Issues in applying advance directives to psychiatric care in the United States

Abstract

Created while competent, psychiatric advance directives (PADs) are legal documents that specify treatment preferences and may also include designation of a surrogate decision maker for use during later periods of acute illness in which competent decision making is impaired. The paper begins with an overview of the potentially therapeutic effects of PADs and then addresses four areas in which legislation and methods of implementing PADs need to consider implications of therapeutic jurisprudence: competence to create PADs, when to activate them, whether revocation should be permitted during incapacity and circumstances for overriding PADs. The paper draws on the research carried out in the US by the author and sponsored by the National Institute of Mental Health. The ways in which issues have been resolved in practice in the US point to applications in other jurisdictions.