BMJ Support Palliat Care 2:294-300 doi:10.1136/bmjspcare-2012-000253
  • Features

Guideline for the management of terminal haemorrhage in palliative care patients with advanced cancer discharged home for end-of-life care

  1. Dylan G Harris2
  1. 1St Raphael's Hospice, Cheam, Sutton, Surrey
  2. 2Palliative Care Department, Prince Charles Hospital, Merthyr Tydfil, Cwm Taf, UK
  1. Correspondence to Edith Ubogagu, St Raphael's Hospice, Heam, Surrey, UK eau00{at}
  1. Contributors EU formulated the idea, algorithm and aide memoire, compiled the guidelines and wrote the drafts. DGH edited the drafts.


Objective Terminal haemorrhage is a rare and distressing emergency in palliative oncology. We present an algorithm for the management of terminal haemorrhage in patients likely to receive end-of-life care at home, based on a literature review of the management of terminal haemorrhage for patients with advanced cancer, where a DNAR (do not attempt resuscitation) order is in place and the patient wishes to die at home.

Method A literature review was conducted to identify literature on the management of terminal haemorrhage in patients with advanced cancer who are no longer amenable to active interventional/invasive procedures. Electronic databases, the grey literature, local guidelines from hospitals and hospices, and online web portals were all searched systematically. The literature review was used to formulate a management algorithm.

Results The evidence base is very limited. A three-step practical algorithm is suggested: preparing for the event, managing the event (‘ABC’) and ‘aftercare’. Step 1 involves the identification and optimisation of risk factors. Step 2 (the event) consists of A (assure and re-assure the patient), B (be there – above all stay with the patient) and C (comfort, calm, consider dark towels and anxiolytics if possible). Step 3 (the aftercare) involves the provision of practical and psychological support to those involved including relatives and professionals.

Conclusion Terminal haemorrhage is a rare yet highly feared complication of advanced cancer, for which there is a limited evidence base to guide management. The suggested three-step approach to managing this situation gives professionals a logical framework within which to work.


  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed

  • Received 22 March 2012.
  • Accepted 17 July 2012.
  • Published Online First 4 September 2012

Free sample issue
This recent issue is  free  to all users to allow everyone the opportunity to see the full scope and typical content of BMJ Supportive & Palliative Care.

View free sample issue >>

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.

Navigate This Article