What is the management approach for Kennedy ulcers?

Kennedy Terminal Ulcers: Management Approach

Kennedy terminal ulcers are unavoidable skin wounds that signal imminent death within 3-14 days, requiring an immediate shift from curative to comfort-focused care with pain management as the absolute priority. 1

Recognition and Immediate Actions

Kennedy terminal ulcers (KTUs) represent skin failure at the end of life, appearing as rapidly progressing wounds—often evolving from stage I to stage IV within 24-48 hours—typically in a pear, butterfly, or horseshoe shape over the sacrum or coccyx. 2, 3, 4 The diagnosis should trigger:

• Immediate reassessment of goals of care with the patient and family, as death typically occurs within 3-14 days 1
• Limitation of therapeutic effort given the irreversible physiological decline 3, 4
• Recognition that these wounds occur despite comprehensive preventive care and are fundamentally different from pressure injuries 2, 5

Pain Management: The Primary Priority

Administer analgesics 30-60 minutes before any dressing changes or repositioning to minimize suffering, as pain control supersedes all other interventions. 1

• Apply topical lidocaine or morphine gel directly to the wound during dressing changes for localized pain relief 1
• Escalate systemic opioids as needed without concern for traditional dosing limits, as comfort is the sole therapeutic goal 1

Conservative Wound Care

The goal is protection and comfort, not healing:

• Apply hydrocolloid dressings as the primary treatment to maintain a moist environment while protecting the wound 1
• Clean wounds gently with water or saline only—avoid harsh antiseptics that cause unnecessary pain and tissue damage 1
• Control exudate with absorbent dressings (hydrocolloid or foam) to prevent maceration, odor, and skin breakdown 1
• Avoid aggressive sharp debridement unless advancing cellulitis or sepsis requires urgent intervention 1

What NOT to Do

• Do not use dextranomer paste, as it is inferior to other wound dressings 1
• Avoid dressings with antimicrobial agents solely to accelerate healing, as healing will not occur 1
• Do not pursue aggressive interventions like electrical stimulation, negative-pressure wound therapy, or surgical repair—these are inappropriate and harmful in terminal patients 1

Modified Pressure Redistribution

Traditional aggressive repositioning protocols cause more harm than benefit:

• Use advanced static mattresses or overlays rather than alternating-air systems, which provide adequate pressure relief without the noise and disruption that disturb dying patients 1
• Extend repositioning intervals to every 4 hours to minimize discomfort 1
• When repositioning is tolerated, use 30-degree tilt position rather than 90-degree lateral rotation to reduce pressure on bony prominences 1
• Do not use alternating-air mattresses, as evidence shows no benefit over static surfaces and they add unnecessary noise disturbance 1

Selective Infection Management

Avoid reflexive antibiotic use:

• Reserve systemic antibiotics only for advancing cellulitis, osteomyelitis, or systemic infection that causes patient distress 1
• Consider topical antimicrobial therapy rather than systemic antibiotics for superficial infection signs 1
• Avoid obtaining wound cultures unless results would change management decisions aligned with comfort goals 1

Nutritional Support (If Appropriate to Goals)

• Provide protein supplementation (1.2-1.5 g/kg/day) only if the patient can tolerate oral intake and has nutritional deficiencies 1
• Avoid vitamin C supplementation alone, as it shows no benefit over placebo 1
• Recognize that nutritional interventions will not prevent progression or promote healing of KTUs 2, 5

Common Pitfalls to Avoid

The most critical error is misdiagnosing KTUs as pressure injuries, which leads to aggressive, futile interventions that increase suffering and distress for patients and families. 2, 5 Key distinguishing features include:

• Rapid progression (hours to days vs. weeks) 3, 4
• Characteristic shapes (pear, butterfly, horseshoe) 2
• Appearance despite optimal preventive care 2, 5
• Context of multi-organ failure and dying process 2, 5

Other pitfalls include:

• Pursuing wound healing as a goal when physiological decline makes this impossible 5
• Failing to communicate the terminal prognosis to families, leading to unrealistic expectations 3, 4
• Continuing aggressive repositioning schedules that cause pain without benefit 1

Documentation and Communication

• Document the diagnosis of KTU clearly to guide the healthcare team's decision-making regarding limitation of life support 4
• Explain to families that these wounds are a manifestation of the dying process, not a failure of care 2, 5
• Establish realistic outcomes focused on dignity, comfort, and quality of remaining life rather than wound healing 3