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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: David Oliver: How can we plan for old age if we won’t discuss it honestly? David Oliver. 357:doi 10.1136/bmj.j2759

David Oliver asks: How can we plan for old age if we won’t discuss it honestly? A desperate distancing from the uncomfortable fact of our own ageing and mortality feeds a failure to plan for future housing and care, potential loss of mental or physical capacity, or difficult decisions towards the end of life.

David Oliver is right, but like politicians of all persuasions, he evades the crucial issue of “The only way to avoid getting older is to stop living.”

We all extol the merits of living well with a worthwhile preservation of many if not all our faculties, independence and freedoms. But when they decline and survival brings serious impairments of our quality of life then the time has come to confront how we are to end life. Voluntary and assisted euthanasia require the utmost care and caution. Yet we do little to deal with dreadful pain, disabilities and failure of contact with family and friends, in a way we would deem cruel if applied to our dogs and other loved pets.

The age itself is a meaningless number. The decision whether continued existence is or is not worthwhile must always be an individual one, preferably made after candid but honest discussion with family and friends, if they are available.

But in the end, a civilised society should make due and carefully planned legal and medical provisions that enable a person with or without assistance to terminate their life.

Competing interests: No competing interests

22 June 2017
John Pearce
Emeritus Consultant Neurologist
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Re: David Oliver: Towards a GP consensus on the future of UK general practice David Oliver. 357:doi 10.1136/bmj.j2949

Oliver makes a fair point about the apparent ambivalence amongst GPs for how we see the future of primary care. Partly this is unsurprising, GPs are a heterogeneous specialty, larger in absolute numbers but dispersed in usually much smaller units than our secondary care colleagues. My sense from day to day clinical life, is that these debates are not ‘hot topics’ in the staff room.

The fully salaried model clearly has some attractions and I personally I would happily work directly for an NHS trust, rather than through a quasi-independent provider. But the prospect of transferring the entirety of primary care seems pretty far-fetched. Any government would be foolish (admittedly, foolishness is no stranger to health policy) to take on additional accountability that is now diluted across countless providers, at great cost and incurring an outcry from GP partners. Arguably, a salaried model is expanding piecemeal by default, through the collapse of individual practices and their absorption into trusts or larger organisations. It is worth remembering that some of the advocates for salaried vision are effectively partners in vast practices, who might well be happy to be at the helm but perhaps wouldn’t envisage being an employee themselves.

The proponents of ‘new models’, although highly vocal, seem to be drawn from a fairly sparse fringe of enthusiasts. Some of their optimism is probably amplified by the policy wonks whose job it is to believe that we will achieve more with less. We should be grateful to the innovators, these are the people who have the courage to run with new ideas and push us towards constant incremental improvement. But we should also be realistic about what the ‘new models’ might achieve. In a few cases cases, there is some encouraging evidence, for example in some of the projects involving care homes. By contrast, much of the impetus behind ‘working at scale’, seems based on assumption rather than evidence and is motivated by the assertion that traditional General Practice is ‘not fit for purpose’ and ‘unsustainable’. By unquestioningly abandoning traditional features of primary care, such as continuity of care and the gate keeper function, which have successfully contained cost and reduced iatrogenic harms we risk losing much more than we gain.

From my experience what most GPs want for primary care is straightforward; survival. They want the stabilisation of the health service. Few of us really believe this can be delivered by service tweaks substituting for adequate investment. Most of us seem happy to have the freedom to choose whether they work as salaried GPs or become partners. This sensible, if often discreet, corpus of front line doctors should continue to demand evidence and apply a rational dose of scepticism to every great new solution that comes along.

Competing interests: No competing interests

22 June 2017
Stephen Bradley
GP and Clinical Research Fellow
University of Leeds
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Re: Evidence based medicine manifesto for better healthcare Helen Macdonald, Duncan Jarvies, et al. 357:doi 10.1136/bmj.j2973

One problem with guidelines is that too often they end up clutching at straws. In very many cases, no good treatment exists yet recommendations are still made. A good example is non-specific low back pain. The NICE guidelines recommended acupuncture despite lousy evidence that it works to any useful extent. Eventually that was revised, and acupuncture was removed. There wasn't a lot left, and even the new guidelines fail to say explicitly that it's an unsolved problem.

Even Cochrane reviews seem to not yet understand the myth of P < 0.05. If you observe a P value close to 0.05 then in order to achieve a false positive rate of 5% you have to assume that you are 87% certain that there's a real effect before the trial is done. That's clearly preposterous.

Even if you observe P = 0.001 you would still have a false positive rate of 8% if the hypothesis was implausible (prior probability 0.1). For details, see

And remember that these numbers apply to perfect unbiassed experiments. They apply before you get to all the other problems of P-hacking, multiple comparisons etc etc.

These misunderstandings must be responsible for many false positive results. And every false positive not only harms patients (and budgets) but also provides ammunition for the anti-science brigade who now are now so evident.

Competing interests: No competing interests

21 June 2017
David Colquhoun
Research professor
Gower St, WC1E 6BT
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Re: Smoking ban in psychiatric hospital led to drop in violent assaults Anne Gulland. 357:doi 10.1136/bmj.j2952

It's evident, that a smoke-free policy in hospitals is important to protect health. It may be confusing to add some other aspects to the article of D. Robson et al. [1]. Their conclusion is a reduction of physical assaults after introduction of smoke-free policies in Departments of Psychiatry. In addition, psychotic disorders are associated with high rates of cardiovascular diseases (metabolic complications induced by antipsychotics, physical inactivity, smoking, poor diet).

The authors are right, that smoking during a psychiatric hospital admission has been a “longstanding, accepted and expected norm”. The concept to prohibit smoking in psychiatric wards is not new. An Australian analysis from 2008 [2] concluded that a implementation may have untoward effects in institutional mental health setting, staff expectation and the importance an adequate preparation and training of the staff. Today, there are dramatic problems in financial and personal resources [2]. In a study [3] with the focus on acute suicide risk and the prevalence of smoking in psychiatric inpatients, the authors showed that 80.41% of the sample of patients was hospitalized due to acute suicide risk, including affective disorders (80.3%), substance abuse disorders (36.1%), anxiety disorders (19%), psychotic disorders (16.4%), and personality disorders (10.3%). Of this sample 45.9% were current smokers. Substance abuse and psychotic disorder diagnoses were significantly correlated with current smoking status (<.0001, .02) with 77.1% and 55.9%, respectively. Research into the association between suicide risk, smoking and mortality in the seriously mentally ill patients remains unclear.

Tobacco smoke is known to affect plasma levels of many drugs, including the antipsychotic clozapine. The effects of suddenly stopping smoking on patients who take clozapine can be severe, as plasma concentrations are expected to rapidly rise, potentially leading to severe toxicity [4].

The implementation of smoke-free policies in secure psychiatric units is complicated, needs resources (staff) and an intensive Therapeutic Drug Monitoring (TDM) for patients receiving clozapine and other atypical antipsychotics.

At the moment, I think a smoke-free policy in secure psychiatric wards will not reduce physical assaults: it's dangerous. Therapy of tobacco addiction is not the main point of acute psychiatric inpatient treatment.

1) Robson D et al. Effect of on physical violence in a psychiatric inpatient setting: an interrupted time series analysis. Lancet Psychiatry. 2017 Jun 14. pii: S2215-0366(17)30209-2. doi: 10.1016/S2215-0366(17)30209-2. [Epub ahead of print]
2) Gagea SH, , Olivia M Maynard OM.Smoke-free policies in psychiatric hospitals need resources. Lancet Psychiatry, online 15 June 2017.
3) Lineberry TW et al. Population-based prevalence of smoking in psychiatric inpatients: a focus on acute suicide risk and major diagnostic groups. Compr Psychiatry. 2009 Nov-Dec;50(6):526-32. doi: 10.1016/j.comppsych.2009.01.004.
4) Gee SH et al. Effects of a smoking ban on clozapine plasma concentrations in a nonsecure psychiatric unit. Ther Adv Psychopharmacol. 2017 Feb;7(2):79-83. doi: 10.1177/2045125316677027.

Competing interests: No competing interests

21 June 2017
Detlef Degner
senior consultant, Psychiatry
Department of Psychiatry, Medical School of Georg-August University, Goettingen
Von-Siebold-Str5, D-37075 Göttingen, Germany
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

We are grateful to Sharma for comments on our recent article on the association between physicians’ age and patient outcomes in the U.S.(1) Although we agree that hospitalists may rely on specialists to treat their patients, the attending physician for a patient is ultimately responsible for the care and outcomes of that patient. Moreover, differences in specialist use do not bias our estimates because hospitalists’ decision to consult a specialist is part of the causal pathway. In other words, compared to older hospitalists, younger hospitalists may be more likely to consult with specialists who deliver better care, and this is part of why patients of younger hospitalists fare better. In addition, from a patients’ perspective, it does not matter whether mortality is lower because younger hospitalists provide higher-quality care themselves or consult high-performing specialists. We were aware that our findings can potentially be confounded by do-not-resuscitate (DNR) directives of patients, but our findings remained unaffected after excluding patients with cancer and those discharged to a hospice, both of which are important predictors of DNR directives. Also, our quasi-randomization approach should address differences in DNR directives across physicians of varying age. The results were also consistent when we studied Medicare beneficiaries aged 64 or younger, supporting the generalizability of our findings.

Li and Chen raised interesting points about additional adjustment variables. We agree seasonality may exist for some conditions. However, it is unlikely that older doctors treat patients during winter (when patients are sicker) and younger doctors practice during other seasons (when patients are less severe), and therefore, this does not introduce bias. For all our analyses, we adjusted for 27 comorbidities (Elixhauser comorbidity index) including renal failure. We did not adjust for right ventricular failure, BMI, and smoking, as information was not available in Medicare claim data. However, we are not aware of any evidence suggesting that older doctors are more likely to treat patients with these conditions, and our quasi-randomization approach demonstrated balance across a wide range of patient characteristics, raising the question of why right ventricular failure, BMI, or smoking should differ.

As Hsu et al. pointed out, our study did not directly evaluate the skills of older hospitalists. However, a previous systematic review has shown that medical skills and knowledge may decline as physicians age.(2) We agree that older physicians may be engaged in management work, but from patients’ point-of-view, it is irrelevant why mortality is higher among older hospitalists (i.e., is it because of depreciation of knowledge or due to part-time clinical work secondary to non-clinical, management responsibilities). The patient mortality in our data may be higher than in previously reported studies because we restricted our sample to non-elective admissions. This was important in order to minimize the impact the bias due to hospitalists selecting their patients (i.e., selection bias).

We agree with Mittler that multiple hospitalists may be involved in each admission, and that is exactly why we examined three different ways of attributing patient outcomes to physicians. We confirmed that our findings are not sensitive to how we attribute patients to physicians. Although we could not demonstrate a causal relationship between physicians’ age and patient mortality, our study was built upon a previous systematic review that found older physicians are less likely to deliver standard care and may not have up-to-date skills and knowledge.(2) We have no intention to politicize science, but we believe that patients have every right to understand physician characteristics associated with high-quality care. Furthermore, there is an active interest in the medical community to better understand how care quality changes over a physician’s career and to identify what interventions are needed to maintain skill.

Liepmann commented that the number of patients each hospitalist treated seemed too small. This is due to our method of attributing patient outcomes to a single doctor for a given hospitalization. Using this approach, only one doctor can be responsible for each admission. For example, if three high-volume hospitalists are working as a team, each hospitalist is treating 603 admissions (201*3=603) either as a primary (i.e., responsible for patient outcomes) or secondary (not responsible for patient outcomes) hospitalist.

Heston asserts that standard deviation (SD) may be more informative than standard errors (SE). We used SE because we were interested in whether patient mortality differs between younger and older doctors, rather than how variable patient mortality was within age category. It is important to note that a large sample size does not introduce biases in any way. Instead, a large sample size allows us to make precise estimates so that even a small difference in patient mortality between younger and older doctors can be detected. We agree that, given precise estimates, it is extremely important to appropriately account for confounders when we use big data. However, given that the large sample size leads to precise estimates without introducing any biases, there is no downside of using the data with a large sample size.

While we agree with Maslove that there is no single rule that can perfectly attribute the quality of care, the methods we used have been studied (3) and used in previous studies.(4) We have not randomly chosen physician characteristics that may be associated with patient outcomes. Instead, we rely on previous scientific evidence that suggested that older doctors may deliver lower-quality care than younger colleagues.(2) We are only interested in physician characteristics that have a plausible causal association with patient outcomes.

Sakurai raised an interesting point. In our study, physicians’ age was the exposure (treatment) variable of interest, whereas physicians’ sex was adjusted for as a confounder, and it is important to distinguish exposure variables and confounders. Confounders are the factors that influence the relationship between exposure and outcome variables, and therefore, regression coefficients of confounders are not meaningfully interpretable. The research questions are also completely different between physician age and sex, each of which was built on previous studies that led to different hypotheses.(1, 5)

1. Tsugawa Y, Newhouse JP, Zaslavsky AM, et al. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ 2017;357:j1797. doi: 10.1136/bmj.j1797
2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142(4):260-73.
3. Adams JL, Mehrotra A, Thomas JW, et al. Physician cost profiling--reliability and risk of misclassification. N Engl J Med 2010;362(11):1014-21. doi: 10.1056/NEJMsa0906323 [published Online First: 2010/03/20]
4. McWilliams JM, Landon BE, Chernew ME, et al. Changes in Patients' Experiences in Medicare Accountable Care Organizations. N Engl J Med 2014;371(18):1715-24.
5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875

Competing interests: No competing interests

21 June 2017
Yusuke Tsugawa
Research Associate
Anupam B. Jena
Harvard University
42 Church Street, Cambridge, MA
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Re: Half of salaried and locum GPs are stressed, BMA survey finds Abi Rimmer. 357:doi 10.1136/bmj.j2943

We read the recent BMA sessional GP survey results with interest and concern. (1) We know that the current challenges facing general practice can induce stress for GPs and call for the new Government to implement our 'Six Steps for Safer General Practice', launched ahead of the recent General Election. (2)

The GP workforce is crucial in sustaining the high-quality of care delivered to patients in general practice and the well-being of GPs is central to this. The NHS GP Health Service has been one early success of the General Practice Forward View (GPFV), as highlighted in the College's interim assessment. (3) We now need to ensure it is easily accessible to any GP who needs it, and that it is properly resourced on an ongoing basis to cope with demand.

We also need all the promises made in the GPFV, including £2.4 billion extra a year for general practice, 5,000 more full-time equivalent GPs, and 5,000 more practice staff members, to be invested in full and as a matter of urgency. (4) This would ease pressures on GPs and enable GPs to continue to work safely for the more than one million patients cared for by general practice surgeries daily.

The Royal College of General Practitioners Mental Health Toolkit ( has electronic resources for supporting healthcare professionals mental health and we urge stressed GPs to access these.

1) Rimmer A. Half of salaried and locum GPs are stressed, BMA survey finds. BMJ 2017;357:j2943 (
2) Royal College of General Practitioners. Six Steps for Safer General Practice: General Election Manifesto 2017 for England from the Royal College of GPs. April 2017 ( Accessed 21st June 2017
3) Royal College of General Practitioners. GP Forward View Interim Assessment. February 2017 ( Accessed 21st June 2017
4) NHS England. General Practice Forward View. April 2016. ( Accessed 21st June

Competing interests: No competing interests

21 June 2017
Faraz Mughal
GP and Royal College of General Practitioners (RCGP) Clinical Fellow for Mental Health
2) Elizabeth England, RCGP Clinical Champion for Mental Health 3) Helen Stokes-Lampard, Chair RCGP
Royal College of General Practitioners
London, NW1 2FB, UK
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Re: Association between trial registration and positive study findings: cross sectional study (Epidemiological Study of Randomized Trials—ESORT) Bethan Copsey, Susan Dutton, Virginia Chiocchia, Michael Schlussel, et al. 356:doi 10.1136/bmj.j917

We thank Spiegel et al. for their interest in our article [1]. We agree that the inability to account for unpublished trials is a limitation. However, it is difficult to predict whether and how the inclusion of unpublished trials would affect our results. While it is a reasonable assertion that unpublished trials are more likely to have negative study findings, it is less clear what percentage of unpublished trials are registered versus not registered in a trial registry.

Therefore, the inclusion of unpublished studies should be the focus of future research on trial registration and would respectfully disagree with the suggestion by Spiegel et al. that this research question is impossible to answer. Following an initial period of reluctance [2], research ethics committees have increasingly provided researchers with access to clinical trial protocols. Most recently, the United Kingdom Heath Research Authority has provided access to clinical trial protocols as well as “end of study reports” (equivalent to synopses of clinical study reports) for the Adherence to SPIRIT Recommendations Study (ASPIRE) [3]. This allows for the assessment of trial registration status as well as a determination of whether study findings were “positive”, irrespective of whether the trial results are published in a scientific journal. With these study details, one can determine whether there is indeed an inverse association between trial registration and positive study findings. These findings will be important for informing future efforts to expand or refine trial registration policies.


1 Odutayo A, Emdin CA, Hsiao AJ, et al. Association between trial registration and positive study findings: cross sectional study (Epidemiological Study of Randomized Trials-ESORT). BMJ 2017;356:j917.
2 Chan A-W, Upshur R, Singh JA, et al. Research protocols: waiving confidentiality for the greater good. BMJ 2006;332:1086–9. doi:10.1136/bmj.332.7549.1086
3 Odutayo A, Copsey B, Dutton S, et al. Characteristics and Dissemination of Phase 1 Trials Approved by a UK Regional Office in 2012. JAMA 2017;317:1799–801. doi:10.1001/jama.2017.1471

Competing interests: No competing interests

21 June 2017
Ayodele Odutayo
Resident Physician
Sally Hopewell
Centre for Statistics in Medicine University of Oxford Botnar Research Centre Windmill Road Oxford OX3 7LD UK
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Re: David Oliver: Towards a GP consensus on the future of UK general practice David Oliver. 357:doi 10.1136/bmj.j2949

I'm one of those people who still likes their job. Probably through an accident of location and job roles. I work in a small rural practice, 5000 patients, but despite being a small practice we still punch above our weight. I sit on the board of the local Fed, which provides a fascinating insight into how GP's can work together in a variety of different ways.

Our "cornershop", partner led model still works. We have GPs, a pharmacist, an NP, nurses, HCA and a relatively stable albeit aging rural population. Our pressures are those of distance and social isolation, rather than sheer patient volume. We are investigating working with other rural local practices.

Life as a GP is a rich and varied career, but many of my colleagues are not so fortunate as I. Unsafe patient numbers, increasingly unrealistic patient expectations, deprivation and inequality contributing to a tide of humanity needing care.

We practice community based medicine, translate complex science and treatment plans into understandable English, advocate for our patients in a system that feels messy with increasingly Byzantine pathways of care.

General practice is expert medical generalism, and in a world of increasing specialisms and multimorbidity, generalism is all the more important for the foundations of care.

Where can general practice go from here? Keep what's good, change what isn't, and let the solutions be local to the population it serves. A supermarket of care may suit urban populations, but for widespread rural communities this may result in no care at all.

Competing interests: Fed NED.

21 June 2017
Matthew Piccaver
GP Partner/Fed NED
Glemsford Surgery
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Re: David Oliver: Towards a GP consensus on the future of UK general practice David Oliver. 357:doi 10.1136/bmj.j2949

David’s hypotheses is that there is more that divides us (GPs) than unites us and he challenges us to find a consensus. This is long overdue, but there are fundamental problems that cannot be overcome very easily. Underlying our differences lie ontological and epistemic uncertainties. Put simply, there is no consensus on what a GP is, or what GPs do. These differences of form and function are not just philosophical, but are actual differences in how we practice and moral differences in what we ought to be and ought to do.

Many GPs chose to leave institutional life in hospitals because they value independence and autonomy more than their secondary and tertiary care peers. I have no evidence but I’d guess that doctors who had a happier time in boarding school are over-represented in not-so-dissimilar hospital institutions. GPs are the historical descendants of 19th century community apothecaries who worked in the communities they served. There were only allowed to join the medical profession – who boarded themselves away from communities, in hospitals - after a long and acrimonious battle. Suspicions, snobbery and differences remain even though this is far beyond the living memory of any doctor working today. My experience of 17 years in General Practice, which followed 4 years of hospital specialty posts and a stint overseas, is that I have become, and am becoming, something increasingly far removed from a hospital doctor. I practice social medicine, or as I have recently described it, ‘Poverty medicine’. My job, as I see it, is to help patients make sense of suffering and it is through making sense of suffering that everything else follows. I first grasped that this was what I was trying to do when I read Iona Heath’s 1995 Mystery of General Practice shortly in 2001. This short book does more than any other to try and define what a GP is and does.

She also warns that there are social processes in which patients are being transformed into consumers, healthcare into a commodity, and divisions between health and social care are being defined according to who is responsible for payment and delivery. These were even better articulated in Julian Tudor Hart’s, The Political Economy of Healthcare and are still being debated by everyone from the Kings Fund to Keep Our NHS Public today. The transformation is being driven by factors ranging from GP contracts to neoliberal individualism.

These changes have led to increasingly divergent philosophies of being and practice among GPs. Some see themselves as medical practitioners working in community clinics, with biomedical boundaries imposed by both resources and philosophy. Others see ourselves as social practitioners and community advocates, with boundaries imposed by bureaucrats with no understanding of patient needs. There are similar divides between those that see healthcare as a profit-oriented business and those who see healthcare as a human right that is fundamentally undermined by profit motives. Some business-oriented GPs may be fully committed to social medicine, but there are others who believe that the Inverse Care Law will ultimately lead to resources being distributed away from areas of greatest need the more that profitability drives investment. These ontological differences about what we are shape our moral differences about what we ought to be and what we ought to do, and therein lie some of the fundamental problems.

There is a reciprocity between making sense of suffering with the patients that I see every day and my identity as a GP. The one shapes the other. And as a trainer for the last two years, I have seen this transformation in my trainees. I think that we need to pay more attention to what GPs are and what we do. I suspect that most younger GPs will want to be in a Salaried Post so that they can concentrate on clinical activities like care, quality improvement and service development without the partnership pressures of finance, HR and contracts. And I believe, with some, possibly naïve optimism, that the next generation will be even more committed to social medicine than my own.

Competing interests: No competing interests

21 June 2017
Jonathon P Tomlinson
GP Partner Trainer
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Re: Margaret McCartney: Nurses must be allowed to exercise professional judgment Margaret McCartney. 356:doi 10.1136/bmj.j1548

The case, and in particular the NMC's behaviour, is on the face of it very troubling indeed, as Dr McCartney points out.

More generally, there is a lot of medical debate around 'should CPR be 'routinely offered if patients are very frail?''.

Personally, I believe that the clinical consequences of attempted CPR must be properly explained to patients - especially 'elderly frail patients' - and that it is not more 'DNACPR Orders' (things signed by clinicians) which we need, but more Advance Decisions refusing CPR (signed by patients). We need to do two things around CPR: promote ADRTs (which equates to 'if the patient has made the decision then everyone else simply follows that decision') and get all HCPs, including crucially 999 paramedics, to respect ADRTs [currently - and absurdly 'in a legal sense' - the 999 services respect 'DNACPR forms' but tend to respect written ADRTs refusing CPR much less: but it is the written ADRT which is 'legally-binding'].

On the theme, a retired doctor who I exchange e-mails with, recently sent this to me (I have permission to use it from the doctor), and I agree with this (the upper case was in the e-mail I received):

Until the doctors, the nurses and other " heath care givers" start understanding that the PATIENT SHALL HAVE THE LAST WORD every time", we will remain in the clutches of everyone who chooses to poke his nose in to the decision making of, for and by the patient.

Competing interests: No competing interests

21 June 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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