Contents:
Background
Massive haemorrhage (bleeding) is a life-threatening emergency. It can be distressing for patients, the people close to them, and health and social care professionals. It is important to recognise those patients most at risk, so that appropriate planning and management can be anticipated.
Risk factors for bleeding
There should be a multidisciplinary approach to assessing the likelihood of the occurrence of bleeding.
Several factors increase an individual’s risk of uncontrolled bleeding at the end of life:
- Site of cancer with fungating/malignant ulceration near major anatomical vasculature e.g. head and neck, breast, penile cancer, or propensity for bleeding e.g. haematological
- Presentation with bleeding e.g. haemoptysis in lung cancer, melaena
- Co-existing disease e.g. gastrointestinal bleeding, oesophageal varices
- Smaller warning (herald) bleeds
- Local infection at the tumour site
- Clotting abnormalities (including liver failure)
- Certain medications which may increase the risk, e.g. non-steroidal anti-inflammatory drugs (NSAIDs), steroids, anticoagulants
For those identified as high risk for major bleeding, a plan should be individualised, reviewed and clearly documented.
Signs of bleeding:
- Haemoptysis
- Haematemesis
- Melaena
- Haematuria
- Bleeding from ulcers, tumours or wounds on the skin.
Bleeding may also be internal in which case the patient may have symptoms of shock or a rapid loss of consciousness with no apparent source of bleeding.
Who needs to be informed?
Discussion with patients and relatives may cause unnecessary anxiety and concern. There should be careful assessment of how beneficial this may be for a particular individual. However, it is good practice to offer patients/families the opportunity to discuss any worries or concerns they may have about the mode of death.
In some situations, it is advisable to discuss the risk of major haemorrhage:
- If it is raised by the patient or family
- If knowledge about the risk allows the patient/family to change their behaviour in a helpful manner and facilitate other care planning e.g. place of care
- If there have been warning bleeds
- If there are special circumstances which make it valuable for the family to know e.g. children in the home
Communicate risk and care plan to healthcare professionals involved by documenting clearly in the clinical care record. For some patients in their own home, having a written plan of what to do in an emergency might be helpful for family members/carers.
Risk reduction
- If any of these risk factors are identified this should trigger a multidisciplinary approach to reducing the risk of major bleeding and of distress to both patient and families if it happens.
- There should be consideration of the appropriateness of radiotherapy, chemotherapy, cauterisation or embolisation.
- If wound infection felt to be present treatment should be considered.
- Review and stop anticoagulants and antiplatelet drugs where possible.
- Minimise trauma during dressing changes by cleaning gently with irrigation and using non-adherent dressings.
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.