Kennedy Terminal Ulcers

Key Takeaways 

Kennedy ulcers, also called Kennedy terminal ulcers (KTUs), are skin changes associated with the dying process and are widely understood as a form of skin failure. They typically appear suddenly, most often over the sacrum or coccyx, and can progress rapidly despite appropriate preventive interventions. Unlike traditional pressure injuries, Kennedy ulcers are generally considered unavoidable and are linked to systemic decline rather than prolonged pressure alone. For wound care nurses, accurate assessment, clear documentation, and compassionate communication are essential. Management focuses on comfort, symptom control, and support for both the patient and family during end-of-life care. 

What Are Kennedy Ulcers? 

Kennedy ulcers are rapidly developing areas of skin breakdown that occur in individuals who are nearing the end of life. First described in 1989 by Karen Lou Kennedy, these wounds are considered by many clinicians to represent skin failure, a condition in which the skin, like the heart, kidneys, or lungs, begins to fail as part of multisystem decline. 

As the body transitions toward the end of life, circulation becomes compromised and blood flow is prioritized to vital organs. The skin, being the largest organ of the body, may receive inadequate oxygen and nutrients. This hypoperfusion can lead to tissue ischemia and necrosis, even when evidence-based pressure injury prevention strategies are consistently implemented. Understanding this pathophysiology is essential for wound care nurses who must differentiate between unavoidable skin failure and preventable pressure-related injury. 

Kennedy Ulcers Symptoms and Early Warning Signs 

One of the defining characteristics of Kennedy ulcers is their sudden onset. Unlike pressure injuries that typically develop gradually over time, Kennedy ulcers may appear within hours and progress quickly from intact skin to significant tissue loss. 

Early signs often include a sudden area of discoloration over the sacrum or coccyx. The skin may appear red, maroon, purple, yellow, or even black. The lesion may resemble a bruise initially but deteriorates rapidly. This change frequently occurs alongside other indicators of systemic decline, such as reduced oral intake, decreased urine output, increasing fatigue, altered level of consciousness, or changes in respiratory patterns. 

For clinicians, the timing of these skin changes in relation to overall clinical deterioration provides important diagnostic context. 

Causes of Kennedy Ulcers: Understanding Skin Failure 

The primary cause of Kennedy ulcers is believed to be skin failure secondary to systemic hypoperfusion. As cardiac output decreases and the body diverts blood to essential organs, the skin becomes vulnerable to ischemic injury. In patients experiencing multiorgan failure, advanced cancer, end-stage cardiac or renal disease, sepsis, or severe malnutrition, the risk of skin failure increases. 

Importantly, Kennedy ulcers may develop even when patients are receiving appropriate repositioning, pressure redistribution surfaces, moisture management, and nutritional support. This distinction is critical in both clinical practice and regulatory review. Wound care nurses must understand that these ulcers are not necessarily the result of substandard care but rather reflect the body’s physiologic decline. 

What Do Kennedy Ulcers Look Like? 

Kennedy ulcers most commonly develop over the sacrum and coccyx, although they may occasionally appear on the heels or posterior lower legs. They are often described as pear-shaped, butterfly-shaped, horseshoe-shaped, or irregular in appearance. The borders are typically uneven rather than symmetrical. 

The lesion may begin as an area of intact but discolored skin and then rapidly progress to partial- or full-thickness tissue loss. Necrosis can develop quickly, and the surrounding skin may appear fragile, thin, or mottled. Because their presentation can initially resemble a deep tissue pressure injury, careful assessment and ongoing observation are essential. 

Thorough documentation of the wound’s initial appearance, rapid progression, and the patient’s clinical status at the time of discovery is a cornerstone of appropriate management. 

Kennedy Ulcers vs. Pressure Injuries 

Distinguishing Kennedy ulcers from pressure injuries is one of the most important responsibilities of wound care nurses. Pressure injuries result from sustained pressure, shear, and microclimate factors that impair local circulation over time. In contrast, Kennedy ulcers are associated with systemic organ failure and tend to develop suddenly and progress rapidly. 

While pressure injuries are often preventable with appropriate interventions, Kennedy ulcers are generally considered unavoidable when they occur in the context of active dying. Reviewing repositioning schedules, support surfaces, nutritional status, and overall compliance with preventive protocols helps support accurate classification. Interdisciplinary collaboration is especially important when determining whether a wound represents skin failure rather than a preventable injury. 

Diagnosis of Kennedy Ulcers 

There is no laboratory test or imaging study that definitively diagnoses a Kennedy ulcer. Diagnosis is clinical and based on a combination of rapid onset, characteristic location and shape, evidence of systemic decline, and documentation of preventive measures already in place. 

A comprehensive assessment should include the patient’s prognosis, comorbid conditions, hemodynamic stability, and overall trajectory. Collaboration among wound care specialists, bedside nurses, physicians, advanced practice providers, and hospice teams strengthens diagnostic clarity. 

Detailed documentation should describe the wound’s size, color, depth, and borders at the time of discovery, as well as the patient’s clinical condition and goals of care. Clear communication within the medical record is essential for regulatory compliance and family understanding. 

Is Testing Required? 

Kennedy ulcers do not require specific diagnostic testing. However, laboratory findings may reflect the systemic decline associated with skin failure. Abnormal renal or liver function tests, elevated lactate levels, hypoalbuminemia, hypotension, or signs of sepsis may support the broader clinical picture of organ dysfunction. 

While these findings are not diagnostic of a Kennedy ulcer, they reinforce the understanding that the wound is occurring in the context of multisystem deterioration rather than isolated pressure exposure. 

Treatment of Kennedy Ulcers: A Comfort-Focused Approach 

When a Kennedy ulcer is identified, the plan of care often transitions from aggressive wound healing to comfort-centered management. Because the underlying cause is systemic decline, complete healing is typically not the goal. 

Treatment focuses on pain control, odor management, exudate control, and protection of surrounding skin. Non-adherent dressings may reduce trauma during changes, and absorptive products can help manage drainage. Gentle cleansing techniques and barrier products protect fragile periwound tissue. Debridement is generally avoided unless necessary for comfort. 

Equally important is aligning the wound care plan with the patient’s goals of care. In end-of-life settings, minimizing discomfort may take precedence over strict repositioning schedules or invasive interventions. 

Life Expectancy After a Kennedy Ulcer Appears 

The appearance of a Kennedy terminal ulcer is strongly associated with impending death. Although timelines vary, many patients die within days to weeks after the lesion develops. It is important for clinicians to avoid offering exact predictions while acknowledging the seriousness of the sign. 

Sensitive communication is essential. Families benefit from understanding that the ulcer may indicate that the body is shutting down and that the focus of care is comfort and dignity. 

How to Comfort Patients With Kennedy Ulcers 

Comfort measures are central to care. Administering analgesia before dressing changes, using gentle handling techniques, and avoiding unnecessary manipulation of the wound can significantly reduce distress. Adjustments to repositioning frequency may be appropriate if movement causes pain and aligns with established goals of care. 

Family support is equally important. Explaining that the skin can fail as part of the natural dying process helps reduce guilt and confusion. Wound care nurses should provide clear, empathetic explanations and validate emotional responses. Language that avoids blame and reinforces the team’s preventive efforts fosters trust during a vulnerable time. 

Documentation and Regulatory Considerations 

Accurate documentation is critical when Kennedy ulcers are suspected. The record should reflect the patient’s terminal status, preventive interventions in place prior to wound development, and the rapid progression characteristic of skin failure. Interdisciplinary notes that demonstrate consensus further support appropriate classification. 

Regulatory scrutiny often centers on whether a wound was avoidable. Clear, thorough, and timely documentation helps differentiate Kennedy ulcers from preventable pressure injuries and protects both patients and clinicians. 

What Wound Care Nurses Need to Know About Kennedy Ulcers 

Wound care nurses play a leadership role in recognizing Kennedy ulcers, guiding interdisciplinary discussions, and supporting families through complex decisions. Clinical expertise must be paired with compassionate communication and strong documentation practices. Understanding the pathophysiology of skin failure, recognizing patterns of rapid onset, and aligning interventions with end-of-life goals are essential competencies. 

Beyond technical skill, wound care nurses serve as educators and advocates, ensuring that patients receive comfort-focused care and that families understand what is happening during the final stages of life. 

The Role of WCEI in Advancing Wound Care Knowledge 

The Wound Care Education Institute (WCEI) provides advanced wound care education designed to equip clinicians with the assessment skills, clinical judgment, and documentation expertise needed to manage complex wounds, including Kennedy ulcers. Through evidence-based education and case-based learning, WCEI supports wound care nurses in differentiating skin failure from pressure injuries and delivering compassionate, patient-centered care at the end of life.