Issues in the development of advance directives in mental health care

Abstract

Background: Interest in advance directives in mental health care is growing internationally. There is no clear universal agreement as to what such an advance directive is or how it should function. Aim: To describe the range of issues embodied in the development of advance directives in mental health care. Method: The literature on advance directives is examined to highlight the pros and cons of different versions of advance directive. Results: Themes emerged around issues of terminology, competency and consent, the legal status of advance directives independent or collaborative directives and their content. Opinions vary between a unilateral legally enforceable instrument to a care plan agreed between patient and clinician. Conclusion: There is immediate appeal in a liberal democracy that values individual freedom and autonomy in giving weight to advance directives in mental health care. They do not, however, solve all the problems of enforced treatment and early access to treatment. They also raise new issues and highlight persistent problems.

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

“…However, the effect of value criteria on choosing specific options may be of interest beyond the limited set of options selected within the context of this study. For example, one important issue discussed in the literature about PADs is their possible legally binding status, the liability of clinicians to honour the statements, and the definition of conditions for overriding them (Atkinson et al 2003a;Van Dorn et al, 2006), particularly for proscriptive PADs Kim et al 2008;Swanson et al 2007). Although the legal status of the document was not discussed in our study, our results indicate that options for designing a PAD intervention should be driven by the enhancement of user autonomy, which might, in some contexts, mean making the PAD document legally enforceable.…”

Opportunities for independent living using direct payments in mental health

“…This is because they were able to negotiate with their workers in advance what kind of response and support they wanted in the event of a mental health crisis. Advanced directives or statements can be developed so the service user can determine in advance the support or treatment they would (or would not) like in the event of lessened capacity due to a mental health crisis (Mental Health Foundation 2002, 2004, Atkinson et al . 2003).…”

Models of advance directives in mental health care:

“…It was the approach in the Mental Health Bill in England and Wales through 'advance agreements' [4]. Scotland opted for the more neutral 'advance statements' [12,19].…”

“…Interest has been greater in the United States [15,16] which may have increased following the implementation of the Patient Self-Determination Act 1990 [17,18]. Conceptual issues in using advance directives in practice have been discussed elsewhere [19]. This research looks at survey results of the views of different stakeholder groups to models of advance directives.…”