The ABC of terminal hemorrhage management

By Sarah Guy, medwireNews Reporter

To best cope with terminal hemorrhage, at-risk patients should be identified by healthcare professionals while their families and caregivers are prepared, supported, and instructed to assure, be there for, and calm and comfort the patient as the event occurs, say researchers.

This three-step approach to managing this "rare yet highly feared" complication of advanced cancer gives professionals a logical framework within which to work, they add, in the BMJ Supportive and Palliative Care.

The authors note that the potential for terminal hemorrhage to occur in the home is increasing as more patients request to be discharged home for terminal care and, therefore, management in this setting requires specific consideration.

Edith Ubogagu (St Raphael's Hospice, Cheam, Surrey, UK) and Dylan Harris (Prince Charles Hospital, Cwm Taf, UK) searched electronic databases for guidelines on the management of terminal hemorrhage, and identified 12 relevant articles to assist with the development of their algorithm.

All patients in the studies identified had Do Not Resuscitate orders in place and wished to die at home.

While the researchers found that incidence of terminal hemorrhage varied by cancer type, it was highest among head and neck cancer patients - particularly those who had undergone radiotherapy - and among those with hematologic malignancies.

The first step of the proposed algorithm involves identifying patients at risk for bleeding, and discussing the possibility of such events with the patient and their family/caregivers without raising undue alarm.

Usual management strategies documented in the existing research included supportive care alongside pharmacotherapy for symptom control (such as sedatives and/or anxiolytics), speaking reassuringly to the patient while accepting the limits of the situation (ie, presumed fatality and limited time available), as well as practical measures such as using dark towels to disguise large volumes of blood.

Ubogagu and Harris included these measures as a second step in the algorithm: devising the "ABC" of assurance, being there, and calming/comforting the patient as a priority.

"The ABC aide memoire aims to simplify the processes involved and defuse some of the anxiety associated with the situation," they write.

The final step of the management algorithm includes supportive measures needed after the event, with all individuals involved offered support, including "postevent debriefing and counselling."

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