Had a patient one time who was actively dying. She did have previous skin breakdown from before I worked there. It was healing though, after I came and took over her wound care. But the night she died, she went from not a mark on her hip to a full scale stage 4, all the way to the bone: Overnight! I knew this would be her last day of life and she didn't want to be turned anymore after I looked at it so I let her be comfortable. There was no point preventing the ulcer from worsening, she was gone that afternoon. The PU was shaped kinda like a bow/butterfly, same description you describe here. She had no previous issues in that area and had a low air loss mattress and lots of positioning, I religiously turned her every 2 hours when she was not actively dying, and her one skin breakdown area was improving. Until 2 days before, when it started to deteriorate (I was told) then the night I came back to work she was actively dying. I wanted to turn her off that spot as soon as I saw it was red, but she said it hurt to lay on the other side (she had always preferred one side) so I didn't force her. I could see in her eyes her mind was slowing and then her breathing changed, then she was in and out of consciousness and then the terminal secretions started, I did oral care, swabbed with a few drops of water, used the atropine, everything. Oxygen for comfort, morphine for pain and to slow respirations when she seemed to start getting uncomfortable. I felt guilty as could be that when they released her body that she would go off to the funeral home with that horrible wound. I am glad to know that it was something that is expected and not just a mistake on my part. I prayed with her and her family. My first patient death.