Intended for healthcare professionals

Rapid response to:


Continuous deep sedation in patients nearing death

BMJ 2008; 336 doi: (Published 10 April 2008) Cite this as: BMJ 2008;336:781

Rapid Response:

Palliative care and sedation: the Liverpool Care Pathway

I have followed the online debate about continuous deep sedation in
patients nearing death with growing concern, for the debate is in danger
of being sidelined by semantics. Dr Adrian Treloar need not have
apologised for using the term ‘continuous deep sedation’ in relation to
the Liverpool Care Pathway (LCP) (1). It matters not whether we discuss
continuous deep sedation or a lesser degree of sedation. Any level of
sedation, even a small dose of morphine in the frail elderly, can result
in dehydration that may prove fatal if left untreated for days.
Unfortunately palliative carers tend to overlook this basic fact. They
prefer to discuss sedation and hydration as separate issues without
linking the two in their minds. In doing so they are in danger of missing
or evading the point, which is that sedation without hydration kills.

Palliative carers try to reassure the worried public by saying that
some patients (in fact a mere 3-5% according to Ellershaw) improve when
placed on the LCP (2). There are always exceptions that prove the rule!
Patients with heart failure that has been made worse by fluid overload may
improve when drips are stopped. Patients who have been made worse by their
medication may improve when the offending drugs are stopped. The lucky few
will recover when placed on the LCP- (providing that someone notices their
improvement and takes them off the pathway in time), but the great
majority will die.

Therefore before putting anyone on the LCP doctors should be
confident of their clinical diagnosis. They should have considered and
tried to treat any reversible factors and they should be capable of
accurately predicting close proximity to inevitable death. But these are
counsels of perfection and doctors are fallible. A recent study has shown
that health care professionals in a hospice setting are wrong 50% of the
time when predicting patient survival (3). Such is the pressure to roll
out the LCP nationwide that many patients, especially the frail elderly,
are at risk of having their lives shortened prematurely. That may suit
economists and politicians with eyes on the balance sheet rather than the
patient, and it may suit those who resent having elderly bed-blockers on
their wards, but it is not good medicine. Poor end of life care undermines
the trust between doctors and their patients.

It is surely time to put the LCP on hold until all the concerns that
have been raised online at and elsewhere (4,5) have
been carefully considered. It is time for those who advocate sedation
without hydration at the end of life to examine their motives. It is time
for the medical profession to take collective responsibility for end of
life care, for this topic is far too important to be left to palliative
carers and the Department of Health. We must not allow ourselves to be
driven by individuals or organisations with vested interests or by quasi-
governmental committees meeting behind closed doors. It is time to say
enough is enough!

Yours truly,

Dr Gillian M Craig.

E mail:

References and notes.

1. Adrian J. Treloar . LCP concerns:-clarifications and an apology.
(6 May 2008) accessed

2. John E. Ellershaw . Re: Continuous deep sedation in the UK-Dutch
research reflects problems with the Liverpool Care Pathway. (4 May 2008)
http:/www as above.

3. Feargal Twomey, O’Leary N, O’Brien T. Prediction of patient
survival by healthcare professionals in a specialist palliative care
inpatient unit: a prospective study. American Journal of Hospice Care, Vol
25 No 2. April/May 2008, p139-145. DOI:10.1177/1049909107312594

4. Gillian Craig. Palliative care in overdrive: patients in danger.
American Journal of Hospice and Palliative Care, Volume 25 No 2, April/May
2008, p 155-160. DOI:10.1177/1049909107312596

5. For a decade of debate about sedation without hydration see Craig
GM (Ed) “No Water-No Life: Hydration in the Dying”. Fairway Folio 2005.
ISBN 0 9545445 3 6. Available from Medical Ethics Books PO Box 341
Northampton NN3 2WZ. E mail

Competing interests:
None declared

Competing interests: No competing interests

19 May 2008
Gillian M Craig
Vice Chair Medical Ethics Alliance
a retired Consultant Geriatrician