Psychiatric Advance Directives as a complex and multistage intervention: a realist systematic review

Abstract

Psychiatric Advance Directives (PADs) are documents that allow users with severe and chronic mental illnesses to notify their treatment preferences for future crisis relapses and to appoint a surrogate decision‐maker for a period of incompetence. Despite many supposed clinical and organisational benefits, their take‐up rate has remained very low and their clinical evaluation has given contradictory results for organisational outcomes. Intermediary results are available, however, which rely on different theoretical views about how PADs are supposed to work. We carried out a realist systematic review that considered the PAD as a multistage intervention including the definition of the document, its completion and its access and honouring. We identified the theoretical frameworks underlying this kind of intervention and examined the available evidence that supported or contradicted the expectations at each stage of the intervention. Forty‐seven references were retrieved, ranging from 1996 to 2009. Three frameworks underlie a PAD intervention: enhancement of the autonomy of the user, improvement of the therapeutic alliance and integration of care through partnership working. Although designed in the first place with a view to sustaining the user’s autonomy, results indicate that the intervention is more efficient within a therapeutic alliance framework. Moreover, much is known about the completion process and the content of the document, but very little about its access and honouring. The mixture of expectations makes the purpose of PADs unclear, for example, crisis relapse prevention or management, advance planning of long‐term or emergency care, or reduction in the resort to coercion. This may explain their low take‐up rates. Hence, frameworks and purpose have to be clarified. The shape of the whole intervention at each stage relies on such clarification. More research is needed, particularly on the later stages of the intervention, as the evidence for how PADs should be implemented is still incomplete.

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

“…The study followed the conclusions of the literature review mentioned above (Nicaise et al 2013) and was in two phases, which were carried out in Belgium between 2010 and 2011.…”

“…At the intervention design stage, the literature review reported that the range of stakeholders involved in the drawing up of PADs was one key variable among types of PADs (Henderson et al 2008;Nicaise et al 2013). When developed with a view to enhancing user autonomy, PADs were meant to be produced by the user alone or within a facilitation process, but without the involvement of clinicians (Amering et al 2005;Atkinson et al 2004;Khazaal et al 2008;Sherman 1998;Swanson et al 2006b;Van Citters et al 2007).…”

“…in relation to electroconvulsive therapy Nicaise et al 2013;Swanson et al 2006b) or the legal status of the document (Atkinson et al 2004;Henderson et al 2008), and overriding statements ), were not included in the survey as they did not apply to the current situation in the Belgian care system or did not provoke differences of opinion among stakeholders. Finally, the literature review reported that very little was known about the honouring stage (Nicaise et al 2013;Russo 2008, 2007). The options included in the study for the third stage of the intervention were suggested during the focus groups.…”

“…A realist systematic literature review noted that the effectiveness of PADs depended on the theoretical expectations underlying the intervention (Nicaise et al 2013). Nicaise and colleagues identified three distinct theoretical frameworks that underlay the rationale for which a PAD intervention would be effective.…”

Facilitation of Psychiatric Advance Directives by Peers and Clinicians on Assertive Community Treatment Teams

“…Previous research suggests very high consumer interest in PADs, but studies have found low rates of actual completion (2)(3)(4). PADs are challenging to complete without assistance, and there are misunderstandings of processes involved, concerns that directives may not be followed, and feelings of uncertainty about directing future decisions in unknown circumstances.…”