To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour.
To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services.
Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis.
Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient’s mental capacity at the time of writing), time constraints and significant legal/ethical complexities.
The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area.
Declaration of interest
D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.
This article examines radical and socialist responses to Malthus's Essay on population, beginning with the response of William Godwin, Malthus's main object of attack, but focusing particularly upon the position adopted by his most important admirer, Robert Owen. The anti-Malthus position was promoted and sustained both by Owen and the subsequent Owenite movement. Owenites stressed both the extent of uncultivated land and the capacity of science to raise the productivity of the soil. The Owenite case, preached weekly in Owenite Halls of Science, and argued by its leading lecturer, John Watts, made a strong impact upon the young Frederick Engels working in Manchester in 1843–4. His denunciation of political economy in the Deutsch-Französische Jahrbücher, heavily dependent upon the Owenite position, was what first encouraged Marx to engage with political economy. Marx initially reiterated the position of Engels and the Owenites in maintaining that population increase pressured means of employment rather than means of subsistence, and that competition rather than overpopulation caused economic crises. But in his later work, his main criticism of the Malthusian theory was its false conflation of history and nature.
In this study photo-identification data were used to better understand movements, population structure and abundance of common bottlenose dolphin (Tursiops truncatus) in south-west England and surrounding waters, to inform conservation efforts. A catalogue of 485 photographic sightings of 113 individuals was compiled from ~150 common bottlenose dolphin encounters made on 87 dates between March 2007 and January 2014. From these and other data, three likely sub-populations were identified in the western English Channel, demarcated by bathymetry and distance to land: (1) south-west England – inshore Cornwall to Devon, (2) offshore English/French waters and (3) inshore France from Brittany to Normandy. Maximum abundance estimates for south-west England coastal waters, using two methods, ranged between 102 and 113 (range 87–142, 95% CL) over the period 2008–2013, likely qualifying the region as nationally important, whilst the yearly maximum was 58 in 2013. The population was centred on Cornwall, where 19 well-marked animals were considered ‘probable’ residents. There were no ‘probable’ resident well-marked individuals found to be restricted to either Devon or Dorset, with animals moving freely within coastal areas across the three counties. Movements were also detected within offshore English waters and French waters (from other studies) of the western English Channel, but no interchange has as yet been detected between the three regions, highlighting the possible separation of the populations, though sample sizes are insufficient to confirm this. Given the findings, south-west England waters should be considered as a separate management unit requiring targeted conservation efforts.