Major bleeding in palliative care
Major bleeding in a patient with a life-limiting illness generally happens unexpectedly. This makes warning the patient’s family problematic, because doing so generates fear about something that may not happen. Discussion of how emergencies should be managed and the creation of an advance care plan can be of great benefit if a crisis does occur—see Planning for management of bleeding in palliative care.
Management of major bleeding depends on the cause, potential benefits and burdens of each intervention, and the patient’s prognosis, preferences and goals of care—see Emergencies in palliative care. If active intervention for major bleeding in a patient with palliative care needs is clinically appropriate, the patient requires management in a critical care setting (eg emergency department, intensive care unit). Initial emergency management includes:
- considering suitability for intubation
- securing intravenous access
- blood tests to assess for anaemia and coagulopathy
- blood group and cross-match
- haemodynamic support.
If bleeding is catastrophic and apparently a terminal event (eg erosion of a large artery by a tumour), it is unlikely that drug therapy can be administered in time to relieve distress. Remain with the patient to provide psychological support and the comfort of a calm physical presence. This is more important than attempting to give drug therapy.
If drug therapy is used to minimise distress and pain, see the regimens in Drug therapy for catastrophic terminal events in palliative care.