Les directives anticipées en psychiatrie : revue de la littérature qualitative, état des lieux et perspectives

Abstract

Les directives anticipées sont un ensemble d’instructions écrites, rédigées à l’avance par une personne consciente, pour le cas où elle serait dans l’incapacité d’exprimer sa volonté. Dans certains pays, les directives anticipées sont aussi utilisées en psychiatrie dans la prise en charge de pathologies chroniques sévères comme la schizophrénie ou les troubles bipolaires. L’objectif est alors de permettre à un patient d’exprimer à l’avance ses volontés concernant sa prise en charge future, s’il devait traverser une nouvelle décompensation et se trouver dans l’incapacité de donner son consentement. Les directives anticipées permettent de donner des informations concernant les traitements médicamenteux, des instructions non médicales et de désigner une personne de confiance. Elles ont pour principal objectif la réduction de la fréquence des réhospitalisations, notamment lorsqu’elles se font sous contrainte. La revue de la littérature présentée dans ce travail permet de dresser un état des lieux de l’utilisation actuelle des directives anticipées en psychiatrie (DAP). Les bénéfices en termes de perception par les patients et de diminution des soins sous contrainte sont prometteurs. De plus, cette forme d’intervention s’inscrit bien dans les nouvelles perspectives de soins actuelles qui mettent l’accent sur les actions d’éducation thérapeutique et de prévention. Au vu des résultats présentés, un modèle particulier de directives anticipées, le joint crisis plan (JCP), nous semble proposer l’approche la plus intéressante et la plus riche sur le plan clinique. Advance Directives are written documents, which are used for people to notify their preference for a future situation when they are unable to give their consent. In psychiatry, psychiatric advance directives (PADs) can be used for patients with chronic psychotic disorders such as schizophrenia, or a bipolar disorder. PADs give the patient an opportunity to state wishes in advance about his/her treatment when he/she is in an acute state of illness. PADs were initially developed as a way for patients to defend themselves against the power of the psychiatrists, but are likely to become a useful tool in psychiatric care. PADs may contain information about medication, non pharmaceutical devices, and the name of a proxy decision maker. The main objective is to reduce the number of compulsory hospitalisations. This article is a qualitative review which carries out a state-of-the-art on the use of PADs for people with chronic psychotic disorders and defines suggestions to include this intervention in the French psychiatric context. We used the keywords psychiatric advance directives , crisis card , Ulysse directives , joint crisis plan (JCP) in the MEDLINE database to propose a qualitative review. We selected original clinical studies about the use of PADs for people with psychotic disorders. We included 36 articles. The qualitative analysis identified seven main themes: different types of PADs, effectiveness of PADs, practical use of PADs, patient's views, clinician's views, economical aspects, and legal aspects. The content of the PADs is consistent with psychiatric standard care in nearly all cases, regarding medical instructions, pre-emergency interventions, non-hospital alternatives and non-medical personal care. Patients use their PADs to describe prodromal symptoms of relapse and to suggest a treatment and a hospitalisation in advance. PADs are not used to refuse all treatments. Patients show a strong interest in creating a directive and a high level of satisfaction when using it. They feel they have more control over their mental health problem and are more respected and valued as a person. Thirty-six to fifty-three percent of clinicians had positive opinions regarding PADs. They valued the increase of the patient's autonomy and the prevention of relapse, but were concerned about difficulties for accessing the documents, and about the lack of training of the medical teams. Clinicians also feared the pressure of relatives or partners on treatment decisions. The qualitative analysis revealed the specific benefit of the JCP, a particular type of PADs negotiated with the medical team, on the reduction of the general number of admissions. We can identify practical problems such as the lack of accessibility to PADs in emergency situations, and the clinician's reluctance to use PADs. The only economical evaluation showed a non-significant decrease in total costs. PADs are used in a few countries, although their benefits in terms of patient's perceptions and compulsory admissions are promising. The JCP proposes a specific clinical approach based on therapeutic alliance. Its creation also involves the clinician, family members and a neutral mediator in a negotiated process. The JCP is likely to be the most efficient PAD model in reducing compulsory admissions. The use of the JCP appears to be relevant in the context of the new French legislation, establishing outpatient commitment orders and could be an effective way to improve the relationships with patients.