Bleeding is a distressing, complex, and relatively common symptom in palliative care. It can present at many anatomical sites and vary in acuity and presentation.
Clinicians need to consider goals of care and prognosis in bleeding assessment, as these factors can impose the degree of investigation and intervention. Some imminently dying patients may not benefit from diagnostic workup or intervention even if the bleeding is profuse, while more stable patients can benefit from investigations if they would prevent a terminal bleed or symptom burden.
Clinicians should also be aware of what testing and interventions can be done in the current environment, as many patients may want to avoid being transferred. A complete blood count (CBC) or serum international normalized ratio (INR) of prothrombin time often can be done at home.
- Apply pressure, if anatomically possible, with an appropriate gauze or dressing.
- Identify agents that can cause or exacerbate bleeding: enoxaparin, oral anticoagulants, aspirin, NSAIDs, chemotherapeutics, fish oil, omega fatty acids, ginseng, and ginkgo biloba.
- Vitamin K: for patients on warfarin or with clotting factor deficiencies
- Transfusions: platelet, fresh frozen plasma, clotting factor concentrate, red blood cell transfusions
Local site management — some interventions are suggested for bleeding in specific anatomical sites:
- head and neck
- respiratory tract
- urinary tract
- gastrointestinal tract
See reference for more information.
All interventions must be considered in the context of the treatment burden and the duration of recovery from treatment, especially when life-expectancy is limited.
Adapted from Liao P, Johnstone C, Rich ER. Palliative Care Network of Wisconsin. Fast facts and concepts #341. Bleeding management in hospice settings. Internet. Accessed on January 5, 2018.