Kennedy Terminal Ulcers and Lividity: One Wound Care Clinician's Theory
by Rick Hall, BA, RN, CWON
Part 5 in a series on Skin Care Changes at Life's End (SCALE) and Kennedy Terminal Ulcers (KTUs).
For part 1, click here. For part 2, click here. For part 3, click here. For part 4, click here.
Contrary to popular myth, not all pressure ulcers are avoidable. The Skin Changes At Life's End (SCALE) panel concluded that our current understanding of the complex skin changes which occur at life's end is limited and additional research and expert consensus is necessary.
How Skin Changes During the Active Process of Dying
As a hospice nurse for over six years, I observed many changes in our patients' skin. In the final weeks of life, the body begins to change. Skin temperature may fluctuate. Mottling, a bluish color, may appear on the extremities.
Muscle wasting happens as the body's appetite decreases or becomes non-existent, and as dehydration and protein depletion occurs. This is a normal process at the end stages of life and is often difficult for the caregiver to accept and understand. It also leads to more serious problems.1
When someone becomes pre-actively or actively dying and the heart slows down causing hypoperfusion, their pre-albumin or albumin is low, less than 18 for pre-albumin or 2.8 for albumin. This causes platelets and serum to leak from the blood vessels and the contents to settle in the skin and stain it giving it the appearance of red, purple, and black colors. Blood has a pH of 7.4 neutral. The skin has a pH of 4-6 acidic. The neutrality of the blood changes the acidity of the skin and the skin, therefore, cannot fight off bacterial invasions. I believe this to be what coroners call lividity, a pooling of blood. Lividity is a way of telling how long a person has been deceased. Based on my observations and experience as a hospice nurse, I believe this lividity may happen before death in some individuals as part of the changes that occur to skin at life's end. If this is true, then the Kennedy Terminal Ulcer (KTU) would not be caused by pressure at all.
Understanding Skin Changes At Life's End Through Research
Further research including the sampling of tissue and extensive blood work from a large dying population would be required to validate this theory on lividity and KTUs. As a member of the SCALE panel and hospice community, I believe this research is warranted and should be pursued to advance our understanding and knowledge of the skin changes that occur at the end stages of life. A greater understanding of KTUs and the relationship between organ and system failure for individuals in the active stages of dying will help us to provide better care for people at this stage of life, as well as support the education of family members and health care and legal systems workers who may require an understanding of these changes that occur in the body. This research would be difficult to get consent to perform, however, due to the invasive nature of the procedures on patients at the end of life.
If lividity is indeed a factor in the development of what we now refer to as KTUs, then this theory supports the case for the unavoidable pressure ulcer, leaving us to redefine our general definitions and understanding of this phenomenon.
1. Hall Rick RN, CWON When the Race Nears the Finish Line Pamphlet for Hospice Education.
About the Author
Rick Hall is a wound and ostomy educator and consultant for Kaiser Permanente.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.