Select Committee on Health Written Evidence


APPENDIX 45

Letter from Don Aston to the Chairman of the Committee (PC 66)

  As you will no doubt be aware The Royal College of Physicians—uniquely well-placed to know at least so far as hospital deaths are concerned—stated in their response dated 23/7/03 to the original Joffe Assisted Dying Bill that "there is no doubt whatsoever that many (dying) patients suffer appallingly, and that death for many people is protracted, undignified and agonising" (para 5.2). Obviously only the present tiny minority are ever likely to die as hospice inpatients but an enormous improvement could easily be brought about if the dying wherever they are being cared for had access to hospice levels of opioid pain relief (and sedation) particularly in the very final stages of their lives.

  A major reason for this is the lack of any consensus in the sources of guidance to doctors (and soon nurses) prescribing opioids in terminal care. You may think unbelievably for the last 7 years the British Medical Association (BMA) has published two such incompatible guides simultaneously—the British National Formulary (BNF) and the British Medical Journal's hospice-influenced ABC of palliative care (please see the attached for these and other examples). You will not need me to tell you that unfortunately heroin-type drugs are indiscriminately demonised in anti "recreational" drugs campaigning when it might have been thought it would be easy to differentiate between the drug class (arguably the most important in medicine) and inappropriate use. The problem is further compounded by the uniquely wide prescribing range in palliative care (at least according to hospice sources)—at least 1,000 times. Local hospital protocols (eg Gosport War Memorial Hospital subject to an ongoing investigation for the last 7 years) are often even more restrictive than nationally published guidelines. In addition terminal sedation (patients being made unconscious until they die with hydration withdrawn) is far more common—and at patients' request and sometimes for many days ) is far more likely to be available in hospices than elsewhere because an alternative description of the practice is "slow euthanasia". Shamefully since the Shipman case (as also in the almost two years leading up to the murder trial of the Newcastle GP, the late Dr J D Moor) there is evidence that some doctors became even more reluctant to prescribe adequate opioids for dying patients than they already were previously. But no far as I am aware no hospice doctor has ever been tried for murder, or been suspended and investigated sometimes for years, or been found to have no case to answer but whose employers refuse to reinstate them even though their accusers remain in post for alleged "inappropriate" opioid prescribing in terminal care. Mainstream doctors have not been so fortunate and details of specific cases can be supplied if required

SOURCES OF GUIDANCE AVAILABLE TO DOCTORS ON THE USE OF OPIOIDS IN TERMINAL CARE


Incompatibilities between sources relate to:

Indicative dose ranges (please see below)
Proportion of patients said to be likely to require high doses (please see below)
Acceptable rate of dose increase when required Treatment of opioid toxicity
Ambiguities relate to:Assumed administration route ie oral or parenteral.

(in some sources) Particular opioid to which the indicative dose range relates
SourceIndicative Dose Range (Assumed to be Oral Morphine Equivalent per 24 hours)
British National Formulary No 32
(to March 97)
30 to 900mg
British National Formulary No 33
(from March 97)
30 to 3, 000mg
MIMSNo upper limit "Contrary to popular misconception, there is no maximum dose for morphine in [severe pain]"
Typical Hospice (eg Palliative Care Handbook Open University K260) 15 to 15, 000mg (assumed smooth progression over dose range)
British Medical Journal Sept 97
(ABC of palliative care)
30 to 15,000mg ("very few need high doses—most require less than 200mg a day")
Palliative Care Formulary 1
Twycross etc
One-third of patients need in excess of 200mg and up to 1, 200mg
Oxford Textbook of Palliative Medicine 15 to 15, 000mg ("whilst most patients require 200mg/day or less some need much higher doses")
Oxford Textbook of Oncology Vol 230-40% of patients will require more than 200mg
Cancer Pain Management—McGuire etc & Textbook of Pain 3rd Ed Wall & Melzack 400-600mg average
Requirement—10%
Require more than 2,000mg
Intramuscularly citing Coyle et al
(1990) Journal of Pain Management



HOSPICE PALLIATIVE CONSULTANTS ON OPIOID OVERDOSES

  "Even with accidental overdose 5-10 times the routine dose, the patient is only likely to become drowsy for a few hours and then recover spontaneously." Dr Kilian Dunphy "There is abundant evidence of people having been given inadvertently 20, 30 and even on one occasion 100 times what had been prescribed. Whilst it can be a tragic error, the patient may wake up 4 hours later to say it is the best sleep he has had for some time . . . there is no danger in these drugs." Dr Derek Doyle.

13 May 2004




 
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Prepared 26 July 2004