Bleeding episodes in hospice care can be distressing for patients, families, and caregivers, making it important to balance effective symptom management with the patient’s established goals of care. In the hospice setting, the focus is generally on comfort, dignity, and minimizing burden, rather than pursuing invasive measures solely to achieve definitive hemostasis.

Management should therefore begin with simple, least-invasive interventions that can provide meaningful symptom relief while avoiding unnecessary pain, distress, or hospitalization. When bleeding becomes refractory or life-threatening, decisions regarding escalation should be individualized through shared decision-making and guided by the patient’s wishes, prognosis, and overall goals of care.

A Stepwise Approach to Nosebleeds in Hospice

The following stepwise treatment approach may be considered:

Step 1: Review antithrombotic therapy:

Consider whether continued anticoagulant or antiplatelet therapy remains consistent with the patient’s goals of care, as benefits may diminish near the end of life while bleeding risk, falls, functional decline, and pill burden increase.

Step 2: Direct nasal compression:

Apply gentle, sustained pressure to the soft portion of the nose against the septum, with the head flexed slightly forward, for about 15 minutes.

Step 3: Topical vasoconstrictors:

Consider oxymetazoline spray (65-75% of patients achieve resolution) for ongoing bleeding, 3 times daily for up to 3 days, with caution in patients with significant cardiovascular conditions.

Step 4: Cautery:

If a bleeding site is clearly identified, consider silver nitrate applied topically twice daily as needed for bleeding after using oxymetazoline spray.

Step 5: Nasal packing:

If bleeding persists, resorbable, low-pressure, self-lubricating packing (rather than non-resorbable packing) may help control bleeding while minimizing discomfort and trauma, particularly in patients with coagulopathy or those receiving antithrombotic therapy.

Alternative Options:

Sucralfate (Carafate®): Binds electrostatically to exposed protein at the ulcerated or eroded mucosal surface, forming an adherent protective coating over the bleeding or raw area.

Use: Sucralfate 1 g tablets and K-Y Jelly. Crush 1 tablet into 5 mL of K-Y Jelly, place on gauze, and apply to coat the nasal mucosa 4 times daily as needed for bleeding.

Tranexamic acid (TXA): An antifibrinolytic that stabilizes clots by competitively inhibiting plasminogen-fibrin binding, and in epistaxis it is best used as an adjunct to standard measures (direct pressure, vasoconstrictors, cautery, packing) rather than a replacement.

Use: Tranexamic acid injection 100 mg/mL. Soak a cotton pledget or gauze/sponge in the solution and place it in the bleeding nostril. Leave in place for approximately 10 to 15 minutes, then reassess and remove once bleeding is controlled.

Step 6: After bleeding is resolved, consider moisturization:

Options: Nasal saline gels/sprays, humidification, and nasal lubricants/emollients (petroleum jelly) may help maintain moisture and reduce recurrent bleeding. For patients using supplemental oxygen, choose a water-based nasal gel instead of petroleum jelly or other petroleum-based products, which are a fire hazard around oxygen.

Avoid burdensome escalation: Base hospitalization, invasive procedures, transfusions, or other aggressive interventions on the patient’s goals, expected benefit, comfort, and overall treatment burden.

In Summary:

Nosebleeds in hospice are best managed with a stepwise, comfort-focused approach that matches the intensity of treatment to the patient’s goals of care. Review whether anticoagulant or antiplatelet therapy still fits those goals, and use direct nasal compression, topical oxymetazoline, cautery of a clearly identified bleeding site, and resorbable nasal packing as needed. Topical sucralfate and tranexamic acid offer additional options, and once bleeding has resolved, keeping the nasal mucosa moist can help reduce recurrence.

At every step, hospitalization, invasive procedures, and transfusions should be weighed against expected benefit, comfort, and overall treatment burden, with decisions guided by the patient’s wishes and prognosis. A calm, prepared, and individualized plan helps keep care at the bedside whenever possible while preserving the patient’s comfort and dignity.

References:

1. Seikaly H. Epistaxis. N Engl J Med. 2021;384(10):944-951.
2. Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020;162(1_suppl):S1-S38.
3. Siupsinskiene N, Žekonienė J, Padervinskis E, Žekonis G, Vaitkus S. Efficacy of sucralfate for the treatment of post-tonsillectomy symptoms. Eur Arch Otorhinolaryngol. 2015;272(2):271-278.
4. Hewett Brumberg EK, Douma MJ, Alibertis K, et al. 2024 American Heart Association and American Red Cross Guidelines for First Aid. Circulation. 2024;150(24):e519-e579.
5. Joseph J, Martinez-Devesa P, Bellorini J, Burton MJ. Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst Rev. 2018;12(12):CD004328.

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