Kennedy Terminal Ulcer: Recognition and Documentation

Kennedy Terminal Ulcer: What Clinicians Must Recognize

The Kennedy Terminal Ulcer (KTU) is one of the most misunderstood wound presentations in clinical practice. First described by Karen Lou Kennedy in 1989, these ulcers appear rapidly in patients who are actively dying, often within hours to days of death. They are unavoidable. They are not the result of inadequate care. And they require a fundamentally different clinical approach than the pressure injuries they are frequently mistaken for.

Misclassifying a KTU as a hospital-acquired pressure injury has downstream consequences. It triggers root cause analysis. It flags the facility for a potentially preventable event. It demoralizes nursing staff who provided appropriate care. And it introduces inaccurate data into quality metrics that drive reimbursement and public reporting.

Understanding the Kennedy Terminal Ulcer means understanding that some tissue breakdown is a physiological event, not a care failure.

Characteristics of the Kennedy Terminal Ulcer

The KTU has a clinical presentation that distinguishes it from standard pressure injuries when clinicians know what to look for.

Onset and Progression

The defining feature is speed. KTUs appear suddenly, often progressing from intact skin to a full-thickness wound within 24 to 72 hours. This rapid onset is inconsistent with the progressive tissue damage seen in typical pressure injuries, which develop over days to weeks of sustained pressure.

Shape and Appearance

KTUs characteristically present in a butterfly or pear shape, most commonly on the sacrum or coccyx. The wound borders are irregular rather than the rounded or oval margins typical of pressure injuries. The wound bed frequently appears red, yellow, or black — and may progress through all three color phases within hours.

Color Changes

Skin changes surrounding the KTU often include a purple, red, or maroon discoloration that appears before the wound opens. This discoloration can resemble a deep tissue pressure injury (DTPI), but the speed of onset and the clinical context of a dying patient differentiate the two.

Location

While the sacrum is the most common site, KTUs can appear on other areas including the heels, posterior calves, and arms. Any rapidly developing wound in a patient approaching end of life should prompt consideration of KTU.

Differentiating KTU from Avoidable Pressure Injury

The distinction between a Kennedy Terminal Ulcer and an avoidable pressure injury matters for clinical accuracy, quality reporting, and regulatory compliance. The differentiation rests on several factors.

Timing relative to clinical trajectory. KTUs appear in patients who are actively declining toward death. If the patient has a terminal diagnosis, declining functional status, decreasing oral intake, and other signs of the dying process, a rapidly appearing sacral wound fits the KTU pattern. If the patient is medically stable or improving, the same wound requires a pressure injury workup.

Speed of onset. A wound that progresses from intact skin to Stage 3 or 4 depth within 48 hours is inconsistent with pressure injury pathophysiology in a patient receiving standard repositioning care. Pressure injuries develop through sustained, unrelieved pressure — they do not skip stages.

Prevention measures in place. Documentation should demonstrate that appropriate prevention interventions were in place — repositioning schedule, support surfaces, moisture management, nutritional support. A KTU occurs despite these measures, not because they were absent.

When the Diagnosis Is Unclear

When the clinical picture does not clearly fit either category, document the wound objectively with measurements, wound bed description, periwound skin assessment, and photographic evidence. Note the timeline of onset and the patient's overall clinical trajectory. Avoid premature classification in either direction — the medical record should reflect clinical reasoning, not assumption.

Documentation for Kennedy Terminal Ulcer

Accurate documentation is the clinician's primary defense against misclassification and the foundation for appropriate care planning.

Essential Documentation Elements

Every KTU assessment should include the date and time of onset or discovery with documentation of prior skin assessment showing intact skin, wound location and dimensions (length, width, and depth), wound bed characteristics including tissue type and color, periwound skin description including any discoloration or maceration, the patient's overall clinical status and prognosis, and prevention measures that were in place prior to onset.

Language That Protects the Record

Use the term "Kennedy Terminal Ulcer" or "Skin Changes at Life's End (SCALE)" in the assessment. Reference the patient's terminal trajectory. Document the rapid onset explicitly — "wound not present on assessment at 0800, noted at 1400 with full-thickness tissue loss" is far more defensible than a generic wound assessment without temporal context.

Avoid language that implies causation by care omission. Phrases like "developed pressure injury" or "breakdown noted" without clinical context invite retrospective scrutiny that may not account for the physiological reality of dying skin.

Hospice and End-of-Life Wound Care Coordination

When a KTU is identified, the care plan shifts from healing-focused intervention to comfort-focused management. This requires coordination across the care team.

Comfort-Focused Wound Management

The goal is symptom management — controlling pain, managing odor, and preventing secondary infection that would increase suffering. Aggressive debridement, advanced wound therapies, and skin substitutes are not appropriate for wounds that reflect the dying process rather than a treatable pathology.

Dressing selection should prioritize patient comfort. Non-adherent dressings that minimize pain during changes, odor-absorbing dressings when needed, and a dressing change frequency that balances wound management with minimizing patient disturbance.

Family Communication

Families need clear, compassionate explanation that the skin breakdown is part of the dying process, similar to how other organ systems fail at end of life. The skin is the largest organ, and it fails too. This conversation should happen proactively when a KTU appears, not reactively when a family member sees the wound and assumes neglect.

For broader context on end-of-life wound management approaches, review the hospice and palliative wound care guide. For clinicians who need to distinguish KTUs from staged pressure injuries in their documentation, the pressure injury staging guide provides the comparative framework. Additional documentation guidance is available in the wound care documentation templates.

Key Takeaways

Kennedy Terminal Ulcers appear rapidly — often within 24 to 72 hours — in patients who are actively dying, and they are unavoidable regardless of prevention measures in place.
The characteristic butterfly or pear shape on the sacrum, combined with rapid onset and a terminal clinical trajectory, differentiates KTUs from avoidable pressure injuries.
Documentation must explicitly record the timeline of onset, prevention measures already in place, the patient's terminal prognosis, and the clinical reasoning for KTU classification.
Misclassifying a KTU as a hospital-acquired pressure injury distorts quality metrics, triggers unnecessary investigations, and demoralizes clinical staff who provided appropriate care.
Care planning for KTUs shifts from healing-focused to comfort-focused, with dressing selection prioritizing pain control and odor management over wound closure.