The Kennedy terminal ulcer (KTU) was first coined in 1989 to describe a skin wound that occurs despite best preventative measures and results from the moribund functional status and underlying skin failure associated with the dying process.
• They can develop and appear within a matter of hours (usual pressure ulcers develop over approximately 5 days). Its appearance is sudden: in the early AM, the healthy skin is intact, hours later a few small blackish spots appear that may resemble “specks of dirt”, then by mid-afternoon, flat, black blisters emerge that may continue to expand in size.
• They are primarily the sacral region but they are also seen in other bony prominences, such as the elbows, shoulders, and heels.
• The wound is usually irregularly-shaped, pear-shaped, or butterfly-shaped; > 2 inches in diameter; and may include red, yellow, black, and/or purple discoloration.

While the etiology of the KTU is not fully determined, they occur primarily in adult or pediatric patients in the final 2 weeks of life. Hence, anyone who is actively dying is felt to be at risk of developing skin failure and KTUs. The overall breakdown process of the skin is associated with the end-stages of a chronic, progressive illness and/or multi-organ failure, even when excellent skin care is provided. Instead of the wound developing from preventable pressure on an isolated part of the body, KTUs are felt to occur from the failure of the skin as an organ system. KTU often go undiagnosed or may be misdiagnosed as a usual pressure ulcer: its most distinguishing factors is the quickness of the wound development, usually occurring in a day or less, in the setting of a terminal illness.

A prevention strategy that is similar for all pressure ulcers and aims to reduce moisture and friction on bony prominences is recommended. This includes:
• turning moribund patients every 2 hours as tolerated
• keeping skin over bony prominences dry and clean
• the use of pressure-relieving devices such as foam mattresses
• placing pillows under the knee to reduce sheer forces on the sacrum whenever the head of the bed is elevated; and the use of pressure-relieving dressings
• the associated tissue death from skin failure can lead to malodor. The use of charcoal infused dressings or topical metronidazole have been described to manage this odor.

Even if all these measures are followed, unfortunately, KTUs may still occur in actively dying patients.
KTUs can often be signs of impending death. Therefore, addressing the signs, symptoms, and expectations of imminent death in the context of the KTU counseling is important.

See reference for more information.

Adapted from Bateman J. Kennedy terminal ulcer. Palliative Care Network of Wisconsin. Fast facts and concepts #383. Internet. Accessed on Sep 10, 2019.