Letters Continuous deep sedation

Good care at the end of life, not hastening death

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39577.425544.3A (Published 15 May 2008) Cite this as: BMJ 2008;336:1085
  1. Lulu Kreeger, consultant palliative medicine
  1. 1Kingston Hospital NHS Trust and Princess Alice Hospice, Esher KT10 8NA
  1. luluk{at}globalnet.co.uk

Treloar misunderstands the fundamental premise of the Liverpool care pathway (LCP).1 A patient is put on the pathway only once it is recognised they are dying imminently, within hours to a few days.2 The evidence does not support that artificial hydration or nutrition has a role to ease symptoms and suffering and may, in fact, add to it.3

Deep sedation is not recommended as part of the Liverpool care pathway and is not usual practice in UK palliative care teaching. Sedation can be a feature of symptom management but is not the prime aim. Morphine will be used to treat pain or breathlessness, glycopyrronium to treat bubbly secretions, haloperidol to treat nausea or agitation and delirium, midazolam to treat distress, etc. Most patients do not need large doses of these medications to achieve the necessary symptom control. In a study from St Christopher’s Hospice, dose increases in sedative medication at the end of life were not associated with a shortened survival.4

The key assessment is the identification of dying. The focus of care is then clarified, and the pathway provides a structured format to achieve this. It is unhelpful to raise concerns about hastening death by deep sedation or denying hydration and only fuels misunderstanding and fear. The introduction of the pathway must be supported by a comprehensive teaching programme, and the structure of the tool supports regular evaluation and audit.

The pathway is not a fait accompli to dying and occasionally patients get better and come off the pathway. In the acute general hospital I work in, where we have supported over 300 patients on the LCP, this has occurred on 14 occasions.

This is an essential time to be effective clinicians. Poor experiences of dying will resonate in relatives’ memories. The Liverpool care pathway supports clinicians to get it right.


  • Competing interests: None declared.


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