Major haemorrhage

Clinically significant bleeding occurs in 6-10% of patients with advanced cancer, often this may be internal.

The most common primary cancer sites include:

  • Lung
  • Head and neck
  • Upper GI

The risk of bleeding can be affected by other factors such as:

  • Coagulopathy (includes patients on aspirin and NSAIDs, anti-coagulant therapy or intrinsic coagulation problems, such as bone marrow failure)
  • Proximity of the tumour to major blood vessels
  • Presence of fungating or infected wounds

Sometimes patients may be known to be particularly at risk of major haemorrhage because smaller (herald) bleeds have occurred. Smaller bleeds can be palliated using topical adrenaline or tranexamic acid, or haemostatic dressings e.g. CELOX (for further information seek specialist palliative care advice).

Sensitive exploration of the patient and carer’s understanding of the clinical situation and potential risk for significant bleeding may reduce distress by providing a clear plan of action in the event.

It is essential to stay with the patient, as loss of consciousness can happen rapidly. Priority should be to stay and comfort patient and family rather than leaving patient to access drugs. If appropriate to leave patient or second HCP available – consider giving medication as per guidance.

Dark coloured towels may be helpful in disguising the appearance of the blood.

Anticipatory prescribing with an anxiolytic/sedative such as midazolam (IV or IM) is the recommended management in the event of an acute terminal bleed.


Route & onset of effect




IV 2 – 3 minutes


Repeat after 10 minutes if needed

IM 5 – 15 minutes
(preferably deltoid)


Repeat after 10 minutes if needed


Route & onset of effect: IV 2 – 3 minutes
Dose: 10mg
Frequency: Repeat after 10 minutes if needed

– – – – – – – –

Route & onset of effect: IM 5 – 15 minutes (preferably deltoid)
Dose: 10mg
Frequency: Repeat after 10 minutes if needed

The subcutaneous route is inappropriate due to peripheral shut down and unpredictable absorption.

Buccal midazolam can also be used.

If the patient is already on large background doses of midazolam or other benzodiazepines seek specialist palliative care advice if required. Larger doses of benzodiazepine may be required.


This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.