Kennedy terminal ulcers occupy a contested space in wound care. They look like pressure ulcers, they form over bony prominences like pressure ulcers, and they damage the same layers of tissue. But whether they actually are pressure ulcers or represent something fundamentally different has been debated by wound care professionals for decades. The honest answer is that experts disagree, and the disagreement runs deeper than semantics because it affects how caregivers are evaluated, how facilities are regulated, and how families understand what happened to a dying loved one.
What a Kennedy Terminal Ulcer Looks Like
The Kennedy terminal ulcer (KTU) was first described in the 1980s by Karen Lou Kennedy, a nurse who noticed a pattern among residents in long-term care: some patients developed distinctive skin wounds shortly before death. In her retrospective review of 95 pressure injuries from 1983 to 1988, more than half of the patients who developed these lesions died within six weeks of their appearance.
The wounds tend to appear suddenly, often within hours, and deteriorate rapidly. They most commonly show up on the sacrum (the lower back, just above the buttocks) and gluteal regions, though they can also appear on calves, arms, and elbows. Their shapes are often described as pear-like, butterfly-shaped, or horseshoe-shaped with irregular borders. The skin color may range from yellow to purple to black.
That rapid onset is one of the features that sets KTUs apart in the eyes of clinicians who consider them a distinct entity. A standard pressure ulcer typically develops over days as sustained pressure cuts off blood flow to tissue. A KTU can seem to appear overnight in a patient who was being repositioned and cared for appropriately.
Why Some Experts Say It Is Not a Pressure Ulcer
The central argument for treating the Kennedy terminal ulcer as something other than a standard pressure injury comes down to mechanism. A pressure ulcer develops because external force, whether sustained pressure or shearing, compresses tissue against bone and starves it of blood. The cause is mechanical. The proposed mechanism behind a KTU, by contrast, is internal: the body’s organs are shutting down, blood pressure drops, circulation to the skin deteriorates, and the skin itself begins to fail as an organ.
This concept is often described as “skin failure” or “acute skin failure.” The idea is that the skin, like the kidneys or the liver, can fail when the body is in crisis. Skin failure is defined as an unavoidable injury resulting from hypoperfusion caused by severe dysfunction of another organ system, and unlike a standard pressure ulcer, it can occur even when all appropriate preventive measures have been implemented.
One influential position in wound care holds that a pressure injury has pressure and shear as its cause, while pressure is not a necessary component of skin failure. The same patient can have both a pressure injury and skin failure at the same time, but they are understood as separate problems with separate origins.
Research on the tissue itself offers some support for this view. Histological examination of skin from terminally ill cancer patients found degenerated skin cells, leakage of red blood cells from capillaries, vascular inflammation, and edema in tissue that had not been subjected to pressure. These changes suggest the dying process itself damages skin at a cellular level, independent of any external mechanical force.
A broader framework groups these injuries into two categories: skin injuries associated with multiple organ dysfunction syndrome, which develop very quickly and progress from superficial to deep stages within hours, and skin injuries associated with severe vasoconstriction, which appear in critically ill patients whose blood vessels have constricted dramatically due to disease or medications like noradrenaline. In both cases, the severity of the injuries does not reflect the quality of care the patient received.
The Counterargument
Not everyone in wound care accepts the Kennedy terminal ulcer as a distinct diagnosis. A notable critique published in 2018 argued that the concept of the KTU is “without physiologic basis and based solely on observation.” The argument goes like this: these wounds still form over bony prominences, they still involve tissue compressed between bone and a surface, and the tissue damage still follows patterns consistent with pressure-related injury. The fact that the patient happens to be dying does not make the wound mechanism different; it just means a sicker patient is more vulnerable to pressure damage.
From this perspective, what clinicians call a Kennedy terminal ulcer is simply a pressure ulcer that developed faster and more severely because the patient’s compromised circulation, poor nutrition, and declining immune function made their skin vastly more susceptible to pressure-related breakdown. The dying process is a risk factor, not a separate cause. By this logic, creating a separate category muddies the picture and may allow facilities to relabel preventable pressure injuries as unavoidable terminal events.
This is a genuine scientific disagreement, not a fringe position. The literature remains unclear on whether KTUs should be considered a pressure injury or a separate skin problem that also happens to occur over bony prominences.
The SCALE Consensus and Where Terminology Stands
In 2008, a panel of 18 internationally recognized wound care experts convened in Chicago to try to bring some order to this confusion. The result was the SCALE framework, which stands for Skin Changes At Life’s End. The panel reached several points of general agreement: the skin, like any other organ, is subject to a loss of integrity due to internal and external insults; not all pressure ulcers are avoidable; and our understanding of the complex skin changes that can occur at end of life, including the KTU, remains limited.
SCALE was a step toward acknowledging that something real and clinically meaningful happens to the skin of dying patients. But it stopped short of definitively settling the question of whether these wounds are pressure ulcers, a subset of pressure ulcers, or an entirely separate phenomenon. Researchers have described KTUs variously as “end-stage skin failure,” as “a subgroup of pressure injury that may develop during the dying process,” and as wounds that originate from skin failure rather than from pressure or shearing. The terminology is not settled, and the variety of labels in use reflects genuine uncertainty about the underlying biology.
A more recent framework proposes thinking about the problem as an intersection: skin failure occurs where tissue deformation meets systemic vulnerability, including hypoperfusion, inflammation, vascular dysfunction, edema, medication effects, immune compromise, nutritional depletion, and age-related changes. Under this view, both pressure and internal organ failure contribute. The wound is not purely one thing or the other. It exists at a crossroads where external mechanical stress and internal physiological collapse amplify each other.
Why the Classification Matters for Families and Facilities
This is not an academic debate with no real-world consequences. The classification of a wound as a standard pressure injury or as an unavoidable skin change at end of life has direct implications for regulatory scrutiny, potential litigation, and the emotional burden on caregivers and families.
In the United States, the Centers for Medicare and Medicaid Services (CMS) uses specific definitions of “avoidable” and “unavoidable” pressure injuries when evaluating nursing facilities. A pressure injury is considered avoidable when a facility failed to properly evaluate the resident’s risk, implement appropriate interventions, monitor their effectiveness, or revise the plan as needed. It is considered unavoidable when the facility did all of those things and the wound developed anyway.
For end-of-life care specifically, CMS guidance states that when a facility has implemented individualized approaches for end-of-life care in accordance with the resident’s wishes, the development or worsening of a pressure injury may be considered unavoidable and consistent with regulatory requirements, provided the facility has also maintained basic care like cleaning, turning, and repositioning.
This is where the Kennedy terminal ulcer concept has its most practical impact. If a wound that appears on a dying patient is understood as an unavoidable consequence of the dying process, the facility is not penalized. If the same wound is classified as a standard pressure ulcer, the implication is that someone failed to prevent it, and that can trigger regulatory citations, lawsuits, and reputational damage.
Pressure injury malpractice litigation is a real and growing concern for healthcare facilities. Standardized risk assessment, rigorous documentation, staff education, appropriate staffing ratios, and institutional accountability can all help reduce both the incidence of pressure injuries and the risk of lawsuits. But accurate classification of wounds matters too. Labeling every end-of-life wound as unavoidable is dangerous; so is holding a facility responsible for biological processes it cannot control. The documentation trail, including a thorough record of preventive measures and the patient’s overall clinical trajectory, is what separates defensible care from negligent care.
For families, the distinction is deeply personal. A relative who sees a large, dark wound on a dying parent’s back may assume the worst: that their loved one was neglected, left lying in one position too long, or not properly cared for. Understanding that the dying process itself can cause skin breakdown, even when care was appropriate, can relieve enormous guilt and anger. Equally, that understanding should not be used to paper over genuine neglect. The tension between these two realities is at the heart of why wound care professionals keep arguing about terminology.
Other End-of-Life Skin Changes
Kennedy terminal ulcers are not the only type of skin change observed near death. A more recently described phenomenon is the Trombley-Brennan terminal tissue injury (TB-TTI), identified in a study of 80 patients. These skin changes were found to be unique and different from both Kennedy terminal ulcers and deep tissue pressure injuries. The median time from the identification of TB-TTI skin changes to death was 36 hours, making them an even more immediate harbinger of dying than KTUs.
Research using long-wave infrared thermography has helped distinguish TB-TTI from deep tissue pressure injuries. Deep tissue pressure injuries showed discolored tissue temperatures that were significantly colder than surrounding skin, while TB-TTI wounds had temperatures much closer to the temperature of the surrounding normal skin. No significant differences were observed in wound size or perimeter between the two types, meaning they can look very similar to the naked eye even though the underlying tissue pathology is different.
This finding underscores a broader point: the skin of a dying person can develop several different types of wounds that resemble each other visually but have different causes and different clinical significance. The differential diagnosis for what looks like a deep tissue injury includes not only pressure ulcers and terminal ulcers but also incontinence-associated dermatitis, bruising, hematoma, venous congestion, arterial insufficiency, and necrotizing fasciitis. Telling them apart requires clinical judgment and, increasingly, diagnostic tools beyond visual inspection alone.
Thermography as a Diagnostic Aid
One promising tool for distinguishing among these wound types is infrared thermography, which uses a thermal camera to map skin surface temperatures. Research on the early stages of Kennedy lesions suggests that the early phase of these wounds may be limited to microvascular injury, which produces a skin temperature reading within the normal range. This is different from a standard deep tissue pressure injury, which tends to show a cooler temperature because the compressed tissue has reduced blood flow.
Thermography is not yet standard practice in most wound care settings. The technology exists, and it can be used at the bedside, but the evidence base is still developing. More studies are needed to confirm whether temperature patterns can reliably distinguish a Kennedy terminal ulcer from a standard pressure injury from a Trombley-Brennan terminal tissue injury in real-time clinical practice. If thermography does prove reliable for this purpose, it could go a long way toward resolving the classification debate by providing an objective physiological marker rather than relying on clinical appearance alone.
What Caregivers Should Know in Practice
If you are caring for someone who is dying, whether at home or in a facility, there are a few things worth understanding about skin changes at end of life.
First, prevention still matters. Turning, repositioning, keeping skin clean and dry, managing nutrition as much as possible, and using pressure-redistribution surfaces are all standard and important interventions. The existence of unavoidable terminal skin changes does not mean you should stop trying to prevent pressure injuries. In many cases, the wounds that appear on dying patients are a mix: some damage from pressure, some from the body shutting down. Good preventive care reduces the pressure component even when it cannot address the systemic one.
Second, if a wound appears suddenly on someone who is clearly declining and receiving appropriate care, recognize that the dying process itself may be responsible. A wound shaped like a butterfly or pear on the lower back, appearing over hours rather than days, with colors shifting from red to purple to black, fits the description of a terminal skin change. It does not necessarily mean care was inadequate.
Third, document everything. If you are a professional caregiver, the single most protective thing you can do is maintain a detailed record of the preventive measures in place, the patient’s overall condition and trajectory, and the timing and characteristics of any wounds that develop. This documentation is what regulators and courts look at when distinguishing unavoidable skin changes from preventable injuries. If you are a family caregiver and you notice a skin change, take photos with timestamps if possible and note when you first saw it. That information is valuable for the clinical team.
Fourth, ask questions. If your loved one develops a wound in their final days or weeks, ask the care team what they believe caused it and what category it falls into. You have a right to understand what happened and why. A care team that has been providing appropriate preventive care should be able to explain their reasoning and show you the evidence in the medical record.
Skin Failure as a Broader Concept
The Kennedy terminal ulcer debate is really part of a larger conversation in wound care about whether the skin should be treated as an organ that can fail in the same way the heart, lungs, kidneys, or liver can fail. When someone dies of multi-organ failure, nobody blames the ICU team for the kidneys shutting down if the underlying disease process was unsurvivable. The question is whether we should extend that same logic to the skin.
In one documented case, acute skin failure was misdiagnosed as a pressure ulcer, leading to a legal dispute. The distinction mattered enormously: a pressure ulcer implied negligence, while acute skin failure implied an unavoidable consequence of the patient’s critical illness. The case illustrates how much rides on getting the classification right and how harmful it can be when clinicians lack the framework or the language to identify skin failure as a separate entity.
The concept of skin failure also applies beyond end-of-life care. Patients in intensive care units on vasopressors, patients in septic shock, patients undergoing prolonged surgery with significant blood loss can all develop skin injuries driven primarily by internal hypoperfusion rather than external pressure. These patients may have skin breakdown on their backs or buttocks that looks indistinguishable from a pressure ulcer but developed through a fundamentally different pathway. Recognizing skin failure as a clinical concept, whether or not you believe the Kennedy terminal ulcer deserves its own name, changes how you evaluate those wounds and the people who were providing care when they appeared.