Persistent bleeding in palliative care

Slow persistent bleeding in patients with palliative care needs may be part of the slow decline to death. Management focuses on the cause and depends on potential benefits and burdens of each intervention and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care. Address reversible causes of bleeding if possible (eg stop antiplatelet therapy). Interventions to target bleeding at the relevant site may be appropriate (eg embolisation of arteries for repeated epistaxis); if such an intervention is not clinically appropriate or possible, topical or oral tranexamic acid may be beneficial. Active or previous history of thrombosis is a relative contraindication to tranexamic acid; although, in some circumstances, the benefit of reducing the bleeding outweighs the risk of further thrombosis.

If using tranexamic acid, the topical formulation should be used if feasible; see Bleeding wounds in palliative care for directions.

For oral tranexamic acid therapy, use:

Review therapy and stop or reduce the dose of tranexamic acid 1 week after bleeding stops. Although therapy is usually stopped 1 week after bleeding stops, if bleeding recurs, therapy may need to be restarted and possibly continued indefinitely. Use oral tranexamic acid with care in patients with haematuria because intravesical clots may develop.