Effectively implementing psychiatric advance directives to promote self-determination of treatment among people with mental illness.

Abstract

Statutes on psychiatric advance directives (PADs) allow competent individuals to document instructions for future mental health treatment in the event of an incapacitating crisis. PADs are aimed at promoting a stronger sense of patient self-determination, considered a central tenet of psychosocial rehabilitation and recovery; however, it is unknown what factors (if any) lead psychiatric patients with PADs to experience this benefit long term. The current study involves examination of 1 year effects on perceived treatment self-determination among 125 people with mental disorders who completed PADs via a 1-on-1 facilitated PAD intervention. Descriptive analyses showed participants documented medically relevant information that would assist doctors in a crisis and participants reported a high level of satisfaction with the facilitated PAD intervention. Multivariate analyses demonstrated that increased sense of autonomy at 1 year was predicted by race, understanding PADs, and verbal memory. Results provide useful guidance for administrators and clinicians, suggesting that PADs show promise in helping empower people with mental illness, especially African-American clients. Further, findings indicate that optimal implementation of PADs will be achieved when facilitated intervention assists people with mental illness to better understand what PADs are and to remember they have a PAD at the time they are experiencing a psychiatric crisis. Legislation aiming to promote advance care planning and treatment self-determination among people with mental illness has proliferated in recent years. In the United States, laws defining psychiatric advance directives (PADs) have been passed in 25 states, allowing competent persons to document advance instructions for their future mental health treatment or to designate a health care agent to make decisions for them, in the event of an incapacitating psychiatric crisis (Appelbaum, 2004;Srebnik & La Fond, 1999;. In addition to recognizing the potential benefits of PADs, many states are beginning to recognize legal obligations under the federal Patient Self-Determination Act of 1991, which includes informing all hospital patients that they have a right to prepare advance directives and-with certain caveats-that clinicians are obliged to follow these directives (Hoge, 1994). As such, federal law helps ensure that people with mental illness, in whatever state they live, can use medical advance directives to specify mental health treatment preferences or to assign proxy decision makers for mental health decisions.If followed by treatment providers, PADs can help patients gain better access to the types of treatment that work best for them, especially during times when they are most in need of care but least able to speak for themselves (Backlar, McFarland, Swanson, & Mahler, 2001;Joshi, 2003;Vuckovich, 2003). Further, the very exercise of preparing a PAD and discussing it with a mental health professional may enhance therapeutic alliance and improve treatment engagement (Atkinson &...

Users’ and Health Professionals’ Values in Relation to a Psychiatric Intervention: The Case of Psychiatric Advance Directives

“…This could explain why rates of uptake of PADs have remained low regardless of their type and why results obtained during clinical trials have been disappointing (Thornicroft et al 2011). At the same time, most studies noted that the endorsement of PADs by users and health professionals was decisive for their actual use (Atkinson et al 2004;Elbogen et al 2006Elbogen et al , 2007Thornicroft et al 2011); hence, understanding the theoretical expectations and values of stakeholders is crucial.…”

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

“…Some individuals may have completed a psychiatric advance directive that provides information about their preferences with regard to medication or other interventions (Elbogen et al 2007). Limited evidence suggests that such advance directives can improve patient adherence with treatment (Wilder et al 2010).…”

Medication Preferences and Adherence Among Individuals With Severe Mental Illness and Psychiatric Advance Directives

“…Although psychiatric advance directives were designed for crisis situations, they can also be used as person-centered plans to coordinate ongoing treatment (30,31). Facilitated psychiatric advance directives, in which a clinician or other support person assists the patient in completing an advanced directive, provide a forum for patients to express their preferences about psychiatric medications in a nonconfrontational manner (28).…”