Printed on: November 21st, 2024

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Bleeding and haemorrhage in advanced cancer

Bleeding and haemorrhage in advanced cancer

Significant bleeding may occur in 10–20% of people with advanced cancer. Catastrophic terminal haemorrhage is rarer but is a very important palliative care emergency.

This article is based on the Scottish Palliative Care Guidelines - bleeding (accessed November 2023).

Consider whether a significant bleed may be anticipated. Typical examples might include:

• Tumour has infiltrated a major blood vessel (sometimes, initial presentation of the cancer may have been a bleed).
• Very large tumours, e.g. lung tumours (primary or metastatic) >10cm have a high risk of bleeding (palliative radiotherapy may be offered to reduce this risk).
• Head and neck tumours close to the carotid artery.
• Thrombocytopenia/abnormal LFTs with abnormal clotting.
• Appearance of pulsatile swellings.
• Smaller warning bleeds (if these occur in the community, discuss with the specialist palliative care team or the oncologists as palliative radiotherapy or interventional radiology techniques may be beneficial and reduce the risk of a catastrophic terminal event).

Gauze soaked in tranexamic acid or adrenaline or haemostatic alginate dressings (e.g. Kaltostat TM) can be applied to bleeding fungating wounds.

Bleeds from the mouth may respond to tranexamic acid or sucralfate mouthwashes.

Gastrointestinal or genitourinary tract bleeding may respond to oral tranexamic acid or sucralfate.

Unless you already have expertise, we recommend that you ask for specialist advice about these treatments. If you have a patient at risk or starting to have small bleeds, consider discussing anticipatory prescribing of these or similar options with your specialist team and district nurses.

Initially, discuss with colleagues and potentially the community specialist palliative care team before deciding whether to have a conversation with the family and/or patient. This is a difficult tightrope to walk and there is potential for this to go wrong!

Discussion with patients and relatives may cause unnecessary anxiety and concern, and there should be careful assessment of how beneficial this may be for a particular individual. It is good practice, however, to offer patients/families the opportunity to discuss any worries or concerns they may have about the mode of death, and it may be appropriate to discuss the risk of terminal bleeding if:

• It is raised by the patient or family.
• Knowledge about the risk allows the patient/family to change their behaviour in a helpful manner.
• There have been warning bleeds.
• There are special circumstances which make it valuable for the family to know, e.g. children in the home.

There should be clear communication with other members of the community team.

• This can be a particularly traumatic event for a family to observe, and the risk may be a very legitimate reason to consider admission to a hospice or nursing home setting for end-of-life care. Some people will still prefer to remain at home.
• This may be a situation in which an advance care plan and a wish to die at home may need review. If the patient no longer has capacity, loved ones will need support in deciding on what is best, including permission to ‘go against’ stated wishes.

• Do a medication review – consider stopping antiplatelets, NSAIDs, DOACs and anticoagulants.
• If caring for someone at home where this is a potential risk, dark colour (dark green or red) towels, gloves and aprons should be available to use to reduce the impact of bleeding should it occur.
• Have ‘just in case’ medication available to deliver in the event of a distressing bleed:
  • Midazolam 10mg IM. Note that this is faster acting than subcutaneous, especially where there is circulatory collapse, but it still takes time to work. Obviously, this will only be an option if someone is available 24/7 to administer, e.g. in a nursing home.
• Non-injectables:
  • Diazepam 10mg PR.
  • Buccal midazolam (10mg/1ml).

Clearly, these are not always appropriate and it may not be possible to administer them, especially if carers are family members or friends.

In reality, most people with a catastrophic bleed will lose awareness very quickly and medications will not have time to work before this happens.

Most importantly, someone needs to stay with the patient. Nobody should die alone this way.

Offer support for staff and family after death.

Lorazepam is a fast-acting benzodiazepine and may be appropriate for use to manage anxiety about escalation of recurrent small bleeds. It can be administered sublingually using the scored blue 1mg tablet preparations, and can be given at a dose of 0.5–1mg 4–6-hourly, with a maximum of 4mg over 24h.

Terminal bleeding Think about it. Talk about it (with colleagues first!). Prepare for it.