What is the management of Kennedy ulcers?

Kennedy Terminal Ulcers: Management Approach

Kennedy terminal ulcers are pressure ulcers that develop rapidly (within hours to days) in dying patients and signal imminent death, requiring a shift from curative to comfort-focused care with realistic goals centered on pain management and dignity rather than healing. 1, 2

Recognition and Diagnosis

Kennedy terminal ulcers present with distinctive features that differentiate them from standard pressure ulcers:

• Rapid progression from Category I to Category IV within 24-72 hours, typically in the sacral or coccygeal region 1, 2
• Characteristic appearance: pear, butterfly, or horseshoe shape with double erythema (outer lighter ring, inner darker ring) and displacement of 30-45° over bony prominence 2
• Clinical context: occurs in patients with severe underlying illness, often bedridden with cognitive impairment or multi-organ failure 1, 2

The diagnosis of Kennedy terminal ulcer should trigger immediate reassessment of goals of care, as these lesions indicate physiological decline incompatible with survival (death typically occurs within 3-14 days) 1, 2.

Management Strategy: Comfort Over Cure

Pain Management (Primary Priority)

• Administer analgesics 30-60 minutes before any dressing changes or repositioning attempts 3
• Consider topical lidocaine or morphine gel for wound-related pain during dressing changes 3
• Systemic opioids should be titrated to patient comfort, not withheld due to concerns about hastening death 2

Wound Care (Conservative Approach)

Apply hydrocolloid dressings as the primary treatment, as they provide a moist healing environment while protecting the wound and are superior to gauze 3, 4. However, recognize that healing is not the goal—preventing further tissue damage and managing exudate/odor for patient comfort is the realistic objective 1, 2.

• Clean wounds gently with water or saline only—avoid harsh antiseptics that cause pain and tissue damage 3
• Control exudate with appropriate absorbent dressings (hydrocolloid or foam) to prevent maceration and odor 3
• Avoid aggressive sharp debridement unless advancing cellulitis or sepsis requires urgent intervention—the pain and trauma outweigh any theoretical benefits in dying patients 3

Pressure Redistribution (Modified Approach)

Use advanced static mattresses or overlays rather than alternating-air systems, as they provide adequate pressure relief with less noise and disruption to dying patients 3.

• Extend repositioning intervals to every 4 hours (rather than the standard 2 hours) to minimize discomfort, as advanced static surfaces allow this without increased ulcer incidence 3
• When repositioning is tolerated, use 30-degree tilt position rather than 90-degree lateral rotation to reduce pressure on bony prominences 3
• If repositioning causes significant distress, discontinue routine turning and prioritize comfort 2

Infection Management (Selective Approach)

Reserve systemic antibiotics only for advancing cellulitis, osteomyelitis, or systemic infection (fever, hypotension, altered mental status), as these infections are typically polymicrobial requiring broad-spectrum coverage 3, 5.

• For superficial infection signs (increased erythema, warmth, purulent drainage), consider topical antimicrobial therapy rather than systemic antibiotics 3
• Bacterial load can be managed with gentle cleansing alone in most cases 5
• Avoid obtaining wound cultures unless results would change management decisions 4

Nutritional Support (If Appropriate)

Provide protein supplementation (1.2-1.5 g/kg/day) only if the patient can tolerate oral intake and has nutritional deficiencies 3, 4. However, recognize that in actively dying patients, forced nutrition may increase discomfort without benefit 1.

• Avoid vitamin C supplementation alone—it shows no benefit over placebo 3
• Do not place feeding tubes solely to "heal" Kennedy terminal ulcers 2

Interventions to Avoid

• Do not use alternating-air mattresses—evidence shows no benefit over static surfaces and they add unnecessary noise disturbance 3
• Do not use dextranomer paste—it is inferior to other wound dressings 4
• Avoid dressings with antimicrobial agents solely to accelerate healing—healing will not occur 3
• Do not pursue aggressive interventions like electrical stimulation, negative-pressure wound therapy, or surgical repair—these are inappropriate for terminal patients 6, 2

Family Communication and Care Planning

Once Kennedy terminal ulcer is diagnosed, initiate discussions about limitation of life-sustaining treatment and transition to comfort-focused care 1, 2. The presence of this ulcer type helps healthcare teams and families understand the irreversibility of the patient's condition 2.

• Develop an individualized care plan using standardized frameworks (e.g., Marjory Gordon's functional health patterns) to identify realistic outcomes focused on dignity and comfort 1
• Provide agony care and family support as death approaches 2
• Document the diagnosis clearly to guide the entire healthcare team toward appropriate comfort-focused interventions 1, 2

Critical Pitfall

The most common error is treating Kennedy terminal ulcers with the same aggressive wound healing protocols used for standard pressure ulcers 1, 2. This approach causes unnecessary pain, false hope, and diverts attention from appropriate end-of-life care. Recognition of the Kennedy terminal ulcer phenotype should immediately shift care priorities from healing to comfort 2.