Kennedy Terminal Ulcer

Overview

A Kennedy Terminal Ulcer (KTU) is a skin injury that can appear suddenly — sometimes within hours or a few days — in a person who is very seriously ill or nearing the end of life. It is often described as a sign of skin failure: the skin breaks down because the body is under extreme stress, has poor blood flow, and cannot keep tissue healthy. It often starts as a purple, dark red, or black area on the lower back, buttocks, or coccyx (tailbone), and may become a blister or open sore. The word terminal can sound frightening. It refers to the link with serious illness near the end of life; it does not mean the ulcer itself is the cause of death. It is not a sign that anyone has failed to provide care.

It is not common in the general population. It is seen more often in people who are already very seriously ill or nearing the end of life, and it may be under-recognised.

It is seen most often in frail older adults who are bedbound or very ill, especially people in hospice, palliative care, or long-term care. It can also happen in younger adults or children with severe illness, but this is much less common.

Symptoms

Common symptoms

• A new area of skin that looks purple, dark red, maroon, or black
• Skin that may be intact at first, then forms a blister or open sore
• The area may grow or change colour quickly
• Pain, tenderness, or a burning feeling, but not everyone has pain
• Warmth, swelling, fluid leakage, or a bad smell if infection develops

Symptoms in children

• KTU is rare in children. Any rapidly changing skin area in a seriously ill child — especially purple, black, blistering, or painful skin — should be checked by a healthcare professional.
• Children may show discomfort through crying, irritability, or guarding the area.

Symptoms in older adults

• Older adults, especially those who are frail, bedbound, or near the end of life, are most affected.
• They may not be able to report pain, so watch for facial expressions, groaning, guarding, or changes in behaviour.
• Skin may break down quickly despite regular turning and good care.

Causes

Main causes

• Skin failure related to severe illness: poor blood flow and oxygen delivery to the skin
• Pressure and shear forces on skin over bony areas, especially when a person cannot move
• Friction and moisture from incontinence or sweat damaging the skin
• Poor nutrition and hydration, weight loss, and loss of body fat that normally cushions the skin
• Multi-organ failure or circulation problems near the end of life

Risk factors

• Being bedbound or chairbound for long periods
• Frailty, older age, and very low body weight
• Serious illness such as advanced heart, lung, kidney, or liver disease, cancer, or infections
• Poor circulation, diabetes, or low blood pressure
• Incontinence or moist skin
• Not being able to feel or report pain, or being unable to change position
• Nearing the end of life or receiving hospice or palliative care

When to see a doctor

See a doctor urgently if:

• A new purple, dark red, or black skin area appears, especially in someone who is bedbound or seriously ill
• A blister or open sore develops or grows quickly
• There is worsening pain, warmth, swelling, drainage, or smell from a skin wound
• A person who is very weak or nearing the end of life develops any new skin breakdown

Book a routine appointment if:

• Any new pressure injury or skin change, even if it seems small
• A care plan review if someone is at risk of pressure injuries
• Questions about skin care, comfort, or goals of care

Diagnosis

There is no single test for a Kennedy Terminal Ulcer. A doctor or nurse diagnoses it by examining the skin and asking about the person's health, mobility, nutrition, and goals of care. They will also check for infection and other causes of skin damage. Some experts use the term skin changes at life's end because the diagnosis is based on the whole picture.

Tests that may be done

• Skin examination and measurements of size, colour, temperature, and drainage
• Photographs to track changes over time
• A wound swab if infection is suspected
• Blood tests or imaging if a deep infection or other problem is suspected
• Review by a wound care or palliative care specialist

What to expect at your appointment

The team will look at the wound and the person as a whole. They may ask about pain, comfort, bladder and bowel habits, and how much the person can move. You may be given a skin care plan, pressure-relieving equipment, and advice on repositioning. The focus is on comfort, preventing worsening, and supporting dignity.

Treatment

Treatment aims to relieve pressure, keep the skin clean and comfortable, manage pain, prevent infection, and support the person's overall comfort and goals of care. A Kennedy Terminal Ulcer is often a sign of serious underlying illness, so care usually involves the whole healthcare team, including nurses, doctors, and palliative care specialists.

Self-care at home

• Check skin at least once a day, especially over the tailbone, buttocks, heels, hips, and elbows
• Follow the care plan for gentle repositioning and pressure relief
• Keep skin clean and dry; use gentle cleansers and barrier products as advised
• Avoid rubbing or dragging the person across the bed
• Report any new colour change, blister, sore, pain, smell, or drainage straight away
• Offer fluids and nourishing food if the person can take them and it fits their goals of care
• Give pain relief as prescribed and use comfort measures

Medical treatments

Healthcare professionals may use special pressure-redistributing mattresses, cushions, and heel protectors. Nurses will clean and dress the wound with products suited to the wound and the person's comfort. If infection is suspected, a doctor may prescribe treatment. Pain and other symptoms are managed carefully, often with input from a palliative care team. Nutrition and hydration are supported when this is in line with the person's wishes. The overall goal is comfort, dignity, and quality of life, not forcing healing at all costs.

When is surgery considered?

Surgery is rarely used for a Kennedy Terminal Ulcer, especially in people who are very frail or near the end of life. In unusual cases, a specialist may discuss surgery for a deep or infected wound, but this depends on the person's overall health and goals of care.

Living with this condition

Day to day, the focus is on comfort and close observation. Keep to the skin care and repositioning plan, check the wound as often as your nurse advises, and keep the person clean and dry. Small changes can matter, so report them early. If the person is near the end of life, comfort measures and emotional support for the family are just as important as wound care.

Lifestyle tips

• Use pressure-relieving equipment as advised
• Keep bedding smooth and free of wrinkles
• Change wet or soiled bedding and clothing promptly
• Encourage gentle movement or a change of position if the person can tolerate it
• Keep the room comfortable and avoid overheating, which can cause sweating
• Ask for help with lifting or moving to avoid friction and shear

Diet and exercise

Good nutrition and enough fluids can help support skin health, but near the end of life the goal may be comfort rather than forcing food or drink. Ask the healthcare team or a dietitian what is right for the person. Gentle movement, such as small position changes or passive exercises, can help circulation if it is comfortable. Do not force exercise if the person is very weak or in pain.

Mental health and emotional wellbeing

Skin changes near the end of life can be very upsetting for patients and families. You may feel guilt, shock, sadness, or anxiety. It is important to know that these ulcers can happen despite excellent care. Talk to the healthcare team about your feelings, and ask for palliative care, counselling, or grief support if you need it. If you or a family member feels overwhelmed or unsafe, contact your local emergency number or a crisis support service in your area.

Prevention

Not all Kennedy Terminal Ulcers can be prevented, because they are linked to severe illness and skin failure near the end of life. Good pressure injury prevention can lower the risk: regular skin checks, gentle repositioning, pressure-relieving equipment, keeping skin clean and dry, and good nutrition and hydration when appropriate. If a skin change appears, early review can help keep the person comfortable.

Vaccines

There is no vaccine for Kennedy Terminal Ulcers.

Screening programmes

There is no screening test. For people at risk, regular skin checks by a carer or healthcare professional are the best way to spot changes early.

Complications

If left untreated

• The wound may become larger or deeper
• Infection can develop and, rarely, spread to the blood (sepsis)
• Pain, smell, and drainage can cause distress
• Healing may be limited if the underlying illness is severe

Long-term outlook

The outlook depends on the person's overall health. Some skin changes can improve if the underlying illness is treated and the person's circulation and nutrition improve. For people near the end of life, a Kennedy Terminal Ulcer can be a sign that death is approaching, but the care team can manage symptoms, keep the person comfortable, and support the family. Many families find it helpful to focus on comfort, dignity, and time together.

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