Although this is rare, some conditions may cause a child to bleed excessively at the end of life, this is often referred to as a catastophic bleed. Catastrophic bleeding is arterial blood and may be bright red in colour. It may spurt. This can very distressing for the child and for the family. The family should be adequately prepared to manage the situation, as the child is likely to die quickly. Haemorrhage may present as haemoptysis (coughing up blood), upper gastrointestinal bleeding (vomiting blood) or bleeding from the mouth or nose (mucosal bleed).

The main aim of treatment is to comfort the patient and support the family

Start non-pharmacological interventions

Major haemorrhages might be preceded by smaller bleeds. Be prepared for a major bleed.

• Warn family members of the possibility of a bleed and prepare them for what needs to be done.
• Move the patient to a side ward or private room so as not to distress other patients.
• Have a staff member stay with the patient at all times, if possible, and attempt to comfort and reassure the patient and family.
• Have aprons and gloves ready and dark towels on hand for mopping up and reducing the visual impact of the haemorrhage (dark green or blue or red blankets and towels)
• Apply towels to the bleeding site for pressure and to absorb blood
• Apply gentle suctioning to the mouth and trachea if needed

Prescribe appropriate treatment

In the event of a bleed, the aim of treatment is to sedate the patient to relieve distress from what will be the terminal event of his/her life.

Give medication ideally intravenously or by deep intramuscular injection. Subcutaneous drugs are poorly absorbed when in shock

• Midazolam 500mcg/kg in children IVI or S/L via buccal mucosa. (Use higher doses in patients who are already on benzodiazepines)
• Morphine 100mcg/kg in children IVI or IMI
• Repeat drugs every 10-15 minutes if needed.