Most people who develop a Kennedy ulcer die within days to weeks, though the range can extend up to roughly six weeks. One early dataset from hospice settings found that more than half of patients with end-of-life skin breakdown died within six weeks of its discovery.1Advances in Skin & Wound Care. SCALE: Skin Changes at Life’s End That timeline is not a countdown set by the ulcer itself; it reflects the fact that a Kennedy ulcer is a visible sign that the body’s organs, including the skin, are already shutting down. The ulcer does not cause death. It signals that death is approaching.
What a Kennedy Ulcer Actually Is
A Kennedy terminal ulcer (KTU) is a specific type of skin breakdown that appears in the final phase of life. It was first described in the 1980s by Karen Lou Kennedy, a nurse working in a long-term care facility, who noticed a distinctive wound pattern on dying patients. Unlike ordinary pressure injuries caused by sustained external force on the skin, a Kennedy ulcer arises from internal collapse: the body, in crisis, redirects blood flow away from the skin and toward vital organs like the heart and brain. The skin, starved of oxygen and nutrients, begins to break down from within.2PubMed Central. Terminal ulcers in end-of-life care: a scoping review
The hallmark of a Kennedy ulcer is its sudden appearance and rapid progression. A patient may have intact skin one day and a dramatic wound the next. Colors range from yellow to deep purple to black, and the shape is often described as pear-like, butterfly-shaped, or horseshoe-shaped with irregular borders. It most commonly shows up over the sacrum (the triangular bone at the base of the spine) or the buttocks, though it can also appear on calves, arms, and elbows.2PubMed Central. Terminal ulcers in end-of-life care: a scoping review The speed at which the wound develops is one of the strongest clues that clinicians are looking at a Kennedy ulcer rather than a conventional pressure sore.
Why the Sacrum Is So Vulnerable
It is not a coincidence that these ulcers favor the sacral area. The blood supply to the sacrum and coccyx depends heavily on the median sacral artery, a small vessel only about two millimeters wide and two to four centimeters long. In roughly two percent of people, this artery is entirely absent, leaving the sacral area dependent on weaker collateral circulation that is especially vulnerable to any drop in blood flow.3Advances in Skin & Wound Care. Kennedy Terminal Ulcers and Trombley-Brennan Terminal Tissue Injuries: Mystery Solved? Even when the artery is present, its tiny caliber means the sacral skin is already living on thin margins. When the circulatory system collapses in the final stages of life, this area loses perfusion first.
That anatomical fragility helps explain the characteristic location. Other bony prominences like heels and elbows have somewhat better blood supply options, which is why Kennedy ulcers appear there less frequently, though they can.
How It Differs from a Regular Pressure Injury
The distinction matters because it changes everything about the care plan. A standard pressure injury develops because sustained force compresses the skin against a bone, blocking local blood flow. It is largely preventable with repositioning, pressure-redistribution surfaces, and good nutrition. A Kennedy ulcer, on the other hand, stems from internal organ failure. The skin is breaking down because the body as a whole is failing, not because nursing care was inadequate.4PubMed. The unavoidable pressure injury/ulcer: a review of skin failure in critically ill patients
This distinction has real consequences for families. When a loved one in hospice or an ICU suddenly develops a large, dark wound, the first reaction is often guilt or anger: somebody must not have been turning the patient, the mattress must have been wrong, someone was negligent. Understanding that a Kennedy ulcer reflects systemic shutdown rather than a care failure can relieve an enormous amount of misplaced blame. Clinicians who recognize the ulcer can shift the conversation toward comfort measures and end-of-life decisions rather than wound-healing protocols that won’t change the outcome.5EnfermerÃa ClÃnica (English Edition). Nursing care plan for the Kennedy terminal ulcer patient. Case report
The Timeline in Practice
Specific survival data tied exclusively to Kennedy ulcers remains limited, partly because the condition has only been formally studied for a few decades and partly because patients at end of life are not typically enrolled in survival-tracking trials. The most commonly cited figure comes from a broader category called SCALE (Skin Changes at Life’s End), which includes Kennedy ulcers and related skin breakdowns: more than 55% of patients died within six weeks of the skin change being discovered.1Advances in Skin & Wound Care. SCALE: Skin Changes at Life’s End
In the original hospice observations by Kennedy, many patients died within two weeks of the ulcer appearing, with some dying within hours. Published case reports paint a similarly compressed picture. One report describes a 69-year-old man admitted to an ICU with severe respiratory failure who developed a rapidly progressing sacral wound within 48 hours of admission. By 72 hours, the lesion’s shape and speed of deterioration led clinicians to diagnose a Kennedy ulcer, and a decision to limit life-sustaining treatment followed shortly after.6PubMed Central. The adapting of a care plan after Kennedy terminal ulcer diagnosis
The honest range, based on clinical experience and the published literature combined, is roughly hours to six weeks, with most patients dying within one to two weeks. There is no way to pin the timeline more precisely because so many variables are at play: the underlying disease, the speed of organ failure, nutritional status, age, and how far along the dying process already was when the ulcer appeared.
Can a Kennedy Ulcer Ever Be Wrong?
Occasionally, yes. Clinicians can misidentify a rapidly worsening pressure injury or a deep tissue injury as a Kennedy ulcer, especially in critically ill ICU patients where conventional pressure injuries also progress quickly. The conditions that make a patient vulnerable to a Kennedy ulcer, such as prolonged immobility, vasopressor use, sepsis, and multi-organ dysfunction, are the same conditions that produce unavoidable pressure injuries from external forces.4PubMed. The unavoidable pressure injury/ulcer: a review of skin failure in critically ill patients And a patient in an ICU, unlike a hospice patient, might recover from the acute crisis. If the wound was actually pressure-related rather than terminal, the patient may survive and the wound may eventually heal.
There is no lab test or biopsy that definitively distinguishes a Kennedy ulcer from a severe pressure injury. Diagnosis relies on the clinical picture: the sudden onset, the shape, the color progression, and the overall trajectory of the patient’s health. If a patient unexpectedly stabilizes and the wound begins to improve, the original identification as a Kennedy ulcer was probably wrong. That ambiguity is uncomfortable, but it is the current state of the science. Researchers have called for better diagnostic criteria and validated assessment tools precisely because the clinical overlap creates confusion.2PubMed Central. Terminal ulcers in end-of-life care: a scoping review
The Terminology Tangle
If you start reading about Kennedy ulcers, you will quickly encounter a confusing thicket of overlapping terms. Kennedy terminal ulcer, Trombley-Brennan terminal tissue injury, SCALE, skin failure, unavoidable pressure injury: these labels have emerged from different researchers and different clinical settings over the past few decades, and they describe overlapping but not always identical phenomena. An integrative review noted that skin failure, SCALE, Kennedy terminal ulcer, and Trombley-Brennan terminal tissue injury are often treated as different names for the same underlying problem.7PubMed. Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review
In practice, “Kennedy ulcer” is used most often when a specific wound with the characteristic pear or butterfly shape appears on the sacrum. “SCALE” is a broader umbrella that includes any skin changes occurring during the dying process, including color changes, breakdown, or wounds in less typical locations. “Trombley-Brennan terminal tissue injury” was introduced to describe wounds that can appear anywhere on the body, not just the sacrum, and that may resemble bruises or blisters rather than classic ulcers. “Skin failure” is the most general concept and borrows from the idea that the skin, as the body’s largest organ, can fail in the same way the kidneys or liver do. For families, the differences among these terms are less important than the shared meaning: the body is dying, and the skin is reflecting that.
What Happens to Care After the Diagnosis
Once clinicians identify a Kennedy ulcer, the care plan typically shifts. Aggressive wound treatment, which might include surgical debridement, negative-pressure wound therapy, or frequent dressing changes, is replaced by comfort-focused measures. The priority becomes managing pain, keeping the wound clean to prevent infection that could add to suffering, and protecting the surrounding skin. The goal is no longer healing the wound. It is ensuring the patient’s remaining time is as comfortable as possible.
This shift is significant for everyone involved. For medical teams, it means documenting that the wound is recognized as unavoidable and terminal in nature, which protects against wrongful liability claims. For families, a clear explanation from the care team can reframe the wound from a source of distress into a signal that helps guide decision-making about things like hospice enrollment, withdrawal of aggressive interventions, and gathering loved ones. One case report described the identification of a Kennedy ulcer as providing “the patient and family with the necessary information to be able to make decisions that facilitate a dignified death, limiting the therapeutic effort.”5EnfermerÃa ClÃnica (English Edition). Nursing care plan for the Kennedy terminal ulcer patient. Case report
Why the Research Is Still Thin
Given that Kennedy ulcers have been described for nearly 40 years, it is striking how little rigorous data exists on exact survival timelines, prevalence rates, or diagnostic accuracy. Several factors explain this. Patients who develop these ulcers are, by definition, at end of life, which makes prospective research studies ethically and logistically difficult. Consent is complicated. Follow-up is measured in days, not months. And because there is no biomarker or imaging finding that separates a Kennedy ulcer from other forms of skin breakdown, even retrospective chart reviews struggle with classification accuracy.
A scoping review that pulled together 26 studies on terminal ulcers highlighted the enormous inconsistency in terminology and diagnostic criteria across the published literature, and concluded that validated assessment tools and clearer definitions are needed before large-scale studies can even begin.2PubMed Central. Terminal ulcers in end-of-life care: a scoping review Until that groundwork is done, the survival estimates clinicians use will continue to be based on small case series and clinical experience rather than large-cohort evidence. That does not make the estimates useless, but it does mean they come with wide uncertainty.
What Families Should Watch For
If you are caring for someone who is seriously ill or in hospice, a few signs suggest a Kennedy ulcer rather than a conventional wound. The wound appears quickly, often over the course of hours rather than days. It tends to sit over the sacrum or tailbone area. The color is dramatic: dark purple, maroon, or black, sometimes with a surrounding zone of reddened or mottled skin. The borders are irregular and may take on a symmetrical butterfly or pear shape. And the wound worsens rapidly despite good skin care and repositioning.
If you see something like this, let the nursing or medical team know. The wound itself does not require a panicked trip to the emergency room; it is a sign of the underlying process that is already being managed. What it does call for is a conversation with the care team about what the wound means, what to expect in the coming days, and whether the current care plan still matches the patient’s goals. It is also worth asking whether a palliative care consultation would be helpful if one is not already in place. These conversations are difficult, but a Kennedy ulcer, properly recognized, can prompt them at exactly the right time.
When Kennedy Ulcers Appear in the ICU
Kennedy ulcers are most closely associated with hospice settings, where patients are already on a recognized dying trajectory. But they also appear in intensive care units, sometimes catching teams off guard. ICU patients face a confluence of factors that can trigger skin failure: prolonged immobility, use of drugs that constrict blood vessels to maintain blood pressure, severe infections, respiratory failure on mechanical ventilation, and multi-organ dysfunction.4PubMed. The unavoidable pressure injury/ulcer: a review of skin failure in critically ill patients In that environment, a rapidly appearing sacral wound forces a difficult question: is this patient dying, or is this a severe but potentially survivable pressure injury?
The answer is not always clear at the time the wound appears. In the ICU, the distinction between a Kennedy ulcer and a deep tissue pressure injury is especially murky because the physiological insults overlap heavily. Clinicians often watch the wound’s trajectory alongside the patient’s overall trajectory. If the wound continues to worsen despite optimal pressure redistribution, and the patient’s organ function is declining, the picture starts to fit a Kennedy ulcer. If the patient stabilizes and the wound stops progressing, the wound was more likely pressure-related and potentially healable. The wound itself is a data point in a larger clinical assessment, not a standalone diagnosis.