Psychiatric advance directives and reduction of coercive crisis interventions

Abstract

BACKGROUND: Psychiatric advance directives are intended to enable self-determined treatment for patients who lose decisional capacity, and thus reduce the need for coercive interventions such as police transport, involuntary commitment, seclusion and restraints, and involuntary medications during mental health crises; whether PADs can help prevent the use of these interventions in practice is unknown. AIMS: This study examined whether completion of a Facilitated Psychiatric Advance Directive (F-PAD) was associated with reduced frequency of coercive crisis interventions. METHOD: The study prospectively compared a sample of PAD completers (n=147) to non-completers (n=92) on the frequency of any coercive interventions, with follow-up assessments at 6, 12, and 24 months. Repeated-measures multiple regression analysis was used to estimate the effect of PADs. Models controlled for relevant covariates including a propensity score for initial selection to PADs, baseline history of coercive interventions, concurrent global functioning and crisis episodes with decisional incapacity. RESULTS: F-PAD completion was associated with lower odds of coercive interventions (adjusted OR=0.50; 95% CI=0.26-0.96; p < 0.05). CONCLUSIONS: PADs may be an effective tool for reducing coercive interventions around incapacitating mental health crises. Less coercion should lead to greater autonomy and self-determination for people with severe mental illness.

Psychiatric Crisis Management in the Emergency Care Hospital Network

“…Thus, in the descriptive analysis of psychiatric emergencies assisted at a hospital complex in the region of Sevilla (Spain), Conde Díaz, Esteban Ortega, Rosado Jiménez, Barroso Peñalver and Romero González (2009) found a growing increase of personality disorders and cases of aggression as the main reason for consultation. Similar data were found in the study by Swanson et al (2008), performed in North Carolina, United States, and Thornicroft, Alem, et al (2010) and Thornicroft, Farrelly, et al (2010) conducted in London and in the English cities of Manchester and Birmingham. Both studies aimed at the evaluation of protocols for the reduction of coercive interventions in crisis situations and action plans for mitigation of compulsory hospitalizations, in order to enlarge the gradients of autonomy and engagement of patients in the choice of therapeutic measures and in exercising control over their treatments.…”

Las voluntades anticipadas en pacientes con esquizofrenia: un instrumento para potenciar la autonomía

“…Si hay confianza entre equipo médico y paciente, los clínicos podrían ayudar a reducir esas intervenciones coercitivas e incluso del período de ingreso involuntario. Por otro lado, si hay constancia de un representante en el DVAP, éste puede consentir que se dé un cierto tratamiento, si es preciso, con el que evitar un ingreso involuntario (21). Además, hay más posibilidad de que haya un respeto por la voluntad del paciente cuando en el DVAP se ha dejado constancia de un representante al que acudir (15).…”

“…Con ello, el DVAP facilita el empoderamiento del paciente en la toma de decisiones, pues se le introduce en la toma de decisiones y se le da más protagonismo sobre las cuestiones referencias a su salud. En definitiva, la realización del DVAP conlleva una mejora en la relación asistencial, en el cumplimiento del tratamiento y por tanto en la recuperación de la persona, y contribuye a respetar el derecho a la autonomía (14)(15)(17)(18)(19)21).…”

Increasing the use of psychiatric advance directives

“…Research indicates that use of a PAD lowers the need for coercive treatment, 7,8 increases a patient's sense of control, 9 lowers acts of violence, 8 and more often results in treatment consistent with patient preference. 10 Further from an ethical perspective, if coercion is required for a patient with a PAD, it is done knowing that the patient, when in a better state of mind, sanctioned the action and helped direct the care.…”

“…Research shows that there are best practices in the use of PADs, such as working with a clinician who knows the patient to develop the PAD 3,7 and barriers to their use such as clinician unfamiliarity. 9,[12][13][14] Therefore, to get the most benefit out of PADs, clinicians and patients should be trained in their use.…”