What Is a Kennedy Ulcer?

A Kennedy Ulcer, or Kennedy terminal ulcer, is a sore that rapidly develops and progresses as terminally ill patients near the end of life. Kennedy ulcers can appear during a patient’s last days, mainly at the sacrum, or tailbone. Their onset is very swift. They first appear as a small spot in the morning, then fully progress into large black blister-type sores by mid-afternoon that same day. Kennedy ulcers are sometimes called “3:30 Syndrome” by nurses and physicians, reflecting the time of day they seem to develop.

This type of ulcer was initially established as its own category of wound in 1989 by nurse practitioner Karen Lou Kennedy. While their exact cause remains unknown, medical experts believe that Kennedy ulcers develop due to tissue death. The skin is the body’s largest organ, so not unlike other organs, skin cells can shut down and fail near the end of life.

Kennedy ulcers are not bedsores, which are ulcers that develop due to continuous pressure on an area of the body for a prolonged period of time. Also called decubitus ulcers or pressure sores, bedsores occur due to compromised circulation and follow a typical pattern of tissue injury once they occur. Kennedy ulcers look very similar, but when examined under a microscope, the skin cells are intact. According to the National Pressure Injury Advisory Panel, further studies are needed to better understand why they occur.

Symptoms of a Kennedy Ulcer

To date, there is little research available on what causes Kennedy ulcers or how to differentiate them from a bedsore. However, they differ so greatly in their clinical presentation from any other type of ulcer that nurses who care for the dying have outlined some ways to recognize them. These include the following criteria:

• Rapid Onset: a blister-like wound that typically develops within hours of onset
• Location: most commonly develops on the sacrum (low end of spine) or tailbone (coccyx). However, they may also appear on other areas of the body, including the calf, heels, arms, or elbows.
• Irregular Shape: most often described as pear-shaped or shaped like a butterfly
• Color: bruise-like shades of black, yellow, or red that darken quickly after onset 
• Surrounding appearance: The skin surrounding the discolored area may be soft to the touch or loose.

Treatment and Prevention

Unlike bedsores, which can usually be prevented with excellent skin care and careful attention to positioning, Kennedy ulcers are thought to be unavoidable. They typically occur very shortly before a patient dies, so there’s little that can be done to help them heal. These ulcers can be painful, so treatment is aimed at patient comfort. Preventing pressure on the sore with special bandages, cushions, or positioning may help, and pain medicine is indicated if the patient is in distress. 

Importantly, caregivers should understand that nothing they did or did not do caused the ulcer to develop. Rather, like other signs of active dying, a Kennedy ulcer is a signal that the person’s body is shutting down. 

Sources

“What Is Kennedy Terminal Ulcer?” WebMD. https://www.webmd.com/skin-problems-and-treatments/what-is-kennedy-terminal-ulcer 

“NPIAP Tackles Issue of Skin Changes in Actively Dying Patients”. National Pressure Injury Advisory Panel. https://npiap.com/news/590421/NPIAP-Tackles-Issue-of-Skin-Changes-in-Actively-Dying-Patients.htm 

“Bedsore”. National Cancer Institute. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/bedsore