Kennedy Terminal Ulcer

Negligence vs Inevitable End-of-Life Symptom

The skin is the body’s largest organ, so skin failure often accompanies terminal conditions. A Kennedy terminal ulcer (KTU) is a severe type of skin wound that develops rapidly during the final stages of life, often signaling a swift physical decline. Some clinicians dispute whether KTU is a distinct diagnosis, and the safest approach is careful assessment and documentation.

In hospice care, the presence of a KTU may be a normal stage of the dying process, but it may also indicate medical neglect. Documentation, such as medical records and nursing charts, can help our pressure ulcer lawyers determine whether negligence was involved. We will also help families seek compensation and hold responsible parties accountable. 

What Is a Kennedy Terminal Ulcer?

A Kennedy ulcer (KTU) is often described as a terminal skin wound. It is sometimes classified within pressure-injury frameworks but comes from different forces. Rather than resulting from pressure like a bed sore, KTUs happen when the skin fails due to widespread tissue death.

KTUs typically occur at sites such as the sacrum, heels, or tailbone. These are called bony prominences because the bone sits close to the skin’s surface, making these areas more prone to ulceration in terminally ill patients. 

In many cases, KTUs present as butterfly- or pear-shaped ulcers, unlike round or oval pressure ulcers. 

A Kennedy ulcer is not a diagnosis of neglect on its own, but must be placed in context with other potential signs like dehydration or physical injuries. 

Recognizing the difference between Kennedy ulcers and neglect-related injuries is critical in legal contexts, as it helps determine whether the skin damage was a natural part of the final stages of life or caused by inadequate care and lack of appropriate prevention measures by healthcare providers.

Kennedy Terminal Ulcer vs Pressure Ulcers 

Kennedy terminal ulcers differ significantly from typical pressure ulcers due to the quick progression and exact cause.

In palliative care literature, KTU is often discussed in the context of end-of-life care. However, evidence and definitions vary. Pressure ulcers result from prolonged pressure and shear forces and can occur in non-terminal patients. 

While Kennedy ulcers develop rapidly and signal the start of the dying process, pressure ulcers develop over time. 

Healthcare professionals will apply the wound care measures needed for pressure-related injuries, such as repositioning, offloading, and support surfaces. However, the goal is to reduce discomfort and further wound development rather than to entirely prevent the ulcer.

Key Differences Between End-of-Life vs Pressure Injuries

Terminal ulcers, like Kennedy ulcers, progress rapidly and present in actively dying individuals or those in their final days. They emerge in bony areas such as the heels, shoulders, or coccyx rather than in areas with sustained pressure. Most notably, they have an irregular pear or butterfly shape and mottled discoloration.

In contrast, pressure ulcers develop over weeks or months. They may appear anywhere that has had sustained pressure or shear forces over time, though are common in bony areas like the coccyx. A bed sore is typically circular, oval, or crater-shaped and is not mottled.

Why Mislabeling Matters

Labeling preventable skin failure as ‘terminal’ can obscure missed prevention steps, making documentation critical. An attorney can review medical charts, doctors’ orders, and nurse testimony to better understand what type of care the patient was receiving and whether it aligned with wound management protocols. 

Historical Background

The term was coined in 1989, associated with observations attributed to Mary Lou Kennedy, NP (Fort Wayne, Indiana), and later debated in wound-care literature. Kennedy noticed that these fast-developing ulcers were distinct from typical pressure sores and were more closely associated with end-stage skin failure.

Some clinicians argue that the term should be retired or used cautiously, while others note that some pressure injuries may be unavoidable.

Causes and Risk Factors

Kennedy Terminal Ulcers (KTUs) develop due to a combination of internal and external factors factors. Risk factors include:

• Advanced age
• Chronic illnesses 
• Comorbid diseases
• Prolonged immobility
• Damage to other organ systems
• Terminal conditions like cancer

Certain physiologic drivers, such as poor perfusion (blood flow to tissues) or multi-organ failure, may contribute to the development of Kennedy ulcers and other unavoidable pressure injuries, but do not necessarily cause the condition. 

Symptoms and Appearance

It is important to understand how pressure injuries and related wounds look, as well as how they develop, in order to distinguish Kennedy ulcers from bed sores. 

KTUs are typically larger and irregularly shaped skin injuries that appear reddish, yellow, black, or mottled. They may have a butterfly or pear shape. They commonly appear on the sacrum, coccyx, and heels, where the skin is thinner. 

Unlike slow-progressing pressure ulcers, Kennedy ulcers can change quickly and may be accompanied by other signs of impending death. 

Diagnosing a Kennedy Terminal Ulcer

With a Kennedy ulcer, assessment focuses on differentiating from avoidable pressure injury and documenting context, onset, and wound characteristics.

Wound care specialists and palliative nurses will consider these factors:

• Onset timing per charting and family reports
• Location, such as on the coccyx or sacrum
• Wound shape and color, like irregular or mottled
• Comorbid decline markers, such as increased lethargy and loss of appetite
• Prevention methods in place, like turning, offloading, and support surfaces

These signs can help medical professionals decide on treatment, including additional comfort measures or pain management.

How Long Does a Person Live After Developing a Kennedy Ulcer?

While a Kennedy ulcer may appear close to death in some cases, it is not a precise indicator. Specialists will consider all the clinical signs, including ulcer progression, to help patients and families understand what to expect and provide emotional support.

Preventative Measures, Management, and Treatment

Managing Kennedy terminal ulcers requires a compassionate approach that focuses on the comfort of patients and preventing further skin damage during the final phases of life. Below are some of the common treatment and management options:  

• Patient Comfort: Gentle handling is crucial, as these ulcers can be painful. Skin care involving pressure-relieving dressings can also reduce pain.
• Odor and Exudate Management: Gentle cleansers and charcoal-infused dressings control odor and reduce skin sloughing. 
• Pain Management Techniques: Pain management improves a terminal patient’s quality of life. 
• Regular Repositioning and Pressure Relief: Repositioning can relieve pressure and help patients stay comfortable. Placing pillows and using pressure-relieving devices can distribute weight.

The Role of Hospice and Palliative Care

Hospice and palliative care teams enhance quality of life through advanced skin wound care, pain management, and regular repositioning, which will prevent more discomfort as patients begin the dying process. They also document the wound progression and other clinical signs, which are essential for legal purposes.

Clinical wound specialists should provide consistent communication with family members to prevent misunderstandings, including clear explanations of what a Kennedy ulcer means and how it is managed.

Legal and Ethical Considerations

The KTU label alone does not decide negligence. Documentation is key to determining whether medical staff acted in accordance with CMS guidelines around pressure ulcer management. Personal injury lawyers can review documentation to identify potential liability, including whether the KTU resulted from negligence or was an unavoidable consequence of a terminal illness. 

Certain records can provide a narrative of events around ulcer development, which may reveal potential neglect. These can include:

• Skin assessments
• Turning, offloading, and repositioning documentation
• Support surface orders
• Wound measurements and progression notes
• Hospice status and goals of care discussions
• Family reports and medical staff communication

Common Misconceptions About Kennedy Terminal Ulcers

Kennedy Terminal Ulcers may be misunderstood by patients and their families, making it important for medical staff to carefully explain what a KTU is and how it develops

• KTUs Are Always Preventable: Some KTUs are preventable, but others are unavoidable. This determination depends on the full picture of the patient’s condition, including any comorbidities and clinical signs of active dying.
• Their Presence Indicates Subpar Care: A KTU does not always indicate subpar care and may be a natural progression of a terminal illness. Documentation of supportive measures can help determine whether the KTU developed due to neglect.
• Legal Action Is Always Necessary When KTUs Develop: Legal action may be required if it can be proven that the KTU developed due to substandard care. If there is clear documentation of appropriate wound care and palliative care, then the KTU may be deemed unavoidable. 
• KTUs Are Misused as an Excuse for Neglect: This may be true in some cases, but not all. Attorneys will look at the totality of the circumstances, including available patient care records and staff communication, to understand how the KTU developed and how nurses responded.

Importance of Early Recognition

Kennedy ulcers can be a clinical sign of impending death. As such, early recognition can enable palliative nursing staff to gently prepare families and patients for the next stage of the dying process. KTU documentation helps clinical staff develop a care plan that prioritizes dignity and comfort while also distinguishing KTUs from bedsores. 

Explore Your Legal Rights!

If you believe a KTU resulted from neglect or improper care at a nursing home or intermediate care facility, you deserve justice and compensation. A nursing home abuse and neglect attorney is here to help you understand your rights and guide you through the process of seeking the compensation you deserve. Contact Nursing Home Law Center today to schedule a free consultation by calling or completing our online form.