Abstract:The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) was the first legally binding instrument explicitly focused on how human rights apply to people with disability. Amongst their obligations, consistent with the social model of disability, the Convention requires signatory nations to recognise that " . . . persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life" and mandates signatory nations to develop " . . . appropriate measures to provide access by persons with disability to the support they may require in exercising their legal capacity". The Convention promotes supported decision-making as one such measure. Although Australia ratified the UNCRPD in 2008, it retains an interpretative declaration in relation to Article 12 (2, 3, 4), allowing for the use of substituted decision-making in situations where a person is assessed as having no or limited decision-making capacity. Such an outcome is common for people with severe or profound intellectual disability because the assessments they are subjected to are focused on their cognition and generally fail to take into account the interdependent nature of human decision-making. This paper argues that Australia's interpretative declaration is not in the spirit of the Convention nor the social model of disability on which it is based. It starts from the premise that the intention of Article 12 is to be inclusive of all signatory nations' citizens, including those with severe or profound cognitive disability. From this premise, arises a practical need to understand how supported decision-making can be used with this group. Drawing from evidence from an empirical study with five people with severe or profound intellectual disability, this paper provides a rare glimpse on what supported decision-making can look like for people with severe or profound intellectual disability. Additionally, it describes the importance of supporters having positive assumptions of decision-making capacity as a factor affecting supported decision-making. This commentary aims to give a focus for practice and policy efforts for ensuring people with severe or profound cognitive disability receive appropriate support in decision-making, a clear obligation of signatory nations of the UNCRPD. A focus on changing supporter attitudes rather than placing the onus of change on people with disability is consistent with the social model of disability, a key driver of the UNCRPD.

Figure 3-Change in middle cerebral artery blood velocity during caffeine and placebo supplementation compared with baseline. Male patients (A) and female patients ( B).

The structure of postgraduate medical training rightly puts enormous emphasis on gathering clinical experience and constantly updating knowledge of relevant medical research to use in practice. At most, this can be contrasted with the slight emphasis on clinical leadership and acquiring the skills to effect change and improve the quality of care. Doctors play central roles in orchestrating the clinical management of patients across multiple settings within the healthcare system. They also routinely encounter the many problems within the systems that they work, affecting their own practices as well as those of other healthcare professionals. They thus represent a tremendous resource for identifying solutions to these problems and playing leadership roles in implementing them. However, physician training programs focus almost entirely on the knowledge and skills to manage clinical problems, with almost no training in skills related to healthcare management or effective quality improvement. In this article, we describe one attempt to improve this situation. In four hospitals in the Severn Deanery in the Southwest of England, first-year doctors carry out a structured and supported quality improvement project of their choice throughout their first year of training. To date, 30 such projects have been or are being run. This has significant benefits for both the trusts they are working for as well as for their own professional development. We describe the successes, difficulties and future of this programme.

Aims It is widely held that tolerance develops to the effects of sustained caffeine consumption. This study was designed to investigate the effects of chronic, staggered caffeine ingestion on the responses of an acute caffeine challenge, during euglycaemia . Methods Twelve healthy volunteers were randomized using a double-blind, crossover design to take either 200 mg caffeine (C-replete) or placebo (C-naïve) twice daily for 1 week. Following baseline measurements being made, the responses to 200 mg caffeine (blood-pressure, middle cerebral artery velocity, mood and cognitive performance) were examined over the subsequent 120 min. Blood glucose was not allowed to fall below 4.0 mmol l -1 . Results After the caffeine challenge, middle cerebral artery blood velocity decreased in both conditions but was greater in the C-naïve condition ( -8.0 [-10.0, -6.1] cm s -1 vs -4.9 [-6.8, -2.9] cm s -1 C-replete, P < 0.02). Systolic blood pressure rise was not significantly different in C-naïve, although this rise was more sustained over time ( P < 0.04). Mood was adversely affected by regular caffeine consumption with tense aspect of mood significantly higher at baseline in C-replete 11.6 ± 0.6 C-naïve vs 16.3 ± 1.6 C-replete, P < 0.01). Cognitive performance was not affected by previous caffeine exposure. Conclusions Overall these results suggest that tolerance is incomplete with respect to both peripheral or central effects of caffeine.

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