Kennedy Terminal Ulcer: Understanding Skin Failure at the End of Life
Updated: 2 days ago
Medically reviewed by Dr. Baraa Alnahhal, MD · Last reviewed: October 2026
Quick Answer: Key Facts About Kennedy Terminal Ulcers
A Kennedy terminal ulcer (KTU) is a skin wound, usually over the sacrum or tailbone, that signals death is near, often days or weeks away. It likely reflects skin failure as the body shuts down. It develops despite good skin care and cannot be prevented or healed, so care focuses on pain relief, odor control and comfort.
Feature | Details |
Common name | Kennedy terminal ulcer (KTU), also called a Kennedy ulcer. [1] |
Primary meaning | A sign that death is near, often days or weeks away. [1] |
Likely cause | Skin failure as the body shuts down. Doctors do not know the exact cause. [1] |
Typical location | Skin over the sacrum or tailbone. [1] |
Distinction | Develops despite good skin care and is not preventable or healable. [1] |
Care goal | Pain relief, odor control and comfort (palliative care). [1] |
Timeline | From as little as 24 hours up to several months before death. [1] |
What the research says
Skin failure is a proposed explanation, and it still needs research. A review of the literature on terminal skin injuries (Kennedy terminal ulcers, Skin Changes At Life's End and related terms) proposed a unifying concept of "skin failure" that can occur with acute illness, chronic illness or the dying process. The authors describe it as different in cause from a pressure injury, although the two can occur together, and they note that validated diagnostic criteria are still needed. (Ayello et al., Adv Skin Wound Care, 2019) [2]
There is little hard data on how common these ulcers are. A scoping review of 32 sources found that prevalence data are limited, no validated assessment tools exist, and Kennedy terminal ulcers may be misclassified as pressure injuries. (Latimer et al., J Hosp Palliat Nurs, 2019) [3]
They can look like pressure injuries but develop differently. An integrative review that found only four quantitative studies (all from the US, published between 1989 and 2019) concluded that pressure injuries and terminal ulcers look similar but differ significantly in how they develop. The lack of a specific assessment tool and staging system raises the risk that these unavoidable wounds are managed as pressure injuries. (Latimer et al., Adv Skin Wound Care, 2022) [4]
What Is a Kennedy Terminal Ulcer?
A Kennedy terminal ulcer is a nonhealing skin sore that may form when a person is dying. The most common site is the skin over the tailbone and the sacrum (the triangular bone at the base of the spine). These sores can be a sign that death is close. [1]
Preventing and caring for wounds is an important part of end-of-life care. Most people are familiar with pressure injuries such as bedsores, which form when skin breaks down after staying in contact with a surface like a mattress for too long. Caregivers can often prevent and heal bedsores. Kennedy ulcers are different because they develop despite good skin care. [1]
What is skin failure in a Kennedy terminal ulcer?
The skin is the body's largest organ, and when someone is dying it is common for organs to fail. The skin can fail too. A dying heart cannot pump blood through the body as it once did, which is called heart failure, and it can no longer keep the skin healthy and hydrated. As a result, the skin can die. [1]
External factors such as pressure can contribute to skin breaking down, but with a Kennedy ulcer the underlying problem is skin failure, much as heart failure is a failure of the heart. Doctors do not know exactly what causes a Kennedy terminal ulcer, but it is most likely a result of the body shutting down. For families and caregivers, understanding that the wound reflects what is happening inside the body, not a lapse in care, can help ease guilt. [1]
What are the symptoms of a Kennedy terminal ulcer and "3:30 syndrome"?
Kennedy ulcers are easy to mistake for bruises, bedsores or other tissue injuries. A Kennedy terminal ulcer may be red, purple, yellow or black (black is often a sign of tissue death). It usually appears over the sacrum or tailbone, but it can also show up on the buttocks, spine, arms, shoulders, legs and heels. On the sacrum or buttocks it may have a butterfly or pear shape, and on the spine, back, shoulders or limbs it may look like squiggly, parallel lines. [1]
Sometimes these ulcers get worse within hours. This fast progression led some experts to name a subtype the "3:30 syndrome." Caregivers who first described it noticed tiny black spots on a patient's skin in the morning that looked like specks of dirt. When they checked again in the afternoon, around 3:30 PM, the spots had grown into blisters the size of a silver dollar. These patients often died within 24 hours. [1]
How is a Kennedy terminal ulcer diagnosed, and what role does hospice play?
Kennedy ulcers usually show up when a person is already dying and receiving hospice care. Skin care to prevent bedsores is an important part of hospice. A new wound that appears despite this care, and that does not respond to healing treatments, is likely a terminal ulcer. [1]
Recognizing a wound as a Kennedy ulcer tells the care team that pain management, not healing, is the goal. This can spare your loved one unnecessary discomfort from healing treatments. [1]
How is a Kennedy terminal ulcer managed with comfort and dignity?
Treatment focuses on easing pain from the ulcer and managing any odor from the dying tissue, so that your loved one can spend their last days with as much comfort and dignity as possible. A hospice team specializes in this type of care. [1]
Pain relief: caregivers may apply gels or foams to the wound to help with discomfort.
Odor control: dying tissue can have an odor. Activated charcoal dressings can absorb it, and essential oils may be placed in the room (not on the wound).
Comfort medicines: the care team provides medicines to ease the transition to death.
How can families be supported through a Kennedy terminal ulcer in the final days?
Seeing a terminal ulcer develop can be distressing for family members, because it is a visible sign that a loved one is near the end of life. It is not a reflection of the quality of care. Your loved one's care team is doing everything they can for them, including caring for the wound. [1]
No one can say exactly how much time a person has once this wound develops, but your medical team can help guide you. Allowing yourself to grieve is essential when you start seeing signs that death is near, and your family, your community and the hospice team can support you. [1]
Conclusion
A Kennedy terminal ulcer is one of the signs that a dying body is shutting down. It is not preventable and it cannot be healed, so the focus is on comfort. Understanding that the wound reflects skin failure, not a lack of care, lets families put their energy into what matters most: love, comfort and dignity. [1]
Learn more. For more evidence-based health guides, visit Rinnit.com.
Frequently Asked Questions
Can a Kennedy ulcer be prevented with enough turning and repositioning?
No. Unlike a standard pressure sore, a Kennedy ulcer develops despite good skin care. It is not preventable and cannot be healed.
Does a Kennedy ulcer always mean death will happen within 24 hours?
Not always. With "3:30 syndrome" the ulcer progresses within hours and patients often die within 24 hours, but a Kennedy ulcer can appear anywhere from 24 hours to several months before death.
Is the ulcer painful for the patient?
The ulcer can be, which is why caregivers treat the wound with gels or foams and the care team provides comfort medicines.
Why do these ulcers often have a butterfly or pear shape?
On the sacrum or buttocks they may have a butterfly or pear shape. This is a common description of how they look; the reason for the shape is not well understood.
Is a Kennedy ulcer the same as a bedsore?
No. Bedsores (pressure injuries) form from pressure over time and can often be prevented and healed. Kennedy ulcers develop at the end of life despite good skin care and cannot be healed.
Should the wound be scrubbed or cleaned aggressively?
Healing is not the goal, so treatment is aimed at comfort. Ask the hospice team how to care for the wound gently.
Can a person recover from a Kennedy ulcer?
A Kennedy ulcer appears when a person is already dying, so the wound is not expected to heal.
What if the ulcer smells?
Dying tissue can produce an odor. Activated charcoal dressings can absorb it, and essential oils may be placed in the room, not on the wound.
Can a new wound in someone who is not dying be a Kennedy ulcer?
Kennedy ulcers are terminal wounds that occur at the end of life. A new wound in a person who is not dying should be checked by a healthcare provider, because it is more likely to be a pressure injury or another wound.
Where on the body can a Kennedy ulcer appear?
Most often over the sacrum or tailbone. It can also appear on the buttocks, spine, arms, shoulders, legs and heels.
Why is it called a Kennedy ulcer?
A Kennedy ulcer is named after Karen Lou Kennedy-Evans, a nurse practitioner and wound care specialist who described these wounds.
Should we tell the patient about the ulcer?
That depends on the patient's level of awareness and the family's wishes. The hospice team can help guide these conversations.
What is the most important thing to do once a Kennedy ulcer is identified?
Make sure your loved one is comfortable and that pain is managed, and use the time to be with them. Death is likely close, although no one can say exactly when.
Related Reading
Bedsores (Pressure Ulcers): Symptoms, Causes, and Treatment explains pressure injuries and how they differ from terminal ulcers.
Stasis Ulcer: Symptoms, Causes, and Management of Venous Wounds covers leg wounds caused by poor vein circulation.
Understanding Negative Pressure Wound Therapy: A Guide to Advanced Healing describes a wound treatment that uses gentle suction.
Scabs: The Body's Natural Protective Shield for Wound Healing explains how skin normally heals after an injury.
References
Cleveland Clinic. Kennedy Terminal Ulcer. Cleveland Clinic. Last updated July 28, 2025. https://my.clevelandclinic.org/health/diseases/kennedy-terminal-ulcer
Ayello EA, Levine JM, Langemo D, et al. Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries. Adv Skin Wound Care. 2019;32(3):109-121. PMID 30801349. https://doi.org/10.1097/01.ASW.0000553112.55505.5f
Latimer S, Shaw J, Hunt T, et al. Kennedy Terminal Ulcers: A Scoping Review. J Hosp Palliat Nurs. 2019;21(4):257-263. PMID 30933013. https://doi.org/10.1097/NJH.0000000000000563
Latimer S, Walker RM, Ray-Barruel G, et al. Defining and Describing Terminal Ulcers in Adults at End of Life: An Integrative Review. Adv Skin Wound Care. 2022;35(4):225-233. PMID 34693923. https://doi.org/10.1097/01.ASW.0000798032.98853.95
Medical disclaimer
This article is for general educational purposes only and is not a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider, including your hospice or palliative care team, with any questions about a medical condition.
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