Psychiatric Advance Directives Research Articles

Psychiatric advance directives: Navigating the regulatory landscape.

Psychiatric advance directives: Navigating the regulatory landscape.

Occupational Advance Directives: Do You Have One?

Occupational Advance Directives: Do You Have One?

Impact of psychiatric advance directive facilitation on mental health consumers: empowerment, treatment attitudes and the role of peer support specialists

Background A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams. Aims We examined ACT clients’ attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference. Methods Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (n = 145) and post-facilitation 1–2-month follow-up (n = 116), to assess perceived consumer-directedness of PAD facilitation, empowerment and various treatment attitudes. Mean scores before and after the intervention were compared for PAD-completers, non-completers, and those who completed a PAD with a peer vs. non-peer. The effect of PAD completion was assessed using logistic and linear regression analysis. Results There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment. Conclusions PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

Psychiatric Advance Directives and their relevance to improving psychiatric care in Asian countries.

People with mental illness may be unable to provide critical input about the care they wish to receive during a psychiatric crisis because of altered mental states. It is therefore imperative that clinicians seek to understand service users' wishes for care while they are well and able to provide meaningful input into the discussion. Achieving such an end may be done by discussing and completing a psychiatric advance directive. However, very few Asian countries have legislation that supports such advance directives. The present article seeks to give physicians more information about advance psychiatric directives and the potential role they could play to improve the healthcare provided in Asia to people at risk of losing capacity due to a mental illness. The degree to which mental health legislation supports psychiatric advance directives is documented for each country of South East Asia and Eastern Asia.

Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial \u2013 DAiP study

BackgroundCompulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France.MethodsA multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis.SettingSeven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews.Participants400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French.InterventionsThe experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care.Main outcomes and measuresThe primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs.DiscussionImplication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed.Trial registrationClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

Psychiatric Advance Directives Under the Convention on the Rights of Persons With Disabilities: Why Advance Instructions Should Be Able to Override Current Preferences.

Psychiatric advance directives (PADs) are documents by means of which mental health service users can make known their preferences regarding treatment in a future mental health crisis. Many states with explicit legal provisions for PADs have ratified the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). While important UN bodies consider PADs a useful tool to promote the autonomy of service users, we show that an authoritative interpretation of the CRPD by the Committee on the Rights of Persons with Disabilities has the adverse consequence of rendering PADs ineffective in situations where they could be of most use to service users. Based on two clinical vignettes, we demonstrate that reasonable clinical recommendations can be derived from a more realistic and flexible CRPD model. Concerns remain about the accountability of support persons who give effect to PADs. A model that combines supported decision making with competence assessment is able to address these concerns.

Psychiatric Advance Directives: Origins, Benefits, Challenges, and Future Directions.

Psychiatric advance directives (PADs) are legal documents that allow individuals with psychiatric illness to designate decisions, while competent, about their future psychiatric care were they to lose competency due to psychiatric illness in the future. Among other items, these documents often include preferences regarding a surrogate decision-maker, types of medications, doses and routes of medications, seclusion and restraints, electroconvulsive therapy, and instructions for care of their property while incapacitated. While the concept and legal recognition of PADs has existed in the United States for several decades, use of PADs by patients and familiarity with PADs among mental health providers remain limited. This column reviews the origin of PADs, discusses several commonly considered arguments for and against the use of these documents, and concludes with a discussion of how PADs are currently used in the United States and their potential future role in mental health treatment.

Psychiatric Advance Directives.

They can enhance the lives of patients with mental illness, but multiple obstacles impede their implementation.

EAT-PAD: Educating about psychiatric advance directives in India.

With India enacting the Mental Health Care Act (MHCA; No. 10 of 2017a), Psychiatric Advance Directives (PADs) have been legalised and have become binding orders for psychiatrists treating patients. There is a paucity of research into acceptability of PADs in Indian mental health care, likely due to a lack of awareness. There are no educational measures about PADs provided for in this Act. Facilitators and facilitation methods have not been elaborated upon as well. The aim of this study is (a) to develop/evaluate the effectiveness of a structured Education-cum-Assessment Tool (EAT) in providing information regarding PADs and (b) to evaluate modes of facilitation required by patients to complete PADs. A tool was developed as per provisions regarding PADs in the Mental Health Care Bill of 2013. This tool was administered to patients ( n = 100), purposively sampled from the adult psychiatry review out-patient department (OPD). Patients were evaluated on retention of information, completion of PADs, modes of facilitation and time taken to write one. Mean years of education was 8.28 (±5.74) years and mean duration of illness was 8.30 (±7.04) years. In all, 65% had Below-Poverty Line (BPL) status. All participants completed valid PADs in an average of 15 minutes. About 93% required facilitation via assistance in writing and reminding. The mean EAT scores implied above 70% retention but did not relate to types of facilitation. EAT scores can be used as an approximate measure of the patient's ability to understand and retain information which is a part of decisional capacity. Types of facilitation can help in understanding patient's ability to communicate their choices. Service providers may find EAT a time-effective tool for uniformly educating service users regarding PADs and indirectly assessing competence.

Advance directives and nominated representatives: A critique.

With the ratification of the landmark United Nations Convention on Rights of Persons with Disabilities by India, it was imperative to revamp the mental health-care legislation, among other changes. Most notably, a presumption of mental capacity has been introduced, which means a paradigm shift in the client and provider relationship. The Mental Healthcare Act, 2017 empowers all persons to make advance directives (AD) and nominate representatives for shared decision-making. Psychiatric ADs (PADs) also seem to improve the information exchange between the care provider and the service user. PADs may also be used as a vehicle of consent to future treatments. While drafting the PAD, the drafter must also plan how such directed care would be financed. Insurance companies have not been mandated to comply with ADs. In the eventuality that the drafter's family refuse support for treatment specified in the PAD, the drafter would be left holding an unimplementable PAD. The AD saw its origins in the care of the terminally ill and decades later came to be utilized in mental health care. After nearly three decades of use in developed countries, evidence at best remains mixed or inconclusive. This review focuses on the AD from the Indian perspective.

Comments on "How Do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study from India".

Comments on "How Do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study from India".

Authors' Response to the Comments on "How Do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study from India".

Authors' Response to the Comments on "How Do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study from India".

How do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study From India.

Background:Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce.Aims:To determine the possible treatment options our clients make as a part of psychiatric advance directives.Materials and Methods:Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices.Results:About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future.Conclusion:The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.

Factors influencing advance directives among psychiatric inpatients in India

ObjectivesAdvance directives are documents stating treatment preferences in case of future lack of decision making capacity. In India, as in many other countries, legislators advocate Psychiatric Advance Directives (PADs), while evidence on its use is limited. This study examined factors influencing PADs by gathering inpatients perspectives on PADs at discharge and investigating patient characteristics associated with the expression of treatment wishes in PADs. MethodsWe conducted a hospital based descriptive study in Bangalore. 200 patients were included. The Mini International Neuropsychiatric Interview, CGI-S and CGI-I (Clinical Global Impression scales), the Insight Scale-2, and an Illness insight assessment were completed within 3days of admission. We used the Bangalore Advance Directive Interview (BADI) to assess attitudes towards PADs. 182 subjects were reassessed within 3days of discharge, along with an interview on their perspectives on PADs. Results67% welcomed the need for PADs in India. 95.6% made their own PADs. 80% followed their doctors' advice in their PAD. Subjects lacking insight or remaining symptomatic at discharge opted significantly more often against ECT, antipsychotics, and inpatient care. Linear regression showed that low socio-economic status, unwillingness to stay in hospital, and having received ECT before were inversely associated with the expression of treatment wishes in PADs. ConclusionsThis study's findings are relevant for India and Western countries alike while generating legislation including patients' perspectives. A majority of patients favoured PADs. Absent insight, severe psychopathology and incomplete recovery may negatively influence the way PADs are completed. Therefore, clinicians must assess patient's capacity to formulate PADs carefully, as capacity may significantly influence patients' views. The timing of when to formulate one's PAD within the illness process may be essential.

Psychiatric advance directives in Australian mental-health legislation.

Following the recent widespread reform of mental-health legislation in Australia, psychiatric advance directives (PADs) have now been incorporated in four jurisdictions. We contextualise the potential role for PADs within the Australian legal framework and note their varying introduction across jurisdictions, with a focus on progressive legislation in the Australian Capital Territory (ACT). The formal recognition of PADs effectively shifts the trajectory of mental-health law towards a stronger recognition of consumer autonomy, albeit to varying degrees across jurisdictions. The most inspiring of these changes may be seen in the ACT Act, where an innovative framing of PAD provisions creates a safe space for clinicians and patients to engage, build therapeutic alliances and develop appropriate frameworks for further change.

Increasing the use of psychiatric advance directives

Increasing the use of psychiatric advance directives

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

Psychiatric advance directives (PADs) provide a legal mechanism for competent adults to document care preferences and authorize a surrogate to make treatment decisions. In a controlled research setting, an evidence-based intervention, the facilitated psychiatric advance directive (FPAD), was previously shown to overcome most barriers to PAD completion. This study examined implementation of the FPAD intervention in usual care settings as delivered by peer support specialists and nonpeer clinicians on assertive community treatment (ACT) teams. A total of 145 ACT consumers were randomly assigned, within teams, to FPAD with facilitation by either a peer (N=71) or a clinician (N=74). Completion rates and PAD quality were compared with the previous study's standard and across facilitator type. Logistic regression was used to estimate effects on the likelihood of PAD completion. The completion rate of 50% in the intent-to-treat sample (N=145) was somewhat inferior to the prior standard (61%), but the rate of 58% for the retained sample (those who completed a follow-up interview, N=116) was not significantly different from the standard. Rates for peers and clinicians did not differ significantly from each other for either sample. PAD quality was similar to that achieved in the prior study. Four consumer variables predicted completion: independent living status, problematic substance use, length of time served by the ACT team, and no perceived unmet need for hospitalization in crisis. Peers and clinicians can play a crucial role in increasing the number of consumers with PADs, an important step toward improving implementation of PADs in mental health care.

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

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

Australian Psychiatrists' Support for Psychiatric Advance Directives: Responses to a Hypothetical Vignette

This study examines whether Australian psychiatrists would support requests in a psychiatric advance directive (PAD) and the reasons underlying their decisions in response to a hypothetical vignette. An online survey was completed by 143 psychiatrists. Fewer than 3 out of 10 psychiatrists supported the patient to create a PAD which requested cessation of pharmacotherapy (27%) or remaining out of hospital and not being subject to an involuntary treatment order (24%) should their depression condition deteriorate. A thematic analysis showed that patient autonomy was the strongest theme among those who supported the patient to create a PAD, whereas the clinical profile of and risk to the patient and the professional or ethical imperative of the psychiatrist were strongest among those who were unsure about supporting the patient or who did not support the patient. These findings provide a challenge about how to fulfil obligations under the United Nations Convention on the Rights of Persons with Disabilities (2006).

Ethically Relevant Differences in Advance Directives for Psychiatric and End-of-Life Care.

Psychiatric advance directives (PADs) represent a shift from more coercive to more recovery-oriented care and hold the promise of empowering patients while helping fill the gap in treatment of non-dangerous patients lacking decision-making capacity. Advance directives for end-of-life and psychiatric care share an underlying rationale of extending respect for patient autonomy and preventing the harm of unwanted treatment for patients lacking the decision-making capacity to participate meaningfully in planning their care. Ethically relevant differences in applying advance directives to end-of-life and psychiatric care are discussed. These differences fall into three categories: (1) patient factors, including decision-making capacity, ability to communicate, and prior experience; (2) decisional factors, including expected outcome and the nature of the decisions; and (3) historical-legal precedent. Specific recommendations are offered. Clinicians need to appreciate the ethical implications of these differences to effectively invoke PADs or assist patients in creating PADs.