Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
British Journal of General Practice
Intended for Healthcare Professionals

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Editorials

‘Please make comfortable’: prescribing opioids in the wake of Gosport

Daniel Knights, Felicity Knights and Stephen Barclay
British Journal of General Practice 2018; 68 (675): 462-463. DOI: https://doi.org/10.3399/bjgp18X698705
Daniel Knights
Princess Alice Hospice, Esher.
Roles: Locum Specialty Doctor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Felicity Knights
Kingston & Roehampton Training Scheme.
Roles: GP Specialty Trainee
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Stephen Barclay
Primary Care Unit, University of Cambridge, Cambridge.
Roles: University Senior Lecturer in General Practice and Palliative Care
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info
  • eLetters
  • PDF
Loading

The latest crisis concerning UK end-of-life care arose in June 2018 with the publication of the Jones inquiry into opioid-related excess mortality at Gosport War Memorial Hospital in the 1990s.1 Hundreds of premature deaths resulted from misuse of diamorphine and syringe drivers, which often followed the clinical instruction ‘please make comfortable’. It is hard to overstate this scandal, one of many in the NHS. The report highlights patient safety failures at multiple levels, concerns about institutional culture, insufficient challenging and investigation of poor practice, and poor support of whistleblowers. Pocock et al’s editorial considers whether this was the result of a rogue clinician or systemic failures, while assessing the effect on palliative care provision.2 What merits further discussion is the complexity surrounding opioid prescribing in palliative and end-of-life care, with its repercussions on both public and political discourse in the UK and further afield.

COMPLEXITY IN THE UK PALLIATIVE CARE DEBATE

Person-centred compassionate palliative care was pioneered in the UK in the 1960s by Dame Cicely Saunders, encapsulated by her quotation: ‘You matter because you are you, and you matter to the end of your life’.3 However, the recent emotionally-charged debate around the now withdrawn Liverpool Care Pathway for the Dying was a painful challenge to this approach, with numerous examples of uncaring and impersonal practice.4 The Gosport scandal provokes further challenge to this rhetoric, now with a focus on the use of strong opioids and syringe drivers. While opioids are well-recognised as highly effective in the management of nociceptive pain in advanced diseases,5 concerns about their safety are widespread and growing among clinicians, patients, and the public.

DEALING WITH CONTRADICTION: THE INTERNATIONAL CONTEXT

‘Opiophobia’ is widespread across the world,6 with other barriers to adequate medical use of opioids including supply chain problems and overly restrictive national policies.7 This is despite the 1961 UN Single Convention on Narcotic Drugs, which highlights the importance of ensuring opioid availability for medical use.8 Access to opioids in Africa is particularly problematic: the recent Lancet Commission on Pain Relief and Palliative Care reported that in Nigeria less than 1% of opioid need is met in ‘health conditions most associated with serious health-related suffering’.9 Since oral morphine is available at very low cost, the enormity of unmet need for pain relief in Africa is arguably equally as shocking as the converse events of Gosport in the UK.

Box 1.

What actually happened in Gosport?

  • Large doses of opioids, commonly diamorphine, were prescribed and administered to patients under the instruction ‘please keep comfortable’.

  • Many of these patients were not experiencing pain and were admitted for rehabilitation or postoperative convalescence.

  • Prescriptions were provided for administration at nurses’ discretion, with unduly wide dose ranges and high starting doses.

  • The practices of prescribing and administering drugs at the hospital conflicted with national and local guidance.

  • The Graseby syringe drivers used for continuous subcutaneous administration of drugs were widely used across the NHS at the time. They were subsequently withdrawn due to a patient safety alert as there were two similar-looking models that infused at different rates. Safer alternative drivers are now used.

  • The doctor who instigated much of prescribing (Jane Barton) was a GP and clinical assistant in a geographically and professionally isolated hospital.

  • Many failed to raise concerns over Dr Barton’s prescribing; the Jones report calls into question the responses of inter alia pharmacists, consultants, the Coroner, and even the General Medical Council.

  • When concerns were raised by families and nurses, they were dismissed or inadequately investigated.

Juxtaposed is the crisis of overuse of prescription opioids in countries such as the US, where the Lancet Commission’s equivalent opioid usage is estimated to be in excess of 3000% of need in the same conditions,9 fuelling tolerance, addiction, and excess deaths.10

Therefore, opioids are essential for the palliation of pain in advanced disease, and when appropriately prescribed do not hasten death nor cause addiction; outside of that context, the risks of addiction and premature death are considerable. Our role as clinicians is to ensure that only patients who need opioids receive them, but also that those who would clinically benefit do not have these essential analgesics withheld due to patient, relative, or professional anxiety — a significant concern following often alarmist and unclear coverage of Gosport.

GP RESPONSES TO THE GOSPORT SCANDAL

To ensure safe and appropriate use of opioids, GP practices can regularly review their own use of opioids and develop safe systems including processes for identifying inappropriate opioid usage and adverse events. Mortality reviews of expected and unexpected deaths are being increasingly introduced into clinical practice: the forthcoming introduction of medical referees who will independently review all deaths will help mitigate such events in the future.

When caring for patients with advanced diseases requiring opioids, good communication and information provision about these drugs is essential. Inviting questions and concerns, explaining that the problems that arose at Gosport deviated from guideline-compliant care, will help to reassure concerned patients and their families. Language and terminology needs to be used with care: is the phrase ‘please make them comfortable’ now inappropriate? The linked BJGP Blog: ‘Pain, Opioids, and Syringe Drivers’ has suggested questions and responses in lay language.11

GPs also need to ensure that they work in an open and transparent way in which they, their clinical colleagues, and the patient’s relatives are empowered to raise concerns, such as through open forums and education on the appropriate use of opioids and signs of toxicity. The challenges faced by those who tried to whistleblow about inappropriate practice in Gosport have been highlighted elsewhere.12 The ‘health advocate’ is one of the CanMEDS roles of the physician,13 thus GPs have a broader responsibility, beyond individual clinical care, to work to reshape the public debate concerning opioids in order to advocate for effective patient-centred care. Not for the first time, the media debate risks becoming sensationalist: a Sunday Times investigation appropriately highlighted the problems with Graseby syringe drivers, but misleadingly infers intravenous administration, and fails to clarify that safer pumps are now in use in the NHS.14

Clinicians skilled in the critique of evidence and clear communication are ideally placed to refocus this debate towards an appropriate and proportionate response. Examples of misuse of the Liverpool Care Pathway led to its withdrawal, to the detriment of palliative care provision, we have argued.15,16 The central role of opioids in palliative care is even more crucial and must be safeguarded through education of clinical colleagues, careful usage, explanation to patients and public communication. With further investigation ongoing and potential prosecutions, the Gosport scandal will remain in the public eye. GPs need to continue to shape this agenda and protect and provide appropriate opioid usage. ‘The response to poor use should be right use, not non-use.’15

CONCLUSION

The debates around palliative care and opioid use are becoming increasingly salient and complex. This growing complexity in the wake of Gosport must be embraced and clearly communicated, not ignored or oversimplified. ‘Balance’ is needed in policy7 but also in patient care, recognising both unmet clinical need and overuse of opioids, empowering patients and relatives to articulate their concerns. We need to continue to strive for Cicely Saunders’ vision of person-centred and compassionate palliative care, and protect the critical role of opioids in enabling comfort towards the end of life.

Acknowledgments

The authors thank Elizabeth Jones and Peter Jones.

Notes

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

  • © British Journal of General Practice 2018

This article is Open Access: CC BY-NC 4.0 licence (http://creativecommons.org/licences/by-nc/4.0/).

REFERENCES

  1. 1.↵
    1. Jones J
    (2018) Gosport War Memorial Hospital: the report of the Gosport Independent Panel. Report no. HC1084. https://www.gosportpanel.independent.gov.uk/panel-report/ (accessed 7 Sep 2018).
  2. 2.↵
    1. Pocock L,
    2. Forbes K,
    3. Reid C,
    4. Purdy S
    (2018) Br J Gen Pract, Now Gosport: what next? DOI: https://doi.org/10.3399/bjgp18X698393.
  3. 3.↵
    1. Twycross R
    Tributes to Dame Cicely Saunders. http://www.stchristophers.org.uk/about/damecicelysaunders/tributes (accessed 4 Sep 2018).
  4. 4.↵
    1. Department of Health and Social Care.
    (2013) Independent Review of the Liverpool Care Pathway More care less pathway: a review of the Liverpool Care Pathway, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf (accessed 7 Sep 2018).
  5. 5.↵
    1. Zech DFJ,
    2. Grond S,
    3. Lynch J,
    4. et al.
    (1995) Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain doi:10.1016/0304-3959(95)00017-M.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Bennett DS,
    2. Carr DB
    (2002) Opiophobia as a Barrier to the Treatment of Pain. J Pain Palliat Care Pharmacother 16(1):105–109.
    OpenUrlPubMed
  7. 7.↵
    1. World Health Organization
    (2000) Narcotic and psychotropic drugs : achieving balance in national opioids control policy : guidelines for assessment. http://www.who.int/iris/handle/10665/66496 (accessed 4 Sep 2018).
  8. 8.↵
    1. United Nations
    (1972) Single Convention on Narcotic Drugs 1961, as amended by the 1972 Protocol amending the Single Convention on Narcotic Drugs, 1961, https://www.unodc.org/pdf/convention_1961_en.pdf (accessed 4 Sep 2018).
  9. 9.↵
    1. Knaul FM,
    2. Farmer PE,
    3. Krakauer EL,
    4. et al.
    (2018) Alleviating the access abyss in palliative care and pain relief — an imperative of universal health coverage: the Lancet Commission report. Lancet 391(10128):1391–1454.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Godlee F
    (2017) BMJ, What we must learn from the US opioid epidemic. DOI: https://doi.org/10.1136/bmj.j4828.
  11. 11.↵
    1. Knights D,
    2. Knights F,
    3. Barclay S
    (2018) Pain, opioids, and syringe drivers. BJGP Life, in press.
  12. 12.↵
    1. Godlee F
    (2018) BMJ, Lessons from Gosport. DOI: https://doi.org/10.1136/bmj.k2923.
  13. 13.↵
    1. Frank J,
    2. Snell L,
    3. Sherbino J
    , eds (2015) The Draft CanMEDS 2015 Physician Competency Framework — Series IV, http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/canmeds2015_framework_series_IV_e.pdf (accessed 4 Sep 2018).
  14. 14.↵
    1. Wheeler C,
    2. Pogrund G,
    3. Rogers L
    (Jun 24, 2018) The great NHS cover-up: opiate syringes may have killed thousands. The Times, https://www.thetimes.co.uk/edition/news/the-great-nhs-cover-up-opiate-syringes-may-have-killed-thousands-mz5jqcwd9 (accessed 4 Sep 2018).
  15. 15.↵
    1. Knights D,
    2. Wood D,
    3. Barclay S
    (2013) Br J Gen Pract, The Liverpool Care Pathway for the dying: what went wrong? DOI: https://doi.org/10.3399/bjgp13X673559.
  16. 16.↵
    1. Knights D
    (2016) Br J Gen Pract, In defence of the ‘tick-box approach’: why end-of-life care is no exception. DOI: https://doi.org/10.3399/bjgp16X685357.
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 68 (675)
British Journal of General Practice
Vol. 68, Issue 675
October 2018
  • Table of Contents
  • Index by author
Download PDF
Article Alerts
Or,
sign in or create an account with your email address
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
‘Please make comfortable’: prescribing opioids in the wake of Gosport
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
‘Please make comfortable’: prescribing opioids in the wake of Gosport
Daniel Knights, Felicity Knights, Stephen Barclay
British Journal of General Practice 2018; 68 (675): 462-463. DOI: 10.3399/bjgp18X698705

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
‘Please make comfortable’: prescribing opioids in the wake of Gosport
Daniel Knights, Felicity Knights, Stephen Barclay
British Journal of General Practice 2018; 68 (675): 462-463. DOI: 10.3399/bjgp18X698705
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • COMPLEXITY IN THE UK PALLIATIVE CARE DEBATE
    • DEALING WITH CONTRADICTION: THE INTERNATIONAL CONTEXT
    • GP RESPONSES TO THE GOSPORT SCANDAL
    • CONCLUSION
    • Acknowledgments
    • Notes
    • REFERENCES
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • Socioeconomic deprivation and post-stroke care in the community
  • Advocating for patients through laboratory tests: what do GPs’ use of blood tests for suspected cancer tell us?
  • Diagnosis of prostate cancer in primary care: navigating updated clinical guidance
Show more Editorials

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2023 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242