Massive haemorrhage in palliative care

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. If someone has a massive haemorrhage, they can deteriorate very quickly. It's important to know who is at risk and what the signs are.

On this page:

What is massive haemorrhage?

A massive (or major) haemorrhage is when a patient loses large amounts of blood. Rarely, a massive haemorrhage from an artery can cause the patient to die. This is called a terminal haemorrhage.

Patients with a terminal illness may lose small amounts of blood. This won't be considered a massive haemorrhage and would not be dealt with as an emergency. But it can sometimes be a warning of a larger bleed. It's important to report any bleeding to the patient's GP, specialist nurse or district nurse.

Patients most at risk of massive haemorrhage

Massive haemorrhage is more common in patients with advanced cancer. It may be caused by:

• the tumour itself, for example if cancer spreads into a blood vessel
• whole-body effects of cancer, such as impaired blood clotting.

Patients with other medical conditions, such as liver disease, may also be at risk of haemorrhage.

Surgery or radiotherapy for head and neck cancers increase the risk of bleeding.

Some medications can also increase the risk, including:

• non-steroidal anti-inflammatory drugs (NSAIDs)
• steroids, such as dexamethasone
• anticoagulants (medicines that help stop the blood clotting) including warfarin and low-molecular weight heparin.

Signs and symptoms of massive haemorrhage

Signs of bleeding include:

• haemoptysis (coughing up blood)
• haematemesis (vomiting blood)
• melaena (dark, tarry faeces caused by bleeding in the stomach or small intestine)
• haematuria (blood in the urine)
• bleeding from ulcers, tumours or wounds on the skin.

Sometimes bleeding is internal. The patient may have symptoms of shock or a rapid loss of consciousness with no apparent source of bleeding.

Care for patients at risk of massive haemorrhage

The healthcare team will decide whether the patient and those close to them should be aware of the risk of haemorrhage. If they decide they should be aware of the risk, the patient's GP, specialist nurse or district nurse should sensitively explain to them what might happen.

Advance care planning

A doctor or nurse should discuss resuscitation with the patient and those important to them. The patient's wishes will be documented in their care plan. Some patients may have recorded their wishes using a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form. This summarises how they would like to be cared for in an emergency, including whether they would like to be resuscitated. The ReSPECT process is currently being rolled out across the UK.

Find out more about the ReSPECT process.  

If a patient wants to refuse certain treatments in an emergency, they may record this in an Advance Decision to Refuse Treatment (ADRT) . This is sometimes called a living will. In Scotland, it's called an Advance Directive.

If a patient doesn't want CPR if they have a cardiorespiratory arrest, this can be recorded in a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form.

Read more about advance care planning.

Helping patients at risk of massive haemorrhage

If haemorrhage is likely, there are things you can do to make it less distressing for the patient and those involved in their care:

• Be aware of what interventions the patient would and would not want if they have a bleed.
• A doctor or specialist nurse may prescribe anticipatory medicine to sedate the patient, which will be used to reduce their distress if they have a bleed. Be aware of whether they've prescribed anticipatory medicine. Know where it is and who to call if it's needed. 
• Make sure they have some dark coloured towels, to help make the bleeding look less dramatic.
• Make sure they know who to call for help.
• Make sure you have a supply of plastic aprons, gloves, and clinical waste bags in case they're needed to clean up.

If a patient has a massive haemorrhage

If a patient has a massive haemorrhage, do the following things:

• Call for help immediately.
• Call 999 if the patient wishes to be resuscitated (doesn't have a DNACPR in place).
• If the patient has been prescribed anticipatory medicine and you're qualified to give it, administer sedation. If you're not qualified, call someone who can give it.
• Try to stay calm and reassure the patient and anyone else present.
• Stay with the patient and keep talking to them.
• Put the patient in the recovery position if appropriate.
• If you can, apply pressure to the bleeding point, using dark-coloured towels.

Getting support afterwards

Dealing with a massive haemorrhage can be very distressing for everyone involved. Talk to your manager if you need support afterwards.

You can support the people close to the person by talking about what happened and suggesting they speak to a bereavement counsellor, if appropriate.

Useful resources 

Scottish Palliative Care Guidelines: Bleeding  

Let us know what you think

Email your feedback to knowledgezone@mariecurie.org.uk 

Disclaimer

This information is not intended to replace any training, national or local guidelines, or advice from other health or social care professionals. 

The Palliative Care Knowledge Zone is not intended for use by people living with a terminal illness or their family and friends, who should access our information for the public.

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