the research, act with consideration toward a consensus, and not predetermine the elimination of the KTU, SCALE, and the TB-TTI. The NPUAP’s pressure ulcer staging conference was thought by many not to have been a consensus conference. I hope any decisions reached at any future NPUAP skin failure conferences would be the results of true consensus. The belief has been expressed that the NPUAP’s 2016 pressure ulcer staging system is a ‘plaintiff attorney’s best friend.’ Essentially, a plaintiff’s attorney can say to the jury, ‘Nurse Joy injured my client’. How? By the NPUAP’s definition, it was due to intense and prolonged pressure. If the NPUAP is successful, the terms skin failure, Kennedy Terminal Ulcer, Skin Changes at Life’s End, and Trombley-Brennan Terminal Tissue Injury will be eliminated, leaving the defense attorney with little to defend any of us.”

Joy Schank, RN, MSN, ANP, CWOCN

1.     Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206–211.
2.     Schank JE. Terminating the Kennedy Terminal Ulcer? Wound Manage Prev. 2019;65(4):18–22.