Letters i MJA 202 (2) · 2 February 2015 most general physicians are very aware of the legal implications of such decisions Buckmaster et al Doctors’ knowledge of the law on withholding and withdrawing life- sustaining medical treatment TO THE EDITOR: Unfortunately, the research performed by White and colleagues 1 appears to be flawed by selection bias. This is the result of their failure to survey specialists in general medicine, who regularly make decisions on the withholding and withdrawing of life-sustaining medical treatment. Therefore, the findings of the survey may not accurately reflect real legal understanding among the specialists in our health system most frequently required to make these kinds of decisions. General physicians’ patients frequently require careful evaluation of any pre-existing advance care directives, and discussion with statutory health attorneys relating to decisions regarding the provision or withholding of life- sustaining treatment. In our view, most general physicians are very aware of the legal implications of such decisions, being required to regularly assess the capacity of patients with multimorbidity, frailty and cognitive impairment to consent to treatment, and to provide or withhold life-sustaining therapy. In addition, they use this knowledge in discussions with relatives and friends, especially when families disagree on the appropriate measures to be taken. General physicians also provide informal training of junior medical officers and medical students in the application of the law to end-of- life care, and in assessing medical futility and the wishes of patients or their statutory health attorneys. White et al should repeat their evaluation to ensure that the mix of specialties surveyed accurately represents the services that provide care for patients when knowledge of the local law is most relevant and critical. Education and training can then be more appropriately 2 Southern Cross University, Gold Coast, QLD. 3 University of Queensland, Brisbane, QLD. bp.white@qut.edu.au Competing interests: No relevant disclosures. doi: 10.5694/mja14.01363  Meeting end-of-life care needs for patients in custody TO THE EDITOR: The medicolegal complexities of withholding and withdrawing medical treatment in end-of-life (EOL) settings have been discussed in the Journal by White and colleagues. 1 EOL care is becoming increasingly important in the incarcerated population, posing unique challenges for health services. Although health teams are accustomed to discussing EOL issues and instituting advance care directives (ACDs) within the general community, knowledge of the legal implications of implementing ACDs in the prison setting is lacking. We see that it is becoming more important to have reference frameworks when exploring the EOL wishes of inmates. An ageing prisoner population, increasing incarceration times, underuse of preventive and screening schemes before incarceration, mental illness, illicit drug use, and high rates of tobacco smoking and alcohol misuse are some of the identified behaviours limiting life expectancy in this group. 2 To ascertain current Australian practices, we emailed the prison health authorities of other jurisdictions. A number of jurisdictions are beginning to engage patients in custody regarding their EOL care wishes, and are trialling the implementation of ACDs. However, to our knowledge, no jurisdiction has established EOL care policies for prisoners with life-limiting diagnoses. Within the Australian Capital Territory, we have access to reinforced in programs where they might have the greatest benefit. Nicholas D Buckmaster MB BS, FRACP Mark Forbes MB ChB, FCP(SA), FRACP Gold Coast University Hospital, Southport, QLD. nick.buckmaster@health.qld.gov.au Competing interests: Nicholas Buckmaster is past President of the Internal Medicine Society of Australia and New Zealand and a current member of its council. doi: 10.5694/mja14.01271  1 White B, Willmott L, Cartwright C, et al. Doctors’ knowledge of the law on withholding and withdrawing life- sustaining medical treatment. Med J Aust 2014; 201: 229-232.  IN REPLY: General medicine was one of eight specialties included at the pilot stage of our research. However, the response rate of general physicians was only 6% — the lowest of all specialties. We considered this rate to reflect a relative lack of interest in the topic, perhaps because end-of- life decision making is only part of the more diverse practice of general physicians. Our method for determining which specialties to survey also included a literature review, and asking doctors who pretested the survey instrument which specialties were most involved in end-of-life decision making. After extensive discussion within the research team, general physicians were removed from the main study. Despite this, we agree with Buckmaster and Forbes that surveying general physicians would be valuable, given their confirmation that end-of-life care is part of this specialty’s practice, and in order to understand the extent to which general physicians know the law. If it is possible to achieve a sufficient response rate, we would welcome the opportunity to conduct the study with this specialty. Ben White LLB(Hons), DPhil 1 Lindy Willmott BCom LLB, LLM, PhD 1 Colleen Cartwright PhD, MPH, BSW(Hons) 2 Malcolm H Parker MB BS, MHMedLaw, MD 3 Gail Williams MSc, MSc(Lond), PhD 3 1 Queensland University of Technology, Brisbane, QLD. surveying general physicians would be valuable White et al