Haemorrhage (also spelled hemorrhage) refers to profuse or excessive bleeding — the escape of blood from a ruptured blood vessel. In palliative care, haemorrhage is one of the most visually and emotionally distressing emergencies for patients, families, and health workers.

While haemorrhage occurs in around 20% of patients with advanced cancer, it contributes to death in only about 5% of cases. However, the fear and trauma it causes can be overwhelming, even when the bleeding is not immediately fatal.

Understanding why bleeding occurs helps nurses anticipate, prevent, and respond appropriately.

This is the most common cause of severe bleeding in advanced cancer.

Example: A patient with advanced cancer of the tongue may have a tumor eroding into the lingual artery. A minor cough or movement can trigger sudden, massive bleeding.

Example: A fungating breast tumor with secondary infection may bleed profusely when the necrotic center sloughs off.

Palliative care patients may have conditions that impair their blood's physiological ability to clot (the coagulation cascade):

Nursing implication: Always review the patient's medication list for drugs that increase bleeding risk. These should be stopped or reduced if bleeding is anticipated or occurring.

When bleeding occurs, assessment must be swift and focused to determine the stage of hypovolemic shock:

The best management of haemorrhage is prevention. Many bleeds can be anticipated and minimized through proactive clinical management.

• Stop or reduce anticoagulants: If bleeding risk is high, warfarin should be stopped or maintained at the lowest effective dose. Consult the prescribing doctor.
• Discontinue NSAIDs: If not essential for pain control, stop ibuprofen, diclofenac, aspirin. Use paracetamol or morphine instead to protect gastric mucosa and platelet function.
• Review all medications: Any drug that affects clotting or irritates the gut should be reconsidered.
• Replace essential medicines safely: If NSAIDs are stopped, ensure alternative pain relief (morphine) is available.

Radiotherapy physically damages the DNA of tumor endothelial cells, leading to fibrosis (scarring) and sclerosis (hardening/shrinking) of blood vessels, making bleeding much less likely.

Nursing role: Identify patients at risk, advocate for referral, and explain to families why radiotherapy is recommended.

• Mechanism: TXA is an antifibrinolytic. It prevents the breakdown of blood clots by binding to and inhibiting plasmin (the enzyme that normally dissolves fibrin clots).
• Use: For patients with a history of smaller bleeds or high bleeding risk.
• Dose: 0.5g to 1g orally, two to three times daily (bd or tds).
• Availability: May not be readily available in all Ugandan settings; advocacy for essential drug access is key.

• Gauze soaked in adrenaline (1ml): Apply firm pressure to the bleeding tumor surface. Adrenaline acts on Alpha-1 adrenergic receptors to cause intense, immediate vasoconstriction (narrowing of blood vessels), drastically reducing blood flow.
• Crushed tranexamic acid applied topically: Mix a tranexamic acid tablet powder with water to form a paste; apply directly to the bleeding surface to stop local clot breakdown.
• Pressure dressings: Firm, continuous pressure with gauze and bandage to artificially close the vessel until a clot forms.
• Surgical ligation: For isolated bleeding vessels, a surgeon may tie off the vessel. (Rarely possible or appropriate in end-stage palliative care).

When severe bleeding is expected (e.g., carotid artery erosion in head and neck cancer), proactive psychological and practical preparation is absolutely essential:

• Counsel the family: Explain that catastrophic bleeding may occur. Describe exactly what it will look like and what they should do.
• Keep dark towels nearby: Blood appears much larger in volume and highly alarming on white or pale surfaces. Dark green or black towels absorb the blood and heavily reduce the visual shock.
• Have sedation available: Diazepam 10mg orally or rectally, ready to give immediately to reduce patient terror.
• Have morphine available: For pain, air hunger, and distress.
• Ensure phone access: The family must be able to call the palliative care team for help immediately.
• Rehearse the plan: Walk through what will happen step-by-step so the family relies on muscle memory and is not caught completely unprepared in a panic.

• Position: Sit the patient upright or lying on the side of the bleeding lung (if known). Physiology: Gravity keeps the blood pooled in the diseased lung, preventing it from spilling into and drowning the healthy lung!
• Calm the patient: Coughing spikes intrathoracic pressure, pushing more blood out. Reassurance reduces the urge to cough.
• Give morphine: Directly suppresses the medullary cough reflex and massively reduces air hunger and distress.
• Apply ice pack: To chest wall over the bleeding site (if known) — cold causes reflex vasoconstriction.
• Suction: Only if blood pools in the upper airway and causes choking.

• Position: Left lateral position (lying on the left side) with the head slightly down. Physiology: Prevents catastrophic aspiration of vomited blood into the trachea/lungs.
• Nil by mouth: Do not give oral fluids or medicines until bleeding is controlled; the stomach needs to rest.
• IV access: If available, for volume resuscitation and IV medications.
• Give proton pump inhibitor: Omeprazole or pantoprazole IV. Reduces stomach acid, creating a neutral pH that promotes stable clot formation.
• Give tranexamic acid: IV or oral if available.
• Monitor for shock: Rapid pulse, falling BP, cold clammy skin.

• Position: Lie on the side with knees drawn up to the chest (fetal position) to reduce abdominal pressure.
• Apply direct pressure: With a gauze pad tightly to the anus if bleeding is external/low.
• Consider rectal tranexamic acid: If available.
• Monitor for shock: Rectal bleeding is extremely dangerous because a massive volume of blood can be hidden inside the colon before it passes.

• Monitor urine output: Blood clots rapidly inside the bladder, blocking the urethra and causing agonizing urinary retention.
• Irrigate catheter: If catheterized, gentle continuous irrigation with sterile saline dislodges clots and keeps the bladder empty.
• Increase fluids: If the patient can drink, oral fluids flush the bladder naturally.

• Apply direct pressure: With gauze soaked in adrenaline (1ml) or crushed tranexamic acid paste.
• Elevate if possible: Let gravity pull blood away from the extremity.
• Apply pressure dressing: Firm bandage over gauze.
• Do not disturb: Once bleeding is controlled, LEAVE THE DRESSING IN PLACE. Peeling it back to "check" will rip off the fragile new platelet plug and restart the bleed.

Children with haematological malignancies (leukaemia, lymphoma) are at massive risk of bleeding due to profound thrombocytopenia and clotting abnormalities. Physiologically, children have a much smaller total blood volume, meaning they decompensate and go into shock much faster than adults.

• Aim for rapid and complete sedation: Using benzodiazepines and/or opioids through parenteral routes (IV or IM) if available.
• If the child can swallow (e.g., severe epistaxis/nosebleeds): Give double the usual dose of morphine, with or without diazepam, as prescribed. This combination aggressively manages the severe pain and acute panic.
• If the child cannot swallow: Give large doses of morphine and diazepam rectally (the rectal mucosa absorbs drugs very rapidly).

• Weight unknown: 5mg for children below 3 years; up to 10mg for children older than 3 years.
• Weight known: 0.5 – 1mg/kg (maximum 10mg).

Nursing implication: Bleeding in children is uniquely distressing. The nurse must balance rapid sedation with strict monitoring for respiratory depression. Always have Naloxone (opioid antagonist) drawn up and available if high-dose opioids are used.

• Family witnesses catastrophic bleeding: Shield them if possible, but do not force them to leave the room if they want to stay with their dying loved one. Prepare them: "There may be a lot of blood. This is what we expect."
• Family panics: Assign one specific staff member to support the family exclusively. Lead them to a quiet area if needed.
• Family wants to help: Give them a meaningful, specific task to ground them: "Please hold her hand" or "Please pray with her."
• After the bleed (survived or died): Debrief immediately. Ask how they are feeling. Explain exactly what happened medically to remove mystery and guilt. Offer ongoing bereavement support.

• Witnessing catastrophic bleeding is highly traumatic. Nurses may experience PTSD symptoms: Nightmares, avoidance of similar patients, guilt ("I should have done more"), or emotional numbness.
• Self-care protocols: Debrief with colleagues after the event. Talk to a counselor or clinical supervisor. Recognize that some tumor bleeds are anatomically impossible to stop — this is not your failure as a nurse. Remember: your calm presence was your greatest medical contribution.

Accurate documentation is legally and clinically essential after a haemorrhage.

• Time bleeding started: Exact time.
• Source and type: Where from; capillary (ooze), venous (flow), or arterial (spurting).
• Estimated volume: Small, moderate, large, massive (quantify in mL if possible, or by number of soaked pads/towels).
• Patient's condition: Consciousness, vital signs, skin colour.
• Interventions: Pressure applied, medications given (dose/route), positioning, dressings applied.
• Response & Outcome: Did bleeding slow or stop? Did the patient die, stabilize, or require transfer?
• Family presence: Who was present; how they coped; support/counseling provided.

• Define haemorrhage and explain why it is a palliative care emergency.
• List the four main causes of bleeding in palliative care (vessel erosion, infection, bleeding disorders, medications).
• Explain how tumors cause bleeding by eroding into blood vessels.
• Describe why thrombocytopenia is common in palliative care patients (bone marrow infiltration, HIV, chemotherapy).
• List medications that increase bleeding risk and explain nursing actions (review, stop, replace).
• Explain the role of prophylactic radiotherapy in preventing bleeding from specific tumors.
• Describe the use of tranexamic acid — dose, route, and when to use it.
• Explain local measures for surface bleeding (adrenaline-soaked gauze, crushed tranexamic acid, pressure).
• Describe the management of catastrophic bleeding — dark towels, sedation, positioning, family support.
• Discuss why the patient should never be left alone during a bleed.
• Explain sedation for catastrophic bleeding — diazepam dose, route, purpose, and limitations.
• Describe management of haemorrhage in children — sedation, morphine dosing, rectal diazepam.
• Discuss psychological support for patient, family, and nurse after a bleeding event.
• Address the Ugandan context — availability of tranexamic acid, radiotherapy access, and family-centered home care.

• Ferrell, B. R., & Coyle, N. (Eds.). Oxford Textbook of Palliative Nursing. Oxford University Press.
• World Health Organization (WHO). Planning and Implementing Palliative Care Services: A Guide for Programme Managers.
• African Palliative Care Association (APCA). Guidelines for Providing Palliative Care to Persons with Advanced Disease in Africa.
• National Institute for Health and Care Excellence (NICE). Palliative Care Guidelines: Management of Bleeding.