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Health News from NHS Choices

Constantly updated health news across a range of subjects.

NHS Choices News

  • Scientists hail '100% effective' Ebola vaccine

    "Ebola vaccine is 'potential game-changer'," says BBC News, while the Daily Mail cites a "100% effective jab" for the disease. These headlines stem from early results of a trial investigating the effects of an Ebola vaccine during the most recent outbreak of the virus in west Africa.

    Researchers gave the Ebola virus vaccine to thousands of people in Guinea who'd had close contact with an infected individual – a process called "ring vaccination". Half the sample were given the vaccine immediately, while the other half were given the vaccine after a delay of three weeks.

    The early results, published in The Lancet and publicised by the World Health Organization (WHO), showed the vaccine had 100% effectiveness when given immediately. Nobody developed Ebola symptoms up to 10 days after being given the vaccine immediately after exposure. However, 16 cases in the delayed vaccination group developed symptoms (0.5%). Further analysis of the results is ongoing.

    The vaccine is not currently licensed for use. The data on its effectiveness and safety will need to be reported and scrutinised before we know whether it could be licensed and widely adopted.

    Researchers are now trying the vaccine in Ebola-affected Sierra Leone. Liberia is the only other country affected by the Ebola virus at the moment, according to government information on Ebola

    What is Ebola?

    Ebola is a serious viral infection that can often be fatal. It is spread by close contact with an infected person, particularly through blood and other bodily secretions. For example, someone caring for a person with the Ebola virus could get infected after changing wound dressings or bed pans.

    The first symptoms of Ebola virus disease can start anywhere up to three weeks after being infected. Symptoms include fever, headache, sore throat, general fatigue and weakness, muscle pains, vomiting and diarrhoea.

    Ebola can also cause internal bleeding, which may present as bruising, a rash, bleeding from the mouth or gums, or blood in the stool. Because of this, the infection is sometimes called Ebola haemorrhagic fever.

    There is no specific treatment for Ebola and care is usually supportive – for example, providing intravenous fluids. The average death rate from Ebola is reported to be 50%, though this varies depending on the health and immunity of the person who has been affected. Prevention of Ebola has always been better than cure.

    In 2014, the largest known Ebola outbreak in history began in west Africa, centring on Guinea, Liberia and Sierra Leone. There were also individual cases of healthcare workers infected in west Africa who then imported the virus into western countries. No licensed Ebola vaccines were available, but they have been under investigation.  

    Why is the Ebola vaccine in the news?

    Early results of a phase III trial of the VSV-EBOV vaccine have been published by the WHO, and have also been reported in The Lancet. Phase III means this trial is in one of the final stages of testing the effectiveness and safety of the vaccine in a large sample of people.

    The vaccination trial began in Guinea in March 2015 and has involved giving the vaccine to 7,651 volunteers. These are the contacts of people who have been infected with the virus (family members, neighbours, colleagues and so on).

    This technique of identifying an infected person, their contacts, and their contacts' contacts is called "ring vaccination". It is said to be based on the strategy used to eradicate smallpox.

    Study co-author, John-Arne Røttingen, who is director of the Division of Infectious Disease Control at the Norwegian Institute of Public Health, says: "The premise is that by vaccinating all people who have come into contact with an infected person you create a protective 'ring' and stop the virus from spreading further."

    An editorial in The Lancet accompanying the research says the ring vaccination process isn't easy, as it can be hard to identify the network of contacts of a particular person, particularly when family and friends can be in dispersed communities across the country.

    Rather than comparing the vaccine with an inactive placebo, roughly half of the contacts in the trial (4,123) were given the vaccine immediately; the remainder (3,528) after a three-week delay.

    The ring vaccination trial stopped recruiting in July 2015. Another trial is said to be being conducted in parallel with the trial of ring vaccination, involving vaccinating frontline workers caring for sick people. 

    What are the early trial results?

    The trial showed 100% effectiveness when given immediately, with no vaccinated cases having Ebola symptoms up to 10 days after the vaccine.

    In the delayed vaccination group, there were 16 people who developed Ebola symptoms up to 10 days after infection, affecting 0.5% of those exposed who received delayed vaccination.

    All of these cases developed symptoms within one week of exposure to the infected person. The overall vaccine effectiveness in all people who received it is estimated to be around 75%.

    As the WHO statement says, better evidence is also needed on the vaccine's capacity to protect the whole population through what is called "herd immunity".

    What this means is that if enough people in a population are vaccinated or immune against an infection, this confers protection on unvaccinated people, as there aren't enough people around to catch and spread the virus in the first place.

    Side effects were examined up to 12 weeks after vaccination. There were 43 serious side effects reported, one of which was a serious fever attributed to the vaccine. This resolved spontaneously. Assessment of side effects is ongoing. 

    What do the results mean at the moment?

    The vaccine is not currently licensed for use. More data on its safety and effectiveness is needed before it can be licensed for widespread use, and it will only pass if the evidence is good enough.

    However, The Lancet reports background preparation may already be under way for its introduction: "If the evidence proves sufficient for licensing, a Global Ebola Vaccine Implementation Team, also under WHO's leadership, has been preparing the ground for its introduction – creating guidelines for the vaccine's use, strategies for community engagement, and mechanisms to expand country capacity for the vaccine's distribution and delivery."

    It is also not possible to say who would be eligible for the vaccine – for example, whether it would just be healthcare workers in affected areas, or those who are known to have come into contact with an infected person.

    The news of the successful Ebola vaccine trials has received widespread welcome from scientists. You can read the experts' views on the Ebola vaccine on the Science Media Centre website.

    Links To The Headlines

    Is the world on the verge of an Ebola vaccine? 100% effective jab 'could be a game changer in the fight against deadly virus'. Mail Online, July 31 2015

    Ebola vaccine success offers hope after trial shows 100 per cent success rate. The Independent, July 31 2015

    Ebola vaccine is 'potential game-changer'. BBC News, July 31 2015

    Links To Science

    Henao-Restrepo AM, et al. Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial. The Lancet. Published August 3 2015


    An Ebola vaccine: first results and promising opportunities. The Lancet. Published August 3 2015

  • Hiding HIV virus 'flushed out' by skin cancer drug

    "HIV flushed out by cancer drug", BBC News reports. This headline was prompted by laboratory research showing the promising results of a cancer drug being used to treat HIV.

    In the early stages of HIV infection, some of the virus effectively goes into hiding in so-called HIV "reservoirs". These viruses are not "active", so standard anti-HIV drug treatments do not kill them.

    In this study, researchers found viruses in blood samples from people with HIV infection could be reactivated using a cancer drug. They believe this would mean the viruses could then be identified by standard drug treatments, and killed. The drug did not appear to be toxic to other blood cells, although it wasn't tested on living humans.

    While these are promising results, the experiments are at an early stage and it is not known if it would be safe to use the drug in this way for people infected with HIV.

    The drug is currently used on the skin to treat a condition called actinic keratoses, which makes it unclear what effects the drug would have if used internally.  

    Where did the story come from?

    The study was carried out by researchers from the University of California, the San Francisco Veterans Affairs Medical Center, and Williams College, all in the US.

    It was jointly funded by the National Institute of Health, UC Davis Research Investments in Science and Engineering (RISE), the Brazilian Federal Agency, and the Swiss National Science Foundation. Researchers say the funding organisations had no role in the study design, data collection and analysis.

    The study was published in the peer-reviewed medical journal PLoS Pathogens.

    In general, the media reported the story accurately, but the study's limitations were not fully explained.

    The BBC reported an interesting quote from one of the researchers, Dr Satya Dandekar, who said: "We are excited to have identified an outstanding candidate for HIV reactivation and eradication that is already approved and is being used in patients. This molecule has great potential to advance into translational and clinical studies."

    But although the drug is being used on patients, it is currently just applied to the skin. The effects may be very different if the whole body is exposed to the drug, as would be required to locate hidden reservoirs of HIV. 

    What kind of research was this?

    This laboratory study aimed to assess whether a drug currently used to treat a skin condition could be used to reactivate the HIV virus.

    Currently available forms of anti-retroviral therapy (ART) are effective in stopping HIV replication, but they do not eliminate "latent" reservoirs of the virus in people infected with HIV. Other studies suggest starting ART early may not prevent latent virus reservoirs forming, or eliminate them.

    More recent studies have looked at how some compounds may disrupt the cell signalling pathways that allow HIV to become latent in someone infected with the virus.

    Researchers say some of these compounds effectively induce latent HIV reactivation in laboratory settings. One of these compounds is ingenol-3-angelate (PEP005), which is currently approved for clinical use and is used to treat a skin condition called actinic keratoses. This can develop into skin cancer if left untreated.

    In this type of study, using cells in a lab, treatments sometimes show positive results, but don't always prove effective in living humans. 

    What did the research involve?

    The research included a cell culture of latent HIV with "defective" genes. Researchers say this clone is widely used for HIV latency studies.

    The researchers collected blood samples from 13 people who were infected with HIV and receiving ART – 12 of these had been on ART for more than three years.

    All the individuals had had "suppressed" viral activity for more than six months. The researchers also collected cells from uninfected individuals to act as a control.

    All the human and cultured cells were incubated, with compounds being tested for 24 or 72 hours to see whether the cells were dead or alive after the tests.

    To determine the potential of PEP005, cells were treated with increasing concentrations of PEP005. 

    What were the basic results?

    PEP005 increased the reactivation of the cell culture of latent HIV. The effect was even greater when PEP005 was combined with other compounds that also activate latent HIV.

    When PEP005 was tested on blood samples from people with HIV infection, it activated latent HIV-infected cells in most of the samples. Again, the effects were higher when PEP005 was used in combination with other compounds.

    Researchers also assessed potential side effects of PEP005 and found no significant toxicity or side effects on other blood cells from these samples. 

    How did the researchers interpret the results?

    Researchers concluded that PEP005 "effectively reactivated HIV from latency in primary CD4+ T cells from HIV-infected individuals receiving ART", and a combination of this and another compound increased this reactivation. They say these results "represent a new group of lead compounds for combating HIV latency". 


    This laboratory study found the cancer drug PEP005 may be able to activate latent HIV. This could mean conventional anti-HIV treatments should then be able to eradicate it.

    The drug has so far only shown positive results in the laboratory setting and has not been tested on humans in this way. As such, it's too early to tell if this really will help people infected with HIV to be free of the virus for good.

    While these are some positive results, the side effects of this drug in humans has not been fully explored.

    There is currently no cure for HIV, but there are treatments that can delay the start of symptoms. The World Health Organization (WHO) reports there are 35 million people currently living with HIV globally. Even if effective treatments were available, it's wise to practice safer sex using barrier contraception.

    Links To The Headlines

    HIV flushed out by cancer drug. BBC News, July 31 2015

    Scientists discover how to flush HIV out of a patient's body, raising hopes they can eradicate the disease. Daily Mail, July 31 2015

    Links To Science

    Jiang G, et al. Synergistic Reactivation of Latent HIV Expression by Ingenol-3-Angelate, PEP005, Targeted NF-kB Signaling in Combination with JQ1 Induced p-TEFb Activation. PLoS Pathogens. Published July 30 2015

  • New 'iClusters' identify five subtypes of prostate cancer

    "Scientists have identified five types of prostate cancer, each with a distinct genetic signature," BBC News reports. The hope is that recognising the genetic signature of a specific cancer could lead to targeted treatments, as is the case with some types of breast cancer.

    By analysing the DNA of prostate cancer cells from 259 men, researchers identified five distinct prostate cancer subgroups. Called "iClusters", the subgroups described the genetic characteristics of the tumour and gave clues about how it might behave in the future.

    In the future doctors might be able to use the iClusters to decide the best treatment for each man. However, they are not yet ready to be used in hospitals to influence treatment decisions.

    Where did the story come from?

    The study was carried out by researchers from the University of Cambridge in collaboration with academic institutions in Sweden, Norway and Belfast.

    It was funded by a large number of academic and charity medical research funders, including the National Institute for Health Research, Cancer Research UK, and the Swedish Cancer Society.

    The study was published in the peer-reviewed medical journal EBioMedicine.

    The BBC's article was balanced and accurate. It quoted researcher Dr Alastair Lamb, who said: "These findings could help doctors decide on the best course of treatment for each individual patient, based on the characteristics of their tumour."

    He also cautioned there were still many questions to be ironed out, including whether the technique could be used routinely in hospitals. 

    What kind of research was this?

    This was a genetic study seeking to identify subgroups of prostate cancer. Prostate cancer is the most common cancer in men in the UK (not counting non-melanoma skin cancer), with more than 40,000 new cases diagnosed every year.

    The cause remains unknown, and some cases of prostate cancer are more aggressive than others. Currently, treatment decisions and prognosis are based on the size and type of the tumour, whether it has spread, and the level of prostate-specific antigen (PSA) in the blood. PSA is a protein produced by the prostate.

    In this study, the researchers wanted to see if the characteristics and behaviour of prostate cancers could be predicted by particular DNA errors.

    Some countries use PSA to screen asymptomatic men for prostate cancer. But current opinion in the UK is this is not accurate enough. Inaccuracy could lead to many unnecessary operations in healthy men that can in turn lead to life-impacting complications, such as urinary incontinence and impotence.

    Understanding the genetics and behaviour of cancer could be fundamental to improving the way we treat the disease in the future. 

    What did the research involve?

    DNA data from the prostate cancer cells of 259 men were number-crunched to produce five distinct subgroups, termed "iClusters". These not only described the tumour's DNA characteristics, but to some degree predicted their future clinical behaviour.

    In total, the researchers studied 482 tumour samples from 259 men with primary prostate cancer. They produced the initial five subgroups using data from 156 men from a Cambridge database. To validate the findings, they repeated the exercise in a further 103 men from a Stockholm database.

    The team also had data on tumour progression, including six-monthly PSA tests and cancer staging. The researchers didn't have survival information, so instead used "biochemical relapse" to predict future clinical behaviour. Biochemical relapse was defined as a PSA level above 0.2ng/ml.

    The number-crunching involved integrating data on the number of copies of genes associated with prostate cancer (copy number alterations) and genetic points linked to changes in gene expression (known as array transcriptomics). This integrated approach is the origin of the "i" in iCluster. 

    What were the basic results?

    The study identified five separate patient subgroups with distinct genomic alterations and expression profiles, based on 100 discriminating genes. These subgroups consistently predicted biochemical relapse and were further validated in a third cohort with long-term follow-up.

    The discriminating genes included six previously associated with prostate cancer (MAP3K7, MELK, RCBTB2, ELAC2, TPD52, ZBTB4), but also 94 not previously linked to the disease.

    The study said the subset of the 100 genes outperformed established clinical predictors of poor prognosis (PSA, Gleason score), as well as previously published gene signatures.

    How did the researchers interpret the results?

    The researchers said the five profiles could be used for the early detection of aggressive cases of prostate cancer in a clinical setting, and inform treatment decisions.

    They said: "Our findings are clinically significant because they will assist urologists in recommending different treatment approaches for those men who are classified as being in low, intermediate or high-risk categories according to conventional clinical criteria."


    Using DNA analysis, this study identified five subgroups (iClusters) of prostate cancer. A large portion of the iCluster-discriminating genes were not previously known to be linked to prostate cancer – an interesting finding in itself. The hope is the iClusters might help doctors treat the disease better based on their specific genetic signature.

    However, this study focused on developing reliable subgroups. It did not look at whether the groups improved treatment, disease progression or death rates from prostate cancer. This research is yet to be carried out.

    One of the main limitations of the research is it used biochemical relapse to estimate survival. This may not be accurate and reduces the ability of the iClusters to predict future survival at this stage.

    Dr Alastair Lamb, quoted by BBC Online, said: "The next step is to confirm these results in bigger studies and drill down into the molecular 'nuts and bolts' of each specific prostate cancer type."

    Also on BBC Online, Dr Iain Frame, of Prostate Cancer UK, said: "For men to truly benefit from these findings, it is now vital that the research community comes together to confirm the most efficient methods for testing for different types of prostate cancer that can be brought to the clinic."

    Links To The Headlines

    Prostate cancer: Five types 'found'. BBC News, July 30 2015

    Prostate cancer could actually be five different diseases, say scientists. The Independent, July 30 2015

    'Five types' of prostate cancer identified. ITV News, July 30 2015

    Scientists discover there are five kinds of prostate cancer: Treatment set to be transformed by findings that allow doctors to distinguish deadliest tumours. Mail Online, July 30 2015

    Links To Science

    Ross-Adams, Lamb AD, Dunning MJ, et al. Integration of copy number and transcriptomics provides risk stratification in prostate cancer: A discovery and validation cohort study. EBioMedicine. Published online July 30 2015

  • Can the so-called 'male menopause' be treated with HRT?

    "New research suggests that testosterone deficiency in older men is much more prevalent than current screening methods suggest, and that more men would benefit from hormone treatment," The Daily Telegraph reports.

    The male menopause, which remains controversial, is said to be a syndrome of associated symptoms linked to the fall of testosterone, which include:

    The research behind the headlines involved more than 2,000 men given trials of testosterone therapy after attending private Men's Health clinics in the UK.

    The men had an average age of 54, though some were aged 90. All the men reported symptoms associated with the so-called male menopause. Most (83%) had testosterone levels that would be considered to be in the normal range, but all were given trials of testosterone therapy.

    The men reported a reduction in symptoms with treatment. However, there are risks associated with testosterone therapy, including an increased risk of prostate cancer and blood clots.

    The study was an audit of men attending a clinic, so there was no control group. This and other factors mean the study's results are less reliable: a randomised controlled trial would have made the research more trustworthy.

    It remains to be seen whether the benefits of testosterone therapy outweigh the risks for men currently considered to have testosterone levels within the normal range, and further studies are needed. 

    Where did the story come from?

    The study was carried out by researchers from the Centre for Men's Health and University College Hospital, both in London, and Edith Cowan University in Australia.

    Funding was not reported, but one of the three authors works for a private Men's Health clinic. The clinic offers treatments for male menopause, erectile dysfunction and prostate health – this represents a potential financial conflict of interest.

    The study was published in the peer-reviewed journal The Aging Male on an open-access basis. The research is available to read for free online.

    Headlines such as "Academics find the male menopause is real" from the Daily Mail are simply not true. This study was an audit of men prescribed testosterone after reporting symptoms such as difficulty getting an erection. This type of study cannot prove whether the male menopause is real or not.

    Reassuringly, all of the UK media outlets that covered the study made it clear the implications of this research have been disputed by other experts.

    Most sources quoted Professor Frederick Wu of Manchester University, who disputed the claims made by this research. He said, "In my opinion, this publication is not only misleading, but potentially dangerous, particularly when the author calls for many more men to be treated, inappropriately, with testosterone." 

    What kind of research was this?

    This was a retrospective audit of men attending private Men's Health clinics in London, Edinburgh or Manchester since 1989 with symptoms of low testosterone.

    This type of study can provide an insight into whether testosterone replacement provides symptom relief, but cannot prove cause and effect.

    A prospective, double-blinded randomised controlled trial would be required to prove a causal relationship, as this eliminates potential biases and confounding factors

    What did the research involve?

    The researchers reviewed the medical notes of 2,693 men who had attended private Men's Health clinics since 1989. Their symptoms, reported to be present for around three to five years before attending the clinics, included:

    • loss of libido
    • low energy
    • difficulty achieving and maintaining an erection
    • loss of morning erections
    • night sweats
    • joint pains
    • depression
    • irritability
    • impaired memory

    The clinics diagnosed the majority of the men (2,247) with inadequate testosterone levels based on their symptoms alone: diagnosis was not based on measured testosterone levels.

    The researchers said many men had been denied treatment before because their testosterone levels were in the normal range. This study questions the reliability of these tests.

    All of the men diagnosed with low testosterone levels based on symptoms alone were offered testosterone therapy in different forms. These included:

    • pellet implants
    • oral testosterone
    • testosterone scrotal cream
    • scrotal gel

    A symptom checklist called the Andropause Checklist assessed changes in symptoms before and during treatment. It uses 20 questions to derive a score from 0 to 80. In this study, a score of less than 10 was considered normal and was the target for treatment. 

    What were the basic results?

    The average age of the men was 54, with a range from 24 to 90. The average length of follow-up to assess symptoms and testosterone levels was one to two years after treatment. Treatment lasted from 3 to 12 years depending on the testosterone delivery (implant, gel, pill or cream).

    Symptomatic relief – defined as a symptom score of less than 10 on a 0 to 80 scale – was achieved for all testosterone therapies two years into treatment.

    Some treatments led to symptomatic relief within a year. Men with more severe symptoms were less likely to respond well to the testosterone therapy.

    None of the men were reported to have an increased prostate after testosterone treatment, but the average follow-up was just one year.

    An unreported proportion of the men had an increased number of red blood cells (polycythaemia) – a known side effect of testosterone treatment that increases the risk of blood clots. These men had to be treated for this by having blood taken regularly to reduce the number back to safe levels.  

    How did the researchers interpret the results?

    The researchers concluded that, "With appropriate and necessary monitoring of safety parameters, testosterone treatment appears safe and economic.

    "Many men who could benefit in terms of symptom relief, with improvement in related clinical conditions and prevention of the long-term effects of testosterone deficiency, may remain untreated because of excessive reliance on laboratory measures of androgens for diagnosis and treatment alongside unwarranted safety concerns." 


    This study found that offering men testosterone when they reported symptoms usually described by men with low testosterone caused a reduction in their symptoms. This was despite 83% of the men having testosterone levels considered to be in the normal range, above 10nmol/l.

    The authors say that treating people according to symptoms should be more important than basing it on testosterone blood levels alone. They say these blood levels may be inaccurate, and some individuals may naturally need higher levels of testosterone than others. This is an interesting concept worthy of further robust study.

    However, there are potentially serious side effects reported with testosterone therapy, and this study does not address these risks or provide evidence that more people should be treated.

    This study's findings have many limitations:

    • Because of the nature of the study, there was no placebo group to act as a control.
    • The study was retrospective, which is a less reliable type of study than prospective trials.
    • The men did not have a laboratory-confirmed diagnosis of low testosterone, and the research relied on self-reported symptoms. The authors say the men's blood results may have been in the normal range for their age, but this may be lower than their individual level used to be. While this is a plausible conclusion, it is not backed by the evidence – the study did not measure each man's testosterone levels when they had no symptoms. Additionally, guidelines recommend that men are only treated if their testosterone level is below 10nmol/l, which was only the case for 17% of these men. Some had four times this cut-off, with levels of up to 40nmol/l.
    • All men were advised to make lifestyle changes, including reducing their stress levels, alcohol intake and weight if necessary, and increasing how much exercise they did, which could have influenced the results.
    • Other interventions were also started where necessary, including treatment for high blood pressure, high cholesterol and diabetes, which may also have affected the results.
    • The authors concluded that testosterone is a safe treatment, saying they have treated men in this way over the course of 25 years and have not seen known problems such as increased prostate size or blood clots. However, the average length of follow-up in this study was just one year.

    The US Food and Drug Administration (FDA) issued a warning in 2014 about the increased risk of blood clots with the use of testosterone replacement. They only recommend that testosterone is prescribed for men who do not produce testosterone or who have low levels as a result of a medical condition that requires treatment, such as chemotherapy.

    In the UK there are no official NHS guidelines, but the Society for Endocrinology recommends that male patients are treated on a case-by-case basis, depending on their symptoms.

    If you suffer from the symptoms described above, it may be worth seeing your GP – testosterone replacement therapy is effective for men who are found to have low testosterone levels.

    It remains to be seen whether the benefits of testosterone therapy would outweigh the risks for men currently considered to have testosterone levels within the normal range.

    Many problems with issues such as erectile dysfunction and loss of libido are often the result of psychological, rather than physical, issues. It may be unwise to seek out hormonal treatments without first speaking to a sex therapist or a similar type of counsellor. The College of Sexual and Relationship Therapists has contact details for accredited therapists.  

    Links To The Headlines

    Is the 'manopause' more widespread than we thought? The Daily Telegraph, July 30 2015

    Male menopause is real, claims controversial new study. The Independent, July 30 2015

    Could testosterone HRT help treat the male menopause: Therapy should be provided as men also suffer hot flushes and low libido once they pass 50. Mail Online, July 30 2015

    Links To Science

    Carruthers M, Cathcart P, Feneley MR. Evolution of testosterone treatment over 25 years: symptom responses, endocrine profiles and cardiovascular changes. The Aging Male. Published online July 28 2015

  • NICE produces new draft guidelines on caring for the dying

    "England's health watchdog has put forward new draft guidance to improve the care of adults in their last few days of life," BBC News reports.

    The guidelines, produced by the National Institute for Health and Care Excellence (NICE), have been proposed as an alternative to the controversial Liverpool Care Pathway, which was phased out in 2014.


    What was the Liverpool Care Pathway?

    The Liverpool Care Pathway was developed during the late 1990s at the Royal Liverpool University Hospital, in conjunction with the Marie Curie Palliative Care Institute. It was intended to provide the best quality of care possible for dying patients in the last days and hours of life, whether they were in hospital, at home, in a care home or in a hospice.

    It was designed to address concerns such as:

    • patients being subjected to invasive testing and treatment that offered no chance of preventing death
    • causing unnecessary pain and suffering by needlessly prolonging life


    Why did it become controversial?

    There were three main issues of controversy that were widely reported in the media:

    • the assessment that a person was dying was not always made by an experienced clinician and was not reliably reviewed
    • the dying person may have been unduly sedated as a result of poor prescribing methods
    • there were claims that hydration and some essential medicines may have been withheld, which may have a negative impact on the dying process

    It appeared that while the Pathway itself was sound, some staff may not have been following its recommendations correctly. For example, withdrawal of nutrition and fluids should never be a routine option, but done only if it is felt to be in the best interests of the patient, judged on a case-by-case basis.


    What are the main recommendations of the new draft guideline?

    A summary of the most important points is provided below. 

    NICE has published the complete guideline, including relevant evidence (PDF, 3.4Mb).

    Recognising when a person is in the last days of their life

    If it is thought that a person may be dying, information should be gathered on their:

    • clinical signs and symptoms, and medical history
    • the person's goals and wishes, as well as their psychological and spiritual needs
    • the views of those important to the person with respect to future care

    The assessment of their clinical state should be made on a team basis and not just by one individual. The assessment should be reviewed at least every 24 hours.


    Establish their communication needs, their current level of understanding and how much information they want to know about their prognosis. If patients or their families do want information, staff should discuss any concerns they have, while avoiding giving false hope.

    Shared decision making

    Find out how much the person wants to be involved in terms of shared decision making when it comes their care plan. As part of this process, find out whether the person has an advanced care plan or decision in place, as well as their goals and wishes.


    A dying person should always be supported if they wish to drink and are able to, though it is important to check for potential risks, such as swallowing problems.

    Encourage friends and family to help with giving drinks and mouth care. Provide any necessary aids, such as sponges.

    Discuss the risks and benefits of clinically assisted hydration, such as intravenous feeding, and their wishes about its use. It is also important to make clear that clinically assisted hydration is unlikely to prolong life.

    Pharmacological interventions

    Discuss what level of symptom control they would want in the last days of their life, as well as the possible benefits and harms of any medicines offered.

    The plan for pharmacological interventions should be regularly reviewed.


    How do I make my views known?

    Consultation on the guidelines will finish on September 9 2015. To register a comment, you will need to belong to an eligible stakeholder organisation, such as a national organisation for people who use health and social care services, or an organisation that funds or carries out research.

    Read more about the commenting and registration process

    Links To The Headlines

    Dying care: 'Improved' guidelines proposed. BBC News, July 29 2015

    New guidelines for care of the dying proposed. ITV News, July 28 2015

    'We must end our industrialised approach to death and show compassion': Professor speaks out as the NHS is forced to remind medics to give dying patients water. Mail Online, July 29 2015

    Doctors and nurses ordered to stop denying dying patients water. The Daily Telegraph, July 29 2015