In the May/June 2010 issue of JWOCN in an article titled "Pressure or Pathology, Distinguishing Pressure Ulcers From the Kennedy Teminal Ulcer (KTU)," the author makes several comments and assumptions that seem to be part of the thinking of many in the wound care community. I would like to respectfully throw out some challenges to that thinking until we have good data that support these concepts.

In the article, it states that "the etiology of a 'KTU' is hypothesized to be shunting of blood away from the skin to other organs during the process of dying" and "it is the ischemia associated with multiorgan failure, rather than the effects of unrelieved pressure or shear that result in an unavoidable skin ulcer." The term skin failure in many ways is also used in the same context as a "KTU," concluding that the skin ulcer in that circumstance is not from unrelieved pressure and is unavoidable.

I have tried to research the literature to find data that support the conditions called a "KTU" and "skin failure" as it relates to pressure ulcers and I have not been convinced that there are data to support these terms. If one can conclusively show that these ulcers were not due to inadequate pressure relief, then it would begin to support these concepts. For example, when we performed a chart review of a group of stage III and IV pressure ulcers, there was inadequate pressure relief that was actually documented on almost every patient's nursing record. Suppose in fact the turning documentation indicated that the patient was turned regularly, when in fact they were not, and pressure ulcers developed. We might deduce that these ulcers were "KTUs" or "skin failure" and were "unavoidable." The salient point here is that in order to accurately label an ulcer a "KTU" or the result of "skin failure" and not inadequate pressure relief, one would have to rule out pressure as a cause. The only way to do this in a scientific way is to conduct a study of patients who are monitored 24 hours a day either by the investigators or by video surveillance to be able to document that despite adequate pressure relief, patients still developed ulcers. Another question that needs to be explained is why almost all "KTUs" and "skin failure" ulcers develop on pressure points. If in fact these concepts are real, why is it rare to see these ulcers develop on nonpressure point locations?

The reason this discussion is important, in my opinion, is that before we label an ulcer as "unavoidable," we should be sure that it was not because we fell down on our care. In order to continue to improve the quality of our care, we must make sure that every ulcer that develops is investigated in a thorough way in hopes of avoiding another in the future.