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FAST FACTS AND CONCEPTS #383KENNEDY TERMINAL ULCERJackie Bateman, DNP, RN,CHPNWhat is a Kennedy Terminal Ulcer (KTU)? The KTU was first coined in 1989 to describe a skin wound that occurs despite best preventative measures and results from the moribund functional status and underlying skin failure associated with the dying process (1). Timing: KTUs can develop and appear within a matter of hours, in comparison to usual pressure ulcers which develop over approximately 5 days (2). The seemingly sudden appearance has led them to be referred as the “3:30 Syndrome”: in the early AM, clinicians note intact healthy skin, hours later a few small blackish spots appear that may resemble “specks of dirt”, then by mid-afternoon, flat, black blisters emerge that may continue to expand in size (1,4).Location: Primarily the sacral region but KTUs are also seen in other bony prominences, such as the elbows, shoulders, and heels (5,6). Description: The wound is usually irregularly-shaped, pear-shaped, or butterfly-shaped; > 2 inches in diameter; and may include red, yellow, black, and/or purple discoloration (3).Who is at risk? While the etiology of the KTU is not fully determined, they occur primarily in adult or pediatric patients in the final 2 weeks of life (2,3,6). Hence, anyone who is actively dying is felt to be at risk of developing skin failure and KTUs (2,3). Skin failure is a term, not well defined, that has been used in the published literature to conceptualize the overall breakdown process of the skin as an organ system that is associated with the end-stages of a chronic, progressive illness and/or multi-organ failure, even when excellent skin care is provided (5). Instead of the wound developing from preventable pressure on an isolated part of the body, KTUs are felt to occur from the failure of the skin as an organ system (5). Both skin failure and the KTU often go undiagnosed or may be misdiagnosed as a usual pressure ulcer. The most distinguishing factors of a KTU is the quickness of the wound development, usually occurring in a day or less, in the setting of a terminal illness (3,6). How does a health care professional prevent a KTU? Most of the current research and published recommendations on KTU prevention are limited to expert opinion and case reports (7,8). Further research is needed regarding the underlying causes, consistent identification, and prevention of KTUs. A prevention strategy that is similar for all pressure ulcers and aims to reduce moisture and friction on bony prominences is recommended by many experts. This includes a) turning moribund patients every 2 hours as tolerated; b) keeping skin over bony prominences dry and clean; c) the use of pressure-relieving devices such as high-specification (cubed, soft, or pressure redistributing) foam mattresses; d) placing pillows under the knee to reduce sheer forces on the sacrum whenever the head of the bed is elevated; and e) the use of pressure-relieving dressings (e.g. Mepilex) (9,10). Even if all these measures are followed, unfortunately, KTUs may still occur in actively dying patients (3). How should a KTU be managed? While KTU management is similar to any pressure ulcer, there a few unique elements.Emotional support and KTU counseling for caregivers are vital. Since KTUs can appear with little warning, caregivers may perceive this wound as a sign of care neglect or even abuse, which without the proper education from clinicians, could create complicated feelings of guilt, mistrust, or anger (3). KTUs can often be signs of impending death. Hence, addressing the signs, symptoms, and expectations of imminent death in the context of the KTU counseling is important (11).Individual judgement is needed to determine the need for frequent repositioning in dying patients. By minimizing pressure to the localized area for patients, frequent repositioning can reduce discomfort in many patients with a prognosis of several days to a week. Yet, many patients with a prognosis of only hours to days may experience more discomfort than benefit from repositioning. Also, family members may wish to avoid repositioning so that their love one can rest in peace. Transparent and ongoing communication with family members is vital. If the patient grimaces or moans with repositioning, pre-medicating with an as needed analgesic is an alternative to discontinuing repositioning (10).Nursing experts suggest that more than one person be utilized to assist with repositioning. Lowering the head of the bed and utilizing slide sheets is also recommended (10). While KTUs are usually irreversible, the use of pressure-relieving surfaces and pressure-relieving dressings is still advised to reduce pain associated from friction (3,4,6). KTUs and the associated tissue death from skin failure can lead to malodor. The use of charcoal infused dressings or topical metronidazole have been described to manage this odor (2).Documentation: There is not a specific ICD 9 or ICD 10 diagnosis code for a KTU. Still, Centers for Medicare and Medicaid Services recognizes the KTU as a part of the dying process and suggests that clinicians differentiate a KTU from a usual pressure ulcer in their medical documentation. With clear documentation, KTUs should not count against a health care institution’s quality metrics or reimbursement (11,12).References:Kennedy K.L. (1989). The prevalence of pressure ulcers in an intermediate care facility. Decubitus. 2(2), 44–45. Reitz, M. & Schindler, C. A. (2016). Pediatric Kennedy terminal ulcer. Journal of Pediatric Health Care. 30(3), 274-278. J.E. (2009). Kennedy terminal ulcer: The “Ah-ha” moment and diagnosis. Ostomy Wound Management, 55(9), 39–44.Kenndy-Evans, KL. Understanding the Kennedy terminal ulcer. Available at . Last accessed July 8, 2019.Langemo, D. K. & Brown, G. (2006). Skin fails too: Acute, chronic, and end-stage skin failure. Advanced Skin Wound care, 19(4), 206-11.Schank, J. E. (2016). The Kennedy Terminal Ulcer: Alive and well. Journal of American College ofClinical Wound Specialists, 8(1-3), 54-55.Brennan, M. R. & Trombley, K. (2010). Kennedy terminal ulcers: A palliative care unit’s experience over a 12 month period of time. World Council of Enterosotomal Therapists Journal, 30(3), 20-22.Khan, r. (2014). Healing a Kennedy terminal ulcer: A case study. Journal of wound ostomy and continence nursing, 41, S33.McInnes E, Jammali-Blasi A, Bell-Syer Sally EM, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews. 2011;(4) CD001735.The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. NICE Clinical Guidelines, No 179. National Clinical Guideline Centre (UK). London: National Institute for Health and Care Excellence (UK); 2014 Apr.Latimer, S., Shaw, J., Hunt, T., Mackrell, K., & Gillespie, B.(2019). Kennedy terminal ulcers: A scoping review. Journal of Hospice and Palliative Nursing. 21(4). 257-263. CMS(2011). CMS LTCH Quality reporting program manual. Section M. Retrieved from: ’ Affiliations: University of Maryland, School of Nursing: Assistant ProfessorConflicts of Interest: NoneVersion History: originally edited by Sean Marks MD; first electronically published in August 2019.Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.Copyright: All Fast Facts and Concepts are published under a Creative Commons Attribution-NonCommercial 4.0 International Copyright (). Fast Facts can only be copied and distributed for non-commercial, educational purposes. If you adapt or distribute a Fast Fact, let us know!Disclaimer: Fast Facts and Concepts provide educational information for health care professionals. This information is not medical advice. Fast Facts are not continually updated, and new safety information may emerge after a Fast Fact is published. Health care providers should always exercise their own independent clinical judgment and consult other relevant and up-to-date experts and resources. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. ................
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