Advance Care Planning / Anticipatory prescribing

This should include:

1. Treatment Escalation Plan Or Recommended Summary Plan for Emergency Care and Treatment (TEP or ReSPECT) to be agreed with patient and family and documented in clinical notes to include DNACPR and preferred place of care and death.
2. A clear written plan documented and shared as appropriate, detailing what to do in the event of a major bleed.
3. Ensure availability of emergency equipment to manage a major bleed including dark towels, face shields (where available), gloves, aprons, plastic sheet or pads, clinical waste bag.
4. Where applicable ensure the availability of topical haemostatic treatment options, to include:
   • Haemostatic gauze or haemostatic granules (See Major Haemorrhage Haemostatic Gauze Granules PDF)
   • 5–10 mL of adrenaline 1 in 1000 (1 mg in 1 mL) on a gauze swab which can be applied with pressure for 10–20 minutes. This causes local vasoconstriction but may also cause ‘rebound’ bleeding once these effects wear off. Care should be taken to avoid ischaemic necrosis.
   • Undiluted 500mg/5ml (10% solution) tranexamic acid ampoule soaked into gauze and applied with pressure for 10 minutes before covering with a dressing.
   • Some brands of alginate claim to have haemostatic properties that can be used to control minor bleeding. Alginate dressings are manufactured from the calcium salt of an alginic acid polymer derived from brown seaweed. It is claimed that calcium ions that are released into the wound from the dressing activate platelets, which results in haemostasis. However, these dressings are not licensed as haemostatic dressings.
5. Prescription of midazolam 10 mg for intramuscular administration use in event of catastrophic bleed with appropriately completed Medicines Administration Form (in home setting) or electronic/paper prescription chart if they are an inpatient.

   Buccal midazolam 5–10 mg can be considered if family or carers are able and willing to administer, especially if the patient lives in a more rural / remote area, to avoid delays in receiving time critical medication. However, carers must be carefully counselled about correct and indicated use of this (mainly to avoid high dose midazolam being given inadvertently given for anxiety/agitation when a lower dose is indicated).

   It is much more important that family members are actively involved in discussions about other aspects of the treatment plan so that they know how to respond and who to call in an emergency situation.