NOT ALL PRESSURE ULCERS ARE PREVENTABLE: THE KENNEDY TERMINAL ULCER

Background:  Pressure ulcers are a quality measure for long-term care facilities and hospitals.  The Centers for Medicare and Medicaid Services (CMS) have regulated reporting of pressure ulcers in these facilities as a measure of nursing care.  CMS will not reimburse patient care if a patient develops a pressure ulcer under the care of the facility.  While most pressure ulcers are preventable there are certain situations that even with proper care and the use of evidence-based practice guidelines patients will develop an ulcer.  One ulcer that appears at the end-of-life is the Kennedy terminal ulcer (KTU). 

Objective:  To identify current literature about pressure ulcers, unavoidable pressure ulcers, skin changes at life’s end (SCALE) and the KTU. 

Design: A literature review of MEDLINE, CINAHL, COCHRANE, and PUBMED was completed to determine if certain pressure ulcers are unavoidable and determine what has been published on the KTU, SCALE and pressure ulcer development. 

Results:  Twenty-two articles have been reviewed.  The overall census is that not all pressure ulcers are preventable.  The National Pressure Ulcer Advisory Panel held a conference to determine if certain pressure ulcers are unavoidable in 2010[1].  After reviewing the literature, the experts in the field determined that not all pressure ulcers are preventable.  An unavoidable pressure ulcer is defined as an ulcer that forms even with the provider evaluating risk factors, taking evidence-based interventions and continuing to assess and reevaluate the plan of care.  This panel also recognized that skin failure is different from a pressure ulcer.  There is no formal diagnostic criterion available on skin failure.  The panel did recognize the KTU as skin failure in end-of-life situations.  This ulcer traditionally appears around the sacrococcygeal area, is a butterfly or pear shape, black/blue, red or purple in color, has irregular borders and develops rapidly[1-5].  The etiology of the KTU is due to hypoperfusion to the skin rather than unrelieved pressure.  The life expectancy after this ulcer is identified as two days to six weeks.   

Conclusion:  There is a growing amount of literature to support that not all pressure ulcers are preventable.  This is due to the complexity of patient’s advanced disease process and comorbidities.  Also, the goal of care may not warrant all preventive measures to be taken, for instance comfort care.  There is minimal literature available on skin failure and KTUs.  A KTU has a different pathophysiology compared to pressure ulcers.  Patient and family education is crucial when a KTU is identified.  It gives the provider the opportunity to use skin failure as a visual aid as to what is happening inside the body and that the patient may pass away soon.  Also, the provider needs to have thorough documentation about prevention measures taken and plan-of-care goals made with the family and patient.  This will help decrease suing rates and also insure reimbursement from insurance due to the ulcer being unavoidable and not due to poor care.   

Key Words: pressure ulcer, unavoidable pressure ulcer, KTU, skin changes at life’s end, pressure ulcer risk factors/prevention, skin changes with aging.