Haemorrhage

Appropriate assessment to identify cause and severity of symptoms

Explanation to patient and family

Non-acute haemorrhage

Correct reversible factors

Consider disease-specific palliative therapy

Prescribe appropriate first-line treatment

Acute terminal haemorrhage

Institute non-pharmacological interventions

Prescribe appropriate first-line treatment

Consider second-line treatment

Explanation to patient and family

Appropriate assessment to identify cause and severity of symptoms 

Haemorrhage occurs in about 20% of patients with advanced cancer and may contribute to death in 5%. Bleeding may be directly from the cancer itself or caused indirectly e.g. by medication causing gastric erosion or thrombocytopaenia. A generalised clotting deficiency seen in thrombocytopaenia, hepatic insufficiency or anti-coagulation with warfarin, are also contributory factors, particularly in patients with cancer. 

Common types of haemorrhage include haemoptysis, haematemesis, erosion of major vessels, rectal bleeding, vaginal bleeding, haematuria, gum and/or oral mucosal bleeding, epistaxis, intracerebral haemorrhage, bleeding into skin/muscle. 

Explanation to patient and family 

Do not alarm the family unless really necessary. Bleeds are often feared but seldom occur. Tell the patient and family what they need to know in small steps according to what they want to know. One needs to be careful not to raise fears of unlikely complications which are terrifying and about which little can be done. 

Non-acute haemorrhage

Correct reversible factors 

• H₂ receptor blockers, e.g. ranitidine 150 mg bd or proton pump inhibitors e.g. lanzoprazole 30 mg daily. Sucralfate may act as a local astringent to stop stomach mucosal bleeding but inhibits absorption of other medications such as proton pump inhibitors. 
• Check INR and adjust warfarin doses. Vitamin K may be needed. 
• Stop anticoagulants, NSAIDS, aspirin. (COX-2 Inhibitors are safe) 
• Correct any platelet abnormality if appropriate 
• Treat infection as infection exacerbates bleeding 
• If the haemorrhage is not immediately fatal, such as with a haematemesis or bleeding from the rectum, vagina or superficially ulcerated wound, the aim of treatment is local control if possible and sedation of a shocked, frightened patient. 

Consider disease-specific palliative therapy 

• Palliative radiotherapy is very useful for superficial tumours and those of the bronchus and genito-urinary tract. 

Prescribe appropriate first-line treatment 

• If radiotherapy is not appropriate, coagulation should be enhanced with oral tranexamic acid 500-1000 mg tds. po or i/v but caution is necessary with haematuria since clots may form in the bladder resulting in further problems. 
• Local measures such as topical tranexamic acid or adrenaline (1:1000) soaks, calcium alginate dressings, e.g. kaltostat, may be useful. 

Acute terminal haemorrhage 

• Erosion of a major artery may be catastrophic and rapidly fatal within minutes 
• It is usually associated with tumour erosion into a major artery such as the femoral or carotid artery (causing external haemorrhage) or the aorta or pulmonary artery (causing haematemesis or haemoptysis). 
• The main aim of treatment is to comfort the patient and support the family 

Institute non-pharmacological interventions 

• If a major haemorrhage is anticipated it is best to be prepared. Major haemorrhages might be preceded by smaller bleeds. 
• Warn family members of the possibility of a bleed and prepare them for what needs to be done. 
• If the patient is in an in hospital or hospice inpatient facility, move the patient to a side ward or private room so as not to distress other patients. Have a senior staff member stay with the patient at all times, if possible, and attempt to comfort and reassure the patient and family 
• Have aprons and gloves ready and dark towels on hand for mopping up and reducing the visual impact of the haemorrhage (dark green or blue or red blankets and towels) 
• Apply towels to the bleeding site for pressure and to absorb blood 
• Apply gentle suctioning to the mouth and trachea if needed 

Prescribe appropriate first-line treatment 

• Have medication ready on hand in case of a bleed. In the event of a bleed, the aim of treatment is to sedate the patient to relieve distress from what will be the terminal event of his/her life. 
• Give medication ideally intravenously or by deep intramuscular injection. Subcutaneous drugs are poorly absorbed when in shock 
• Midazolam 5-10 mg SC, i/v or S/L via buccal mucosa. (Use higher doses in patients who are already on benzodiazepines or heavy alcohol drinkers) 
• Lorazepam 1 mg S/L stat 
• Morphine 10 mg SC OR i/v 
• Rectal diazepam is another option and can be administered by a family member if the patient is at home 
• Repeat drugs every 10-15 minutes if needed. 

Consider second-line treatment 

• Ketamine 150-200 mg i/v stat will rapidly sedate a patient dying from a terminal bleed. If i/m route is used then a higher dose of 500mg is required. 

Explanation to patient and family 

• Bleeds are often feared but seldom occur. Tell the patient and family what they need to know in small steps according to what they want to know. One needs to be careful not to raise fears of unlikely complications which are terrifying and about which little can be done. 
• The palliative care team needs to balance the anxiety of alerting the family to the possibility of an acute bleed, with the likelihood of such an event occurring and the need for the family to be prepared. If the patient chooses to be looked after at home, the issues of managing acute haemorrhage need to be discussed with the family and the home care team and a clear plan worked out. Are there any special circumstances such as children in the house who might be especially traumatised by witnessing a severe bleed? 
• An Emergency Kit containing any of the following is helpful: Syringes, needles, adrenaline, Caltostat®, tranexamic acid, morphine, S/L lorazepam and/or midazolam. 
• After the event: The visual impact of such an event is enormous and anyone present will need support 
• Debrief the family, carers, staff, domestic workers and anyone who witnessed the trauma. Offer them counselling at Hospice or direct them to their usual support network. Offer a follow up meeting to answer any questions they might have.