Kennedy Terminal Ulcers and Lividity: A Theory Follow-up
by Rick Hall, BA, RN, CWON
Those of you who have been following my blog know that I believe the phenomenon we call the Kennedy Ulcer is a form of lividity prior to death, not due to pressure. I find it curious since the publication of SCALE - Skin Changes at Life's End, by the SCALE panel in 2009 and the presentation of this subject throughout my blog series, there has not been much dialogue on the changes we observe in our actively dying patients, especially with the concept of lividity prior to death.
My wife, while reading The Scarpetta Factor by Patricia Cornwell*, stopped and said, "I believe this is what you have been saying and writing about for years." On page 114, she read:
"I've done a lot of literature searches over the years, Kay. Time of death is something I deal with and argue in court fairly frequently. I've found a couple of interesting things. Cases of people who die lingering deaths, let's say from cardiac failure or cancer, and livor mortis begins before they're even dead. And again, there are cases on record of people going into instantaneous rigor. So, hypothetically, if for some reason Toni's livor was already developing right before she died and she went into instantaneous rigor for some very unusual reason?"
Livor mortis is different than lividity. Livor mortis is the result of the cessation of cardiac activity and the settling of blood in the capillaries and venules, thus distending them, in the dependent parts of the body. The dependent engorged blood vessels impart a purple-blue color to the overlying skin with the exception of those parts of the body serving as 'pressure points.' As an example, if someone dies in a supine position (resting on their back) livor mortis will develop on their back with the exception of the shoulder blades, buttocks, calves and heels. It is these parts of the body, which are supporting its weight and thus are referred to as 'pressure points.'
Skin Changes at Life's End: What Happens
So if livor mortis begins with the cessation of cardiac activity, is it possible for lividity to begin prior to death? I still believe with organ failure such as the heart beginning to slow down and the absence of albumin in the vascular system, platelets begin to leak out of the veins and into the skin staining it the purple, yellow, red, black colors we find on some people who are facing Skin Changes At Life's End.
So, with that new angle, I again make a plea for further research on this subject so we can put an end to saying the Kennedy Terminal Ulcer is neglect or abuse. Based on our current understanding of SCALE, my independent research and experience as a hospice provider, I believe it is a phenomenon which happens when some people are actively dying.
Author's Note: My wife Shirley has typed, proofread and edited my writings for over 8 years now. Without her doing those things and taking care of our son and our home while I am away lecturing to nursing students, researching, attending conferences, or educating caregivers on wound care, I could not have helped further Skin Changes at Life's End. Thank you, Shirley, I cannot repay you for all you have done to support me in this cause.
*Patricia Cornwell is a founder of the Virginia Institute of Forensic Science and Medicine, a founding member of the National Forensic Academy, and a member of the Harvard-affiliated McLean Hospital's National Council.
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.