Catastrophic Haemorrhage — Palliative EmergencyAnticipate & plan · crisis midazolam (NOT subcutaneous) · stay with the patient · dark towels · debrief afterwards · GMEC Palliative / PCF8
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A terminal bleed is often a dying event. The harm is minimised by anticipatory planning. In the moment, presence and comfort matter more than drugs — but have crisis midazolam ready (IV/IM/buccal, never SC in a major bleed).StartDecisionInvestigateActionReferStop / Admit
StartPatient at risk of catastrophic haemorrhage
E.g. head & neck or lung tumour eroding a vessel, fungating tumour, oesophageal varices, advanced haematological disease, severe thrombocytopenia. Bleeding may be frank or occult.
Decision · is it happening now?Active catastrophic bleed?
Advance care plan; review anticoagulation; consider tranexamic acid; dark towels at bedside; crisis meds prescribed; brief family/team.
Bleeding now
CrisisStay · comfort · midazolam
Do NOT leave the patient. Apply dark towels, position safely. Midazolam 10mg IV/IM/buccal if distressed and in last hours. Most lose consciousness rapidly.
after the event
AfterwardsDebrief & support
Support and debrief family & team (may be ongoing); dispose of clinical waste; document; review the wider plan.
⚠️ The subcutaneous route is unreliable in a major bleed (peripheral shutdown) — use IV, IM, buccal or sublingual midazolam. If the patient is clearly dying and bleeding massively, presence and comfort matter more than drugs.
1
Safety
Identify Patients at Risk — Anticipate
Catastrophic haemorrhage can be terrifying for patients and carers — much of the harm is mitigated by good anticipatory planning. It may be a terminal event in both advanced cancer and non-malignant disease.
High-risk situations Head & neck or central lung tumours near great vessels, fungating/eroding tumours, oesophageal varices, severe thrombocytopenia, advanced haematological malignancy.
Surface vs internal Eroding skin/fungating tumour, carotid blow-out, major haemoptysis, massive haematemesis/variceal bleed, GI/rectal/vaginal/urinary tract.
Anticoagulation Patients on DOAC/warfarin/antiplatelets or with hepatic failure (coagulopathy) carry added risk — flag early.
Flag it in the record Make the risk visible to the whole team (GP, DN, OOH, hospice) so the plan is in place before any bleed.
Recognising who is at risk lets the team plan ahead — agreeing goals of care, siting crisis medication, and preparing families — so that if a bleed occurs the response is calm and comforting rather than chaotic. Most of the achievable benefit in a terminal bleed is banked before it happens, which is why identification is step one.
2
Recognise
The Sentinel (Herald) Bleed & Types of Bleeding
Sentinel bleed
A smaller “herald” bleed (e.g. a streak of haemoptysis, oozing from a fungating tumour, a small variceal bleed) may precede a catastrophic one by hours to days — treat it as a trigger to finalise the crisis plan, site medication, and brief the family.
Types of bleed
Haemoptysis, haematemesis, melaena, rectal/vaginal bleeding, haematuria, surface/fungating bleeding, epistaxis, variceal bleeding — each shapes positioning and which crisis route is realistic.
Signs in the moment
Visible massive bleeding, hypotension, cool/clammy peripheries, air hunger, anxiety and a sense of impending doom.
Reversible & treatable?
Early on, ask whether the bleed is amenable to treatment (radiotherapy for haemoptysis, endoscopy/banding for varices, palliative radiotherapy or topical measures for fungating tumours) — or whether the plan is purely comfort-focused.
The herald bleed is the single most useful clinical warning available: it converts an abstract “at risk” into an imminent event and is the cue to move from contingency to a fully-prepared plan. Naming the bleeding type matters because it determines safe positioning and whether an oral/buccal route will work or be overwhelmed by blood.
3
Plan
Goals of Care & Ceiling of Treatment
Honest conversation
Where appropriate, discuss the risk and likely course sensitively, in advance, with the patient and those close to them — many value knowing a plan exists. Tailor how much detail to the individual.
Agree the ceiling
Decide and record whether the plan is active (admission, transfusion, intervention) or comfort-focused at home/hospice. Most catastrophic terminal bleeds are not survivable, so comfort is usually the realistic goal.
Resuscitation status
Ensure a DNACPR decision and any ReSPECT/advance care plan are completed and accessible — CPR is futile and undignified in a terminal bleed.
Document & share
Place the plan where OOH, ambulance, DN and hospice can all see it (special patient note / EPaCCS) so no one initiates unwanted escalation.
Without a documented, shared ceiling of care, a frightened carer dials 999 and the patient dies in transit or undergoing futile resuscitation — the opposite of what was wanted. Agreeing and recording the goal in advance is what makes a comfort-focused death at the preferred place of care actually achievable.
4
Treat
Anticipatory Management (Before Any Bleed)
Review anticoagulation
Consider stopping anticoagulant/antiplatelet medication. Consider whether tranexamic acid is indicated for recurrent smaller bleeds (oral/topical) — stop it if it is not helping.
Anticipatory anxiolytic: midazolam 5–10 mg IV / IM / buccal / sublingual. Ensure it is prescribed and physically available where the patient is, with a clear crisis instruction.
Practical measures
Place dark-coloured (green/blue) towels at the bedside to disguise blood loss and reduce distress; keep gloves and waste bags to hand.
Community patients
Ensure a just-in-case box is in the home and the DN/OOH teams know the plan. Consider training a competent family member in buccal/sublingual midazolam — but not if a large amount of blood is likely to come from the mouth.
Anticipatory prescribing and simple measures (dark towels, a written plan, a just-in-case box) transform the experience of a terminal bleed. Stopping anticoagulation and using tranexamic acid where appropriate can reduce the chance or severity of bleeding in the first place.
5
Treat
During a Catastrophic Bleed — Stay & Comfort
First & always
Do not leave the patient
Stay with them; calm reassurance. A second person summons help and supports the family.
Position
Protect the airway
Lie towards the bleeding side in haemoptysis; recovery/upright position for haematemesis. Apply dark towels to absorb and conceal.
Massive bleed, clearly dying
Comfort over drugs
Presence and non-pharmacological care matter more than cannulating — consciousness is usually lost within minutes.
In a true catastrophic bleed, death often comes within minutes and the patient loses consciousness quickly; chasing a cannula or a perfect drug dose can mean the patient dies alone. Presence, positioning and dark towels are the priority.
6
Treat
Crisis Sedation — Midazolam (Route Matters)
Indication
Give only if the patient is distressed/frightened and conscious enough to benefit — it relieves anxiety, it does not stop the bleed.
Dose
Midazolam 10 mg (5–10 mg) stat; may repeat once if distress persists and the patient is still responsive.
Route
IV / IM / buccal / sublingual.NOT subcutaneous in a major bleed — peripheral shutdown makes SC absorption unreliable. Buccal/SL only if the mouth is not filling with blood.
If already on a syringe driver
The crisis dose is given as an additional stat bolus by a fast route — do not rely on the driver to act quickly enough.
Midazolam is for distress, given by a route that actually works when the patient is shut down. In shock the subcutaneous route is too slow and erratic to help in the few minutes available, so IV/IM/buccal/SL is specified — and buccal is avoided when blood would wash the drug away. The goal is rapid anxiolysis, not deep sedation the patient will not live long enough to need.
7
Refer
Specialist Palliative Care & Team Coordination
Specialist palliative care
Involve the SPC/hospice team in advance for high-risk patients — for advice on anticipatory prescribing, place-of-care planning, and support during and after the event.
Consider active options early
If treatment is appropriate to the goals: interventional radiology (embolisation), endoscopy/banding for varices, or palliative radiotherapy for haemoptysis/fungating bleeding — discuss before the patient is in extremis.
Community coordination
Brief the district nurses, OOH and ambulance service; ensure the crisis plan, DNACPR and just-in-case meds are all in place and visible.
Out-of-hours handover
Use the special patient note / EPaCCS so any responding clinician knows the plan instantly.
A terminal bleed crosses several teams — GP, district nurses, out-of-hours, ambulance and hospice — and the response is only as good as the weakest link in that chain. Early specialist involvement secures both the technical options (embolisation, radiotherapy) where appropriate and the coordinated, visible plan that prevents an unwanted 999 escalation.
8
Support
Preparing the Family & Carers
What to expect Explain sensitively what a bleed might look like and that the priority is staying with their loved one and keeping them calm — not heroics.
Simple actions Use the dark towels, stay close, talk reassuringly, and call the agreed number (DN/hospice/OOH) — not 999 unless that is the plan.
Buccal midazolam Where a competent carer has been trained, show exactly how/when to give it — but not if heavy oral bleeding is likely.
Permission to step back Reassure carers it is acceptable to be present without “doing” — comfort and company are the most valuable things they can give.
Families who know what may happen and what to do cope far better, both in the moment and in bereavement, than those taken by surprise. Clear, kind preparation — including permission simply to be present — reduces panic, prevents unwanted emergency calls, and lessens the lasting trauma of witnessing a bleed.
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After
Aftercare — Debrief & Support
Support family & team
Offer support and debriefing to family and staff — this may need to be ongoing. Witnessing a terminal bleed is traumatic; consider bereavement follow-up.
Practical
Dispose of clinical waste appropriately; attend to the deceased and the environment with dignity before family return to the bedside.
Document
Record what happened, what was given (drug/dose/route/time) and who was present. Verify death and follow normal after-death processes.
Team learning
A structured debrief helps staff process the event and improves the plan for future high-risk patients.
A catastrophic bleed is one of the most distressing events families and staff witness. Structured debriefing and ongoing support are part of good care — not an optional extra — and help prevent lasting psychological harm.
Educational use only. Based on GMEC Palliative Care Pain & Symptom Control Guidelines (6th ed, April 2025), PCF8 (Palliative Care Formulary), Scottish Palliative Care Guidelines. Follow your local specialist palliative care and anticipatory-prescribing policy.