Medical Ethics Alliance

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Medical Ethics Alliance

Response to L A C D P consultation

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The Medical Ethics Alliance


Replacement  of the Liverpool Care Pathway





The Medical Ethics Alliance is a coalition of six medical and nursing bodies and on 23rd June 1012 held a conference at the Royal Society of Medicine entitled, “Natural Death - is a pathway needed”(1) Subsequently we welcomed the review established under the chairmanship of Baroness Neuberger, and this paper is a response to the report “ More Care /Less Pathway”.  We wish to comment on four of the recommendations made.



Recommendation 3


“The name Liverpool Care Pathway should be abandoned, and within the area of end of life care, the term “ pathway”, should be avoided, an “end of life care plan”, should be sufficient for both professionals and lay people”



(  John could you please develop this area, especially the legal aspects  )


( We should distinguish between advance statements which are advisory and advance refusals which can be binding if the circumstances that arise were those anticipated.

There are other questions about capacity.

There is a danger that a person can be locked into a bad decision which prevents them receiving help when they need it. 

For example, if there is an obstruction of the bowel they may need relieving surgery)


We do not think that patients would welcome being put on a list of those considered to  have less than a year to live. Such a plan, which was recently advanced by Baroness Jolly in the House of Lords, (2)

 is likely to be seen as a “death list”. If financial incentives are also attached to it these could be misunderstood. In any event , such a prognosis will often be impossible or proved wrong .The case of Al Magrahi  illustrates this and for many families the emotional difficulties would be insurmountable. Though no doubt well intentioned,  those who make such  a proposal have probably not experienced the situation first hand.



Recommendation 5


“The National Institute for Health Research fund research into the biology of dying”.


There was a lack of evidence base for the Liverpool Care Pathway and such as did exist was entirely based on death from malignancy. We do not consider that to be adequate for an understanding of deaths from non malignant conditions. Following the Constantini paper in The Lancet (3),and Currow and Abernathey commentary (4), the need for proper randomised cluster controlled trials was evident. We consider this is essential, and note that Consantini has already indicated protocols for further research and it may be profitable for it to be conducted internationally.



Recommendation 8


“NHS England and Health Education England should collaborate to promote the use of prognostic tools, including awareness of their limitations…”


We  suggest a repeat of earlier studies that compared the cause of death on death certificates with autopsy findings. The results could well be salutary and reveal treatable conditions for example, pulmonary embolus incorrectly diagnosed as pneumonia.


As a matter of good practice all doctors should ask themselves


1                                                                                         Just how secure is the diagnosis?


2                                                                                         Have all reversible conditions been addressed?


3                                                                                         Is the patient able to give informed consent to any action                                                         proposed?


4                                                                                         Has the patient been given the information they seek? Has it been                                    done gently and honestly as it is so important for patients generally                                         to realise the reality of their situation and attend to their spiritual                                                needs. It may take a considerable time for some to reach this                                                 moment. The “Five Stages of Grief”, have to be worked through.


Few patients wish to know their proximity to death and some cope by denying death until it can no longer be ignored. (5)


The M E A  have suggested some questions which relatives may find helpful in discussions with doctors and nurses delivering end of life care. They are;


1                                                                                         Are you sure that death is imminent?


2                                                                                         Can the patient give consent to the treatment proposed?


3                                                                                         Will the treatment reduce consciousness?


4                                                                                         What effects will the treatment have, including the combined                                                      effects of the drugs proposed, and their effectiveness in reducing                                            severely troublesome symptoms?


5                                                                                         Will you assure that the patient will not experience thirst and can                                             fluids be given by mouth or in another way?


6                                                                                         Will death be hastened by what is proposed? (6)



Recommendation 10


“The General Medical Council should review whether adequate education and training is currently provided at undergraduate and postgraduate levels to ensure competence. It should how … it can ensure that practising doctors maintain and improve their knowledge and skills in these areas”. 


It will be necessary to improve the skills of senior doctors and general parishioners in palliative care. There are relatively few palliative care physicians and these are not available out of hours or at weekends. There is therefore a danger that protocols could be brought back rather than making management decisions based on the patient’s  individual needs. The watch word must be treatment should be based on need not prognosis.






We are firmly of the view that all persons  should be treated with ethical, evidence based, compassionate and holistic care at the end of life.







Dr Anthony Cole




Mr J Duddington
























(1)     “Medical Ethics Alliance points towards good end of life care”,       info medethics-alliance, 9/9/13,  A Cole and 10 others


(2)                                                                                      Hansard reports on the House of Lords. Page 955 - 956, 12/12/12


(3)                                                                                      Constantini,  “Liverpool Care Pathway for patients with cancer in                                   hospital, a cluster randomised trial”, The Lancet 16th October,                                                    2013


(4)                                                                                      Currow and Abernathy, “Lessons from the Liverpool Care                                                     Pathway”, The Lancet, 16th October, 2013


(5)                                                                                      Craig “CONSIDER; a mnenonic for care of the dying”, Catholic                                                Medical Quarterly, Vol 63(4) November 2013, page 10



 (6)                                                                                     Press release from Medical Ethics Alliance and Catholic medical                                            Quarterly , Vol 63(4)November 2013 , page 9



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No Water-No Life: Hydration in the Dying.

Published in 2005 by Fairway Folio. Editor Craig GM. ISBN 0 9545445 3 6


This book highlights the dangers of a regime of sedation without hydration in the dying and documents a decade of debate on this subject that preceded the Liverpool Care Pathway. It will challenge and inform readers in many walks of life. Reprints of key papers give the views of the main protagonists including Ellershaw and Dame Cecily Saunders. Case reports show the complexity of the situation. Some dissenting relatives suffered post-traumatic stress. 

   Dr Robin Fainsinger a Director of Palliative Care Medicine in Canada who offers his dying patients subcutaneous hydration said “Dr Craig has performed a great service to palliative care for her thoughtful approach in challenging a long held dogmatic practice…Her book is fascinating and informative.”


Sales and distribution.


Volume 1 costs £10 per copy + p &p of £1. 50


For online sales go to www. OR


Usually in stock at St Pauls’ Bookshop by Westminster Cathedral in London

and at Wildy’s Legal Bookshop behind the Royal Court of Justice off the Strand.


Postal sales only from PO Box 341 Enterprise House Northampton NN3 2WZ

e mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it


NB Stocks are limited. When they are gone there will be no reprint.



Patients in Danger: the Dark Side of Medical Ethics.

   Enterprise House (UK) Editor Craig GM. ISBN 0 9552840 0 7 (p 272.) 


This book was published in June 2006. It covers tube feeding as a form of life 

support and explores ethical dilemmas created by decisions to withdraw or withhold

tube feeding. Medical ethical problems are illustrated by case reports, press  

reports and analysis of professional guidelines. American author Wesley J Smith

paints a worrying picture of futile care theory as practised in the USA, yet we in the

UK are following suit.

Medical practice has become polluted with politics as governments seek to contain the costs of health care. The frail elderly are now at risk. Society is deeply divided about how to tackle these problems. This book is highly topical and should be of interest to all who are involved in difficult “end-of-life decisions”.



Sales and distribution. 


Vol. 2 costs £15. 00 + p&p of  £1. 50


Online orders or personal shoppers are welcome at St Pauls’ Bookshop by Westminster


Cathedral and Wildy’s Legal Bookshop under Lincoln’s Inn Archway, London WC2.         


For online sales go to: www. OR


Postal sales only from PO Box 341 Enterprise House Northampton NN3 2WZ






Medical Ethics Alliance points towards good end of life care

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C     CONSIDER the situation calmly, with care and compassion.

Is the person imminently dying?

Where do they want to be - home or hospital?

How secure is the diagnosis?

Have all reversible aspects been considered?

Have legal issues been considered?

What is your intention for this patient?

Is it time to change gear and to stop striving to keep the patient alive?

No one should be asked to consent to be sedated except for medical reasons such as severe distress or lack of sleep, nor be subject to dehydration.

Is the patient able to give informed consent to any action that is proposed?


O    is for Other.

Consider other approaches i.e. active treatment of chest infection, heart failure.UTI etc.

Consider other diagnoses.


Nis for Nutrition and Hydration.

Is it possible to feed the patient?



Simple services cheer souls. Dying patients may want to see a priest. See Spiritual Guidelines in the Dying: published by Catholic Bishops.


I is for Information

Give the patient information if they seek it, but do so gently. Be honest but gentle. It is so important for patients generally to realise the reality of the situation and attend to their spiritual needs, but it may take a considerable time or some to reach this moment. The "Five Stages of Grief" have to be worked through.

Minimise potential problems and assure them that help will be available if needed.

Do not overstep the bounds of your competence in such discussions. Consult and get professional help when necessary.

 Few patients wish to know their proximity to death. Some cope by denying death until it can no longer be ignored. Be realistic - but leave room for hope, and always try to breath hope into impossible situations in one way or another.


D is for DYING

Discus any issues that arise, but do not force discussions about death on your patients. Help them to live with dignity until they die. 

Try to ensure that family and friends they wish to see are contacted in time. It is always helpful to remember the "Five stages of Grief" hypothesis introduced by Elizabeth Kublar - Ross ( from her book "On Death and Dying" ) that patients have to pass through before accepting death.


E is for Euthanasia

Which should remain unlawful. Resist pressure to assist a suicide  or risk 14 years in jail

If you have serious concerns about a death alert the police and report the death to the Coroner.



Are they coping? Have they said their good byes?

Beware of those who wish the patient dead.

The bad death of a loved one can destroy lives and cause post - traumatic stress.

 Some relatives will need bereavement counselling.


Mental Health Reasons for Abortion

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Psychologist: Most Abortions in Britain Illegal

Says "Charade" is Operating Around Country's Abortion Laws



London, December 04, 2013 ( | 249 hits


  • A British psychologist has said the overwhelming majority of Britain’s abortions are "probably illegal" and that a "charade" is operating around the country’s abortion laws.


  • Addressing a London conference Nov. 29th, Dr. Michael Scott said 99 per cent of abortions in Britain performed each year to protect the mental health of the mother could not be scientifically justified.



The consultant psychologist, who often serves as an "expert witness" with the regional police force in Liverpool, said a "charade" is operating around the working of the 1967 Abortion Act that legalised abortion in Britain.


Abortions on mental health grounds were so dishonest, he said, that they were effectively illegal.


He called for the total abolition of Ground C, the section that permits abortion when the "continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated".


It is under Ground C that nearly all of about 200,000 abortions are performed annually in Britain, most of them for so-called "social" reasons.


Britain's chief prosecutor caused controversy earlier this year when he said Ground C could also have been used to legally justify the sex-selective abortions of female foetuses because of their gender.


Dr Scott, an expert on post-traumatic stress disorder and author of ten books on psychology, said the bogus mental health reasons for abortions under Ground C also made the law impossible to either police or regulate.


Any attempted justification of abortion on Ground C "should be treated with great suspicion", he said, adding that the section was not "fit for purpose".


He noted from experience that whereas assessments for extreme trauma undergo rigorous examination, that is certainly not the case when it comes to terminations. He described both fields as parallel universes, leading him to see most abortions as illegal.


Dr. Scott said he felt there was a "lot of dishonesty" in the area of abortion – a view, he said, shared by people who are pro-abortion. Of the thousands of abortion cases he said he had studied, not one had involved a woman seeking to end her pregnancy on mental health grounds.


"We have de facto abortion on demand," he said.


"I doubt it was the intent of most of the supporters of the Act," he said. "How do we move on from abortion being treated like a visit to the dentist to a more appropriate societal response?"


The London conference was organised by the Medical Ethics Alliance.




Read more on the Diocese of Shrewsbury website



(December 04, 2013) © Innovative Media Inc.


With kind permission of Simon Caldwell




Now that the Liverpool Care Pathway is to be withdrawn here are some questions that relatives may wish ask doctors when individual care plans are being drawn up.

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1 Are you sure that death is immanent?
2 Can the patient give consent to the treatment proposed?
3 Will the treatment reduce consciousness? 
4 What effects will the treatment have, including the combined effects of the drugs  proposed?
5 Will you assure that the patient will not experience thirst and can fluids be given by mouth or another way?
6 Will death be hastened by what is proposed?




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