Terminal hemorrhage is defined as a major hemorrhage that is likely to rapidly result in a patient’s death due to a massive loss of circulating volume.
Patients with head and neck cancers have the highest incidence, as carotid rupture can occur in 3-4%. Other common presentations are: hemoptysis in cancer or cystic fibrosis, gastrointestinal bleeding in liver disease, and vaginal bleeding in cervical or uterine cancer.

Etiologies are local tumor erosion, thrombocytopenia, or a combination of both.
Impending arterial rupture sometimes may be identified by the presence of a ballooning or visible pulsation in arterial vasculature, and/or by minor bleeding occurring 24-48 hours before a major arterial bleed. However, in most cases, terminal hemorrhage events do not occur even in at-risk patients. So, when preparing patients and/or families of the possibility of a terminal hemorrhage, it is important to discuss the rarity of the event.

Initial measures
Identification of the source of bleed; applying pressure to the source if appropriate; using dark towels to camouflage bleeding. Pharmacologic management may be useful in slower bleeds, but it should not detract from non-pharmacologic approaches; patients bled out so quickly that pharmacology had no impact on comfort.

Preparation for the event
- Identify “at-risk” patients: those with a herald bleed, head and neck cancers, hematological cancers, or tumors inclosing major vessels.
- Address modifiable risk factors by stopping anticoagulants, NSAIDs, and aspirin. Consider – if available, possible, and consistent with goals – the use of platelet transfusions, Vitamin K, FFP, radiation, embolization, or coiling to limit the risk of bleeding.
- Prepare a plan of what to expect with regards to prognosis and symptoms when hemorrhage occurs, who to contact, and whether life support will be pursued. Communicate the plan to the patient, caregivers, and health care providers.
- Prepare a “crisis pack” containing:
• sedatives and analgesics, pre-drawn and at bedside for rapid palliation of dyspnea or pain
• large dark towels, a dark basin, and gloves.
• a suction device (typically only beneficial when patients are choking or aspirating blood)
• warm blankets, as ensuring hypotension causes patients to be cold
• a facecloth to clean the patient's face and mouth.
• bags for the disposal of waste and blood-stained materials

Managing the event
Reassure the patient that a care provider is always present. Control symptoms when possible using pre-drawn “crisis” medications. Consider positioning family members so that they can be in close physical contact with the patient but not in direct visual view of the bleed.

See reference for more information.

Adapted from Akinola O, Baru J, Marks S. Terminal hemorrhage preparation and management. Palliative Care Network of Wisconsin. Fast facts and concepts #297. Internet. Accessed on December 27, 2018.