- Email: [email protected]
Living wills in HIV infection and AIDS
4 Kellerman A, et al. Gun ownership as nsk factor for homicide in the home. N Engl J Med 1993; 329: 1084-91. 5 National Association of Medical Examiners. The medical examiner and public health: an example. NAME News 1994; 2: 6.
Living wills
in HIV infection and AIDS
SiR-Meadows (Nov 26, p 1509) presents interesting results on a limited sample of 40 completions of over 20 000 living will forms distributed. Age Concern has published a book on living wills,’ and elderly people who are interested in completing one are directed to the Terrence Higgins Trust and to the Voluntary Euthanasia Society, which might account for the 1 non-HIV-related completion of Meadows’ 17 respondents with terminal disease. The Voluntary Euthanasia Society emphasises the importance of communication of the advance directive with the medical practitioners concerned. A healthcare proxy has no legal power whatsoever. A living will is valid2 only if at the time the will was made the patient had the capacity to consent or refuse the treatment, and the patient must have anticipated and intended his decision to apply to the circumstances that ultimately prevail. The patient’s decision must also have been reached without undue influence. To ensure validity of the completed document communication with medical staff is imperative if possible end-of-life circumstances are to be anticipated, and then decided upon. The Law Commission is reviewing the law in this respect with
view to possible legislation for advance directives, including medical treatment attorneys,3 and its proposals are expected in early 1995. a
George Noble Medical College of St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
individual RMOs should balance its need to protect the Minister, with its recognition of how the statutory powers vested in it determine individual patient care planning. Good practice dictates that communication and coordination at this clinco-political interface is essential. Achieving this end demands that both parties display mutual respect for each other’s agendas. The recent circular’ from the Home Office (dated Dec 5, 1994) is a worrying development because it is clearly based on political expediency after media interest in the case of a restricted patient who had gone on a holiday with the Home Secretary’s consent. Without any prior consultation, the Home Office has written to all RMOs informing them that "with immediate effect, and subject to such exception as he (Home Secretary) may consider appropriate in the circumstances of any particular case, he will normally no longer give consent for restricted patients to have escorted or unescorted leave of absence from hospital for holiday or holiday-type activity". The imperative tone of the letter is disturbing in itself but, coupled with the broad yet confusing definition of holiday and insistence that every decision be referred to him, leaves a very bitter aftertaste. The code of practice for the purposes of the Act states that medical treatment "includes nursing and also includes care, habilitation and rehabilitation under medical supervision, ie, the broad range of activities aimed at alleviating or preventing a deterioration of, the patient’s mental disorder". The Home Secretary’s functions as defined in section 118 (3), Mental Health Act, 1983, indicate that before making any alteration in the code of practice the Home Secretary "shall consult such bodies as appear to him to be concerned". The circular suggests that holidays or holidaytype activities are no longer viewed as being part of medical treatment.
Raymond F Travers Scott Clinic, Prescot,
1 A Working Party Report. The living will. London: Edward Arnold, 1988. 2 Re T (Adult: refusal of medical treatment) (1992) 9 BMLR 46, [1992] 4 All ER 649, [1993] Fam 95, [1992] 3 WLR 782. 3 The Law Commission Consultation Paper No 129. Mentally Incapacitated Adults and Decision-Making. Medical Treatment and Research. London: HMSO, 1993.
Restriction orders and the UK Home Office
1
Merseyside WA9 5DR, UK
Potts JM. Urgent notification: leave for restricted Home Office, 1994.
patients. London:
Effect of liver transplantation on autonomic dysfunction in familial amyloidotic polyneuropathy type I widely accepted that patients with familial amyloidotic polyneuropathy (FAP) type I improve clinically or at least do not get worse after liver transplantation. 1,2 SIR-It is
normal circumstances in the UK, the medical officer (RMO) can grant to any patient responsible who is for the time being liable to be detained in a hospital under Part II of the Mental Health Act 1983, leave to be absent from the hospital subject to conditions (if any) as that officer considers necessary in the interest of the patient or for the protection of other persons (Section 17). Under Part III of the Act, which deals with patients concerned in criminal proceedings or under sentence, certain patients can be subject to special restrictions under a restriction order. These restrictions include powers exercisable only with the consent of the Secretary of State, of which the power to grant leave of absence under Section 17 is one. When a patient’s care team is satisfied that leave of absence, for whatever purpose, is appropriate, and where the patient is subject to a restriction order, the RMO consults with the Secretary of State via his representatives at C3 division, Home Office. The RMO’s relationship with the Home Office has important implications for the doctorpatient relationship, and a balance has to be found between the individual patient’s needs and wider concerns of public protection. Equally, the Home Office’s relationship with
SIR-Under
However,
no measurements
have been done
to
confirm this
3
effect. An FAP patient was investigated between the time before and 8 months after liver transplantation. Although no 123Ilabelled M-iodobenzylguanidine (MIBG) uptake was recognised in the myocardium before transplantation, significant uptake was seen in the anterior wall 8 months after the operation. The coefficient of variance (CV) of the R-R interval revealed electrocardiographic slight
Table:
Changes
in autonomic function before and after
hepatic
transplantation 195
Living wills
in HIV infection and AIDS
SiR-Meadows (Nov 26, p 1509) presents interesting results on a limited sample of 40 completions of over 20 000 living will forms distributed. Age Concern has published a book on living wills,’ and elderly people who are interested in completing one are directed to the Terrence Higgins Trust and to the Voluntary Euthanasia Society, which might account for the 1 non-HIV-related completion of Meadows’ 17 respondents with terminal disease. The Voluntary Euthanasia Society emphasises the importance of communication of the advance directive with the medical practitioners concerned. A healthcare proxy has no legal power whatsoever. A living will is valid2 only if at the time the will was made the patient had the capacity to consent or refuse the treatment, and the patient must have anticipated and intended his decision to apply to the circumstances that ultimately prevail. The patient’s decision must also have been reached without undue influence. To ensure validity of the completed document communication with medical staff is imperative if possible end-of-life circumstances are to be anticipated, and then decided upon. The Law Commission is reviewing the law in this respect with
view to possible legislation for advance directives, including medical treatment attorneys,3 and its proposals are expected in early 1995. a
George Noble Medical College of St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
individual RMOs should balance its need to protect the Minister, with its recognition of how the statutory powers vested in it determine individual patient care planning. Good practice dictates that communication and coordination at this clinco-political interface is essential. Achieving this end demands that both parties display mutual respect for each other’s agendas. The recent circular’ from the Home Office (dated Dec 5, 1994) is a worrying development because it is clearly based on political expediency after media interest in the case of a restricted patient who had gone on a holiday with the Home Secretary’s consent. Without any prior consultation, the Home Office has written to all RMOs informing them that "with immediate effect, and subject to such exception as he (Home Secretary) may consider appropriate in the circumstances of any particular case, he will normally no longer give consent for restricted patients to have escorted or unescorted leave of absence from hospital for holiday or holiday-type activity". The imperative tone of the letter is disturbing in itself but, coupled with the broad yet confusing definition of holiday and insistence that every decision be referred to him, leaves a very bitter aftertaste. The code of practice for the purposes of the Act states that medical treatment "includes nursing and also includes care, habilitation and rehabilitation under medical supervision, ie, the broad range of activities aimed at alleviating or preventing a deterioration of, the patient’s mental disorder". The Home Secretary’s functions as defined in section 118 (3), Mental Health Act, 1983, indicate that before making any alteration in the code of practice the Home Secretary "shall consult such bodies as appear to him to be concerned". The circular suggests that holidays or holidaytype activities are no longer viewed as being part of medical treatment.
Raymond F Travers Scott Clinic, Prescot,
1 A Working Party Report. The living will. London: Edward Arnold, 1988. 2 Re T (Adult: refusal of medical treatment) (1992) 9 BMLR 46, [1992] 4 All ER 649, [1993] Fam 95, [1992] 3 WLR 782. 3 The Law Commission Consultation Paper No 129. Mentally Incapacitated Adults and Decision-Making. Medical Treatment and Research. London: HMSO, 1993.
Restriction orders and the UK Home Office
1
Merseyside WA9 5DR, UK
Potts JM. Urgent notification: leave for restricted Home Office, 1994.
patients. London:
Effect of liver transplantation on autonomic dysfunction in familial amyloidotic polyneuropathy type I widely accepted that patients with familial amyloidotic polyneuropathy (FAP) type I improve clinically or at least do not get worse after liver transplantation. 1,2 SIR-It is
normal circumstances in the UK, the medical officer (RMO) can grant to any patient responsible who is for the time being liable to be detained in a hospital under Part II of the Mental Health Act 1983, leave to be absent from the hospital subject to conditions (if any) as that officer considers necessary in the interest of the patient or for the protection of other persons (Section 17). Under Part III of the Act, which deals with patients concerned in criminal proceedings or under sentence, certain patients can be subject to special restrictions under a restriction order. These restrictions include powers exercisable only with the consent of the Secretary of State, of which the power to grant leave of absence under Section 17 is one. When a patient’s care team is satisfied that leave of absence, for whatever purpose, is appropriate, and where the patient is subject to a restriction order, the RMO consults with the Secretary of State via his representatives at C3 division, Home Office. The RMO’s relationship with the Home Office has important implications for the doctorpatient relationship, and a balance has to be found between the individual patient’s needs and wider concerns of public protection. Equally, the Home Office’s relationship with
SIR-Under
However,
no measurements
have been done
to
confirm this
3
effect. An FAP patient was investigated between the time before and 8 months after liver transplantation. Although no 123Ilabelled M-iodobenzylguanidine (MIBG) uptake was recognised in the myocardium before transplantation, significant uptake was seen in the anterior wall 8 months after the operation. The coefficient of variance (CV) of the R-R interval revealed electrocardiographic slight
Table:
Changes
in autonomic function before and after
hepatic
transplantation 195