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What Is Kennedy Terminal Ulcer?

Medically Reviewed by Dan Brennan, MD on June 01, 2021

A Kennedy terminal ulcer is a skin wound that appears in some people during their final weeks of life. The term "Kennedy terminal ulcer" was first used in 1989. It’s also known as a Kennedy ulcer.

Causes of Kennedy Terminal Ulcer

The exact cause of Kennedy terminal ulcers is unknown. ‌

Some experts say that it may be due to your organs shutting down. Your skin is your body’s largest organ. It's about 10% to 15% of your total body weight. It uses about 25% to 33% of the amount of blood that your heart pumps in 1 minute, or your cardiac output.

Like other organ systems, it can fail, especially as you age. 

Your skin can reflect signs of illnesses. Some illnesses that affect your whole body (systemic illness) can cause characteristic effects on your skin. For example, if you have liver disease, you're likely to have swollen blood vessels (spider naevi) and reddish palms ( palmar erythema).‌

While the cause hasn’t been determined, most people develop Kennedy terminal ulcers in their final weeks of life. Further studies are needed to better understand these ulcers. 

Symptoms of Kennedy Terminal Ulcer

Onset. These skin wounds can appear and develop over a few hours. The skin may be healthy in the morning. A few hours later, some small spots appear. Around mid-afternoon, these become black blisters that may grow larger. This is why they’re sometimes known as the “3:30 Syndrome”. 

This is unlike pressure ulcers or bedsores, which usually take several days to develop. Bedsores are caused by limited blood flow to your skin. This usually happens to people who have medical conditions that cause them to spend most of their time in bed or in a chair.

A study found that 62.5% of people in hospice care had pressure ulcers in their last 2 weeks of life. Many of these pressure ulcers may actually be Kennedy terminal ulcers. 

Color. Kennedy terminal ulcers may be red, yellow, or black. They may look like a bruise and may darken quickly. The surrounding skin may be loose or soft beneath the surface.‌

Shape. Kennedy ulcers have been described as butterfly-shaped, pear-shaped, or irregularly-shaped.

Location. Kennedy terminal ulcers typically appear on your sacrum. This is the lower end of your spine. They may also appear on your tailbone (coccyx). The ulcers may also appear in other parts of your body. This includes heels, arms, elbows, and calf muscles.

Unavoidable. Kennedy terminal ulcers are considered unavoidable. That is, these ulcers appear despite preventative measures and the best care that can be given.

Diagnosis of Kennedy Terminal Ulcers

In many cases, the person who develops a Kennedy terminal ulcer is already under the care of a healthcare team at a hospital or hospice care unit.

Diagnosing Kennedy terminal ulcers may be difficult because there isn’t a standard assessment tool. There’s also a low awareness of this condition among healthcare professionals.

Your doctor may take a detailed medical history, and run some blood tests, like complete blood count, prealbumin blood test.

Treatment of Kennedy Terminal Ulcers

The presence of Kennedy ulcers often means that these are the final stages of life. There’s no treatment to get rid of them. Treatment instead focuses on dignity and comfort in the last weeks of life.

These ulcers are often painful. To help reduce pain, pressure-relieving dressings and surfaces may be used. Painkillers may be given if repositioning causes more discomfort.

Charcoal-infused dressings may be used to help manage odors from the ulcers. 

Prevention of Kennedy Terminal Ulcers

Some tasks that may help reduce the likelihood of these ulcers include:

  • Keeping the skin dry and clean, especially around the bony prominences. These are areas where your bones are close to the surfaces, such as elbows and heels.  
  • Using pressure-relieving foam mattresses
  • Repositioning every few hours, if possible
  • Placing pillows under the knees  

But even if all these methods are used, Kennedy terminal ulcers may still appear.

Learning to Cope

Kennedy terminal ulcers are often a sign of impending death. As they can appear suddenly, it may not be easy to cope with your feelings. Grief is a normal response when a loved one is dying

Grief is different for everyone. It includes many different symptoms, including:

  • Physical symptoms like fatigue, dizziness, nausea, or a fast heartbeat.
  • Feelings like depression, guilt, anger, or fear.
  • Behaviors like loss of energy, trouble sleeping, crying spells, or restlessness.
  • Thoughts like difficulty concentrating, confusion, or hallucinations. ‌

If you’re caring for a loved one who is dying, you should take care of your needs, too. Make sure you get enough sleep, get regular exercise, and eat regular well-balanced meals. Ask for help if you need it. Talk about how you’re feeling with friends, family, a therapist or counselor, or support groups. 

Sometimes grief can turn into depression. If you’re having trouble dealing with your emotions, talk to your doctor.

WebMD Medical Reference

Sources

SOURCES:  

Australian Family Physician: "Skin manifestations of systemic disease."

familydoctor.org: “Grieving: Facing Illness, Death, and Other Losses.” 

Journal of the American College of Clinical Wound Specialists: “The Kennedy Terminal Ulcer – Alive and Well.”

Journal of Hospice & Palliative Nursing: “Kennedy Terminal Ulcers.”

Mayo Clinic: “Bedsores (pressure ulcers).”

Palliative Care Network of Wisconsin: “Kennedy Terminal Ulcer.”

Wound Management & Prevention: “Kennedy Terminal Ulcer: the “Ah-Ha!” Moment and Diagnosis.”

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