Introduction Catastrophic haemorrhage is a rare palliative care emergency that can profoundly impact patients and carers. When caring for at-risk patients, particularly those receiving community care, there are ethical and practical challenges. It should be recognised that: terminal bleeding may not materialise; if bleeding occurs the burden of care often falls on carers, including administering anxiolytics; anxiolytics can unintentionally cause respiratory depression.

Expert opinion in the form of guidelines is available to help specialists navigate challenges, though little evidence exists.

Methods Recommendations from E.Ubogagu and DG.Harris’ guidelines (2018) were collated into eight best practice criteria: (1) an MDT approach, (2) recognising and assessing bleeding risk, (3) risk mitigation (4) considering social circumstances, (5) anxiolytic prescribing decisions, (6) sensitively explaining bleeding risk, (7) introducing crisis-packs and (8) preparing carers. DG.Harris and SIR.Noble’s systematic review (2009) reports midazolam is most established, despite variations in anxiolytic prescribing. At Royal Oldham Hospital (ROH) buccal midazolam is preferred.

At-risk patients, with malignant and non-malignant disease, were identified from ROH palliative care records for referred patients who died March-September 2023. Their documented bleeding risk assessment and management was compared against best practice criteria.

Results ROH at-risk patients accounted for 5.6% of all patients, with those receiving community care accounting for 2.8% (n=9). On average, 29.9% of criteria were met. Highest performing criteria were recognising and assessing bleeding risk (77.8%) and risk mitigation (72.2%). There were no discussions to explain bleeding risk nor prepare carers. Two patients received intramuscular midazolam (11.1%), but no buccal midazolam was prescribed.

Conclusions A pilot project aims to improve practice by creating a new hospital Standard Operating Procedure that includes: (a) a flowchart to assess and mitigate bleeding risk, consider social circumstances and buccal midazolam; (b) advice on explaining bleeding risk; and (c) an ABCDE algorithm and information leaflets to prepare carers.