KTUs are a severe pressure injury occurring in individuals approaching the end of life. These wounds are a significant concern for comfort and palliative care. As with many complex wounds involving tissue death and bacterial presence, Kennedy terminal ulcers have the potential to develop a strong, unpleasant smell. Addressing this potential symptom is a recognized part of providing dignified and supportive care during the terminal phase of illness.
Understanding the Kennedy Terminal Ulcer
A Kennedy Terminal Ulcer (KTU) represents a specific type of unavoidable skin breakdown that manifests in people who are actively dying. It is often considered a sign of “skin failure,” which is the integumentary system’s inability to maintain integrity as a result of multi-organ failure and systemic decline. This distinguishes the KTU from typical pressure injuries, which are primarily caused by prolonged pressure, friction, and shear forces that could otherwise be prevented with standard care.
The appearance of a KTU is often abrupt, sometimes developing and progressing within a matter of hours, a rapid onset that has led to it sometimes being called the “3:30 Syndrome”. These ulcers commonly appear on the sacrum or coccyx, the area above the tailbone, but can also be found on other bony prominences like the heels or elbows. The initial presentation frequently involves an irregular, pear-shaped, or butterfly-shaped lesion that may display a distinct dark maroon or purple discoloration, sometimes progressing to red, yellow, or black tones.
The underlying cause is hypothesized to be the body shunting blood away from the skin to maintain perfusion of the more vital organs, such as the heart and brain, during the final stages of life. This systemic hypoperfusion deprives the skin of the necessary oxygen and nutrients, leading to ischemia and subsequent tissue death. The KTU is therefore less a failure of external care and more a reflection of the internal, physiological collapse associated with the terminal process.
The Biological Causes of Wound Odor
The malodor associated with severe wounds, including Kennedy Terminal Ulcers, stems from a combination of tissue decomposition and bacterial activity. As the skin fails and tissue dies, a process called necrosis occurs, which releases various chemical compounds. This dead tissue provides a rich source of nutrients for bacteria, which then metabolize these substances and produce foul-smelling byproducts.
The most potent and recognizable odors are caused by the metabolic processes of anaerobic bacteria, which thrive in the low-oxygen environment of deep, necrotic ulcers. These organisms break down amino acids, such as lysine, which are present in the decaying tissue. This breakdown process leads to the production of volatile organic compounds (VOCs) that are readily detectable by the human nose.
Two of the most well-known and foul-smelling compounds produced are the diamines putrescine and cadaverine. Putrescine results from the breakdown of ornithine, while cadaverine is a product of lysine decomposition. Both contribute to the “carrion smell” often described as the odor of decaying flesh. Other bacteria, including aerobic types like Proteus and Klebsiella, also contribute to offensive odors.
Controlling and Treating Wound Odor
Managing the odor from a Kennedy Terminal Ulcer is a primary focus of palliative care to maintain the patient’s dignity and comfort, as well as to support the caregivers. The approach to odor control is centered on reducing the bacterial load and absorbing the volatile organic compounds that cause the smell. This includes meticulous wound cleansing, which uses non-toxic agents to reduce surface bacteria and remove malodorous drainage and debris.
Debridement, the removal of necrotic tissue, is an effective strategy for odor control because dead tissue is the main source of the odor-causing compounds. However, in the context of a terminal ulcer, debridement methods must be gentle, such as enzymatic or autolytic debridement, to prioritize patient comfort over aggressive tissue removal. Sharp debridement is generally avoided unless it can be performed with minimal distress to the patient.
Specialized wound dressings are frequently used as a non-invasive way to manage odor. Charcoal-infused dressings contain activated carbon that physically adsorbs aromatic molecules, trapping them within the dressing matrix. These are often placed over the primary dressing to help contain the smell. Antimicrobial dressings containing agents like silver or cadexomer iodine also reduce the overall bacterial count, decreasing the production of odor-causing byproducts.
For deeper infections where odor is particularly difficult to control, topical or systemic antibiotics may be employed. Topical metronidazole, which is effective against the anaerobic bacteria responsible for the most foul smells, is a common intervention. Alongside direct wound care, environmental strategies like using air purifiers, scented candles, or essential oils are often implemented to mask or neutralize the pervasive odor in the patient’s immediate environment.