National Institute on Clinical Excellence




Dear Sir/Madam



The Medical Ethics Alliance, a coalition of World Faiths and Hippocratic medical and nursing bodies,  recently held a conference at the RSM on “Natural Death - Is a Pathway Needed”. As a result, there has been a considerable amount of public interest and many individuals have contacted us with examples of very distressing experiences. Please find enclosed just one such which was published in the Sunday Times 12/8/12



 We are often told that the Liverpool Care Pathway  has the approval of NICE. If that is the case,  then we would like to ask the following questions which arise from  actual incidents, or follow from our reading of nationally accepted formularies.



1          How long should a person be without any fluids?

2          How much fluid should be given to avoid thirst?

3          Is there any experimental evidence that moistening the mouth assuages thirst?

4          What effect does dehydration have on the action of  drugs such as morphine,         diamorphine and hyoscine hydrobromide?

5          Are the doses of morphine and diamorphine in the LCP appropriate? Is there         an evidence base for them?

6          Should narcotics or sedatives be prescribed in anticipation of symptoms which       have not  arisen?

7          What are the likely effects of hyoscine hydrobromide and dehydration on the        respiratory tract ? Will they predispose to respiratory infection?

8          Midozolam, does not appear to be licensed for administration by syringe    driver, is there evidence based research for its use in this way?

9          Halopridol is not licensed for syringe drivers either. What is the scientific   evidence that it is safe to administer in this way?


Finally, and most importantly;

10        Is there any agency collecting reports of adverse reactions to the LCP and will       it   publishing its findings?



In view of the public interest being expressed on these matters, and the adverse effects to the LCP which are coming to our attention, we are posting this letter on our website.



Yours sincerely



Dr Anthony Cole