certain interventions must not prejudice any other aspect of the medical care, such as the treatment of infections or of pain. X Physicians should talk to hunger strikers in privacy and out of earshot of all other people, including other detainees. Clear communication is essential and, where necessary, interpreters unconnected to the detaining authorities should be available and they too must respect confdentiality. X Physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities or others, such as family members. Physicians or other health care personnel may not apply undue pressure of any sort on the hunger striker to suspend the strike. Treatment or care of the hunger striker must not be conditional upon suspension of the hunger strike. X If a physician is unable for reasons of conscience to abide by a hunger striker’s refusal of treatment or artifcial feeding, the physician should make this clear at the outset and refer the hunger striker to another physician who is willing to abide by the hunger striker’s refusal. X Continuing communication between the physician and hunger strikers is crucial. Physicians should ascertain on daily basis whether individuals wish to continue a hunger strike and what they want to be done when they are no longer able to communicate meaningfully. These fndings must be appropriately recorded. X When a physician takes over the case, the hunger striker may have already lost mental capacity so that there is no opportunity to discuss the individual’s wishes regarding medical intervention to preserve life. Consideration needs to be given to any advance instructions made by the hunger striker. Advance refusals of treatment demand are respected if it refects the voluntary wish of the individual when competent. In custodial settings, the possibility of advance instructions having been made under pressure needs to be considered. Where physicians have serious doubts about the individual’s intention, any instructions must be treated with great caution. If well informed and voluntarily made, however, advance instructions can only generally be overridden if they become invalid because of the situation in which the decision was made has changed radically since the individual lost competence. Psychiatric care and treatment plans Page 43