Kennedy Terminal Ulcers – Expert Article on Investigating Pressure Ulcers

In this article, Wound Care Expert, Christa Bakos provides an overview of Kennedy Terminal Ulcers, a type of pressure ulcer that is often considered unpreventable. Her discussion includes a history of KTU’s, an explanation of how pressure ulcers develop, and the appropriate treatment.

Kennedy Terminal Ulcers

The Kennedy Terminal Ulcer (KTU) is an area of skin breakdown that develops when a person is dying and/or in multi-organ failure. The term KTU was named after Karen Lou Kennedy, a Family Nurse Practitioner, who in 1983 first started the process in differentiating this type of skin breakdown from standard pressure ulcers.1 In 1989 the National Pressure Ulcer Advisory Panel (NPUAP) formally recognized KTU’s, by defining them as an unavoidable skin breakdown related to the dying process having certain identifying characteristics that differentiate them from traditional pressure ulcers.1,2 To differentiate a KTU from a standard pressure ulcer/injury, it is essential to immediately identify the characteristics. All five characteristics of a KTU must be present:3

  1. usually located on sacrococcygeal area, however can appear on the heel, elbow, calf, or arm;
  2. appear to be shaped like a pear, butterfly, or horseshoe;
  3. they can be red, yellow, black, blue and/or purple in color;
  4. they have irregular borders;
  5. they have a sudden onset.4

Recent studies have shown that KTU’s can develop in areas that are not over bony-prominences. When development occurs in such areas, i.e. calf or arm, the depth of the injury must be noted as partial or full thickness skin loss. Working collaboratively with the physician, accurate diagnosis of a KTU is dependent on the review of the patient’s medical history to determine if death is imminent and the clinical presentation of the skin breakdown.4 Immediate assessment and documentation upon presentation by the nurse or staff is vital to ensure that appropriate diagnosis and interventions are implemented.

KTU’s develop when the body’s vascular system can no longer adequately supply blood to the skin and tissues. The skin is the largest organ of the body and just like the brain and liver, it requires blood supply to remain functional and alive. Without the appropriate blood supply, the skin can fail. Since the skin is an exposed organ, this failure is visible, whereas an internal organ’s failure is usually seen on diagnostic studies. This can occur when a person is actively dying or critically ill, and on medications that divert the blood supply to vital organs for survival.

Often times, the KTU is not present at the start of a nursing shift but quickly evolves into a stage III ulcer (if not over pressure may progress to full-thickness skin loss) by the end of the shift. The sudden appearance of the newly developed ulcer can be surprising to the staff or caretaker. As with any change in condition, upon identification, KTU’s should be documented immediately by staging or depth determination according to its clinical presentation and the physician should be notified. The documentation should include its identification as a KTU in addition to its stage and or depth (i.e. Stage IV KTU or Full-Thickness skin loss KTU).

If a KTU occurs over a bony prominence and involves pressure it is staged according to the NPUAP definitions. According to the NPUAP, “pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.” In accordance with NPUAP guidelines, pressure ulcers/injuries are staged based on the characteristics of their presentation and visible depth: 5

Stage I – is an area of intact skin with localized non-blanchable redness (a localized area of redness that does not fade or turn white when pressed on).

Image Courtesy of NPUAP
Image Courtesy of NPUAP

Stage II- Present with “partial-thickness skin loss with exposed dermis”. It is a shallow ulcer with a loss of the top layer of skin (epidermis). It is pink, red and moist in appearance. It can also present as an intact clear fluid filled blister.

Image Courtesy of NPUAP
Image Courtesy of NPUAP

Stage III – Presents with a “full-thickness skin loss”. These pressure ulcers/injuries can have a red, grainy appearance or be covered with slough and/or eschar. Slough and eschar are non-living tissue that builds up on the pressure ulcer/injury over time unless removed. They can also present as blood filled intact blisters.

Image Courtesy of NPUAP
Image Courtesy of NPUAP

Stage IV – “Full-thickness skin loss” with bone, tendon, muscle, fascia, ligament, and/or cartilage exposed. These pressure ulcer/injuries can also have slough/eschar present in the ulcer bed.

Image Courtesy of NPUAP
Image Courtesy of NPUAP

Unstageable - “Obscured full-thickness skin and tissue loss” covered with of slough/eschar. Due to the inability to visualize the actual depth of the pressure ulcer/injury it cannot be accurately staged. Once the slough/eschar is removed the pressure ulcer/injury can be appropriately staged.

Image Courtesy of NPUAP
Image Courtesy of NPUAP

Deep Tissue Injury - “Persistent non-blanchable deep red, maroon or purple discoloration.” This discoloration is due to damaged underlying tissue.

KTU and the Dying Process

Karen Lou Kennedy6 published results of a study of approximately 500 residents over 5 years with pressure ulcers. She found that residents that developed pressure ulcers/injuries died within 2 weeks to months of onset, within 6 weeks of onset 55.7% died. Those that are near the end of life frequently experience pressure ulcers/injuries as a form of skin death. According to Hanson, et al7 62.5% patients developed pressure ulcers while in the care of hospice and died within 2 weeks.

As skin is dependent on other organs to function adequately; it requires circulation, nutrition and immunity. Skin requires 25-35% of cardiac output, which is the amount of blood pumped from the heart into the circulatory system with every heartbeat. As people age their circulation begins to fail making this requirement difficult to meet because blood is circulated or diverted to other major organs (brain, lungs, etc.) to survive. According to Langemo and Brown8, skin failure is “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.” Hypoperfusion is decreased blood flow to organs. There are cases in which KTU’s develop in patients that are critically ill experiencing multi-organ failure. This occurs when all attempts are being made by medical staff to sustain life with medications that divert blood circulation to major organs (brain, heart, liver, kidneys, etc.). In cases such as these, KTU’s may be reversible and a patient may survive due to the aggressive medical interventions provided.

Treatment of KTU’s

Since KTU’s are most often associated with end of life and imminent death, the approach to treatment might be different than with traditional pressure ulcers/injuries. Often times, patients will be in hospice or palliative care with the goal of comfort. As always the case, the patient and /or family has the choice to the approach taken. If aggressive treatment methods are refused by the patient and/or family, comfort measures are implemented. If the patient and/or family chooses to pursue aggressive treatment, the KTU will be treated based on the ulcer/injury’s clinical presentation and staging. In this case, general standards of wound care would apply.

KTU’s are considered unavoidable due to the dying process; therefore it is important to immediately document the appearance on identification/assessment and notify the physician to obtain a diagnosis. The key to appropriately identifying KTU’s is educating staff. Treatment plans should be developed and implemented based on clinical presentation and staging of the wound, keeping in mind the wishes and expectations of the patient and/or family. In some instances KTU’s are not properly identified.

The healthcare experts at Robson Forensic possess the education, training, and experience necessary to identify the type and stage of pressure ulcer in each case and determine if healthcare workers provided the proper identification, documentation and treatment.


The experts at Robson Forensic are frequently retained to investigate the adequacy of care provided in hospitals, nursing homes, and hospice care facilities. Our experts can address many aspects of these cases from administrative policies and procedures, to the level of care provided by healthcare professionals, or the maintenance and custodial practices of care facilities.

For more information submit an inquiry or contact the author of this article.

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