Abstract
What Is a Kennedy Terminal Ulcer?
The term 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. 1
Timing: KTUs can develop and appear within a matter of hours, in comparison with usual pressure ulcers that develop for approximately five days. 2 The seemingly sudden appearance has led them to be referred as the “3:30 Syndrome”: in the early AM, clinicians note intact healthy skin, hours later a few small blackish spots appear that may resemble “specks of dirt,” and then by mid-afternoon, flat black blisters emerge that may continue to expand in size.1,3
Location: Primarily the sacral region, but KTUs are also seen in other bony prominences, such as the elbows, shoulders, and heels.4,5
Description: 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. 6
Who Is at Risk?
Although the etiology of the KTU is not fully determined, they occur primarily in adult or pediatric patients in the final two weeks of life.2,5,6 Hence, anyone who is actively dying is felt to be at risk of developing skin failure and KTUs.2,6 Skin failure is a term, not well defined, that has been used in the published literature to conceptualize the overall breakdown process of the skin as an organ system that is associated with the end-stages of a chronic progressive illness and/or multiorgan failure, even when excellent skin care is provided. 4 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. 4 Both skin failure and the KTU often go undiagnosed or may be misdiagnosed as a usual pressure ulcer. The most distinguishing factors of a KTU is the quickness of the wound development, usually occurring in a day or less, in the setting of a terminal illness.5,6
How Does a Health Care Professional Prevent a KTU?
Most of the current research and published recommendations on KTU prevention are limited to expert opinion and case reports.7,8 Further research is needed regarding the underlying causes, consistent identification, and prevention of KTUs. A prevention strategy that is similar for all pressure ulcers and aims to reduce moisture and friction on bony prominences is recommended by many experts. This includes (1) turning moribund patients every two hours as tolerated; (2) keeping skin over bony prominences dry and clean; (3) the use of pressure-relieving devices such as high-specification (cubed, soft, or pressure redistributing) foam mattresses; (4) placing pillows under the knee to reduce sheer forces on the sacrum whenever the head of the bed is elevated; and (5) the use of pressure-relieving dressings (e.g., Mepilex).9,10 Even if all these measures are followed, unfortunately, KTUs may still occur in actively dying patients. 6
How Should a KTU Be Managed?
Although KTU management is similar to any pressure ulcer, there a few unique elements.
Emotional support and KTU counseling for caregivers are vital. Since KTUs can appear with little warning, caregivers may perceive this wound as a sign of care neglect or even abuse, which, without the proper education from clinicians, could create complicated feelings of guilt, mistrust, or anger. 6
KTUs can often be signs of impending death. Hence, addressing the signs, symptoms, and expectations of imminent death in the context of the KTU counseling is important. 11
Individual judgment is needed to determine the need for frequent repositioning in dying patients. By minimizing pressure to the localized area for patients, frequent repositioning can reduce discomfort in many patients with a prognosis of several days to a week. Yet, many patients with a prognosis of only hours to days may experience more discomfort than benefit from repositioning. Also, family members may wish to avoid repositioning so that their loved one can rest in peace. Transparent and ongoing communication with family members is vital.
If the patient grimaces or moans with repositioning, premedicating with an as needed analgesic (most commonly an opioid) 10–30 minutes prior is an alternative to discontinuing repositioning. 10
Nursing experts suggest that more than one person be utilized to assist with repositioning. Lowering the head of the bed and utilizing slide sheets is also recommended. 10
Although KTUs are usually irreversible, the use of pressure-relieving surfaces and pressure-relieving dressings is still advised to reduce pain associated from friction.3,5,6
KTUs and 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. 2
Documentation
There is not a specific ICD 9 or ICD 10 diagnosis code for a KTU. Still, Centers for Medicare and Medicaid Services recognizes the KTU as a part of the dying process and suggests that clinicians differentiate a KTU from a usual pressure ulcer in their medical documentation. With clear documentation, KTUs should not count against a health care institution's quality metrics or reimbursement.11,12