Use Of Psychiatric Advance Directives Research Articles

Protecting the Autonomy of Patients with Severe Mental Illness Through Psychiatric Advance Directive Peer-Facilitation

Protecting the Autonomy of Patients with Severe Mental Illness Through Psychiatric Advance Directive Peer-Facilitation

Cultural Influences on the Creation and Use of Psychiatric Advance Directives.

Little published research exists on how culture influences mental health service users when they create or use psychiatric advance directives (PADs). This column reports the results of a study (N=38 participants) of cultural factors that might encourage New Zealand Māori who engage in mental health services to make greater use of PADs in their care. The most important factor identified was the inclusion of family and friends in decision making during PAD creation and use. Discussions revealed multiple culturally important themes that were synthesized into a conceptual model, pou herenga (mooring place), which focuses on the importance of reassessing all aspects of one's life journey when creating a PAD.

Psychiatric Advance Directives: A Call for Humanization

Psychiatric Advance Directives: A Call for Humanization

Psychiatric advance directives and consent to electroconvulsive therapy (ECT) in Australia: A legislative review and suggestions for the future

Psychiatric Advance Directives (PADs) have been adopted in many jurisdictions around the world and in most Australian states and territories. They are seen as a less restrictive and patient-centered approach to the provision of mental health care. Electroconvulsive therapy (ECT) is a restricted treatment in most jurisdictions in Australia and across the world. This paper explores the history, regulation and use of ECT and PADs and the intersections between them. It provides an overview of the legislative framework in each Australian state and territory and explores some of the issues which have arisen such as complexity of the regulatory framework, making PADs binding for refusing and consenting to ECT, involving treating teams in how PADs are made, using restrictive interventions to implement PADs, and the role of the Tribunal. While PADs are often framed as an important legal tool for allowing patients to refuse psychiatric treatment (especially ECT), the paper emphasizes that they can also be an innovative way for people to consent to psychiatric treatment in advance and an empowering option to access mental health care. It then makes some suggestions for future reform.

Help and Hindrances to Completion of Psychiatric Advance Directives.

Psychiatric advance directives (PADs) allow service users to participate in their own mental health care in the event that they have a future mental health crisis and are deemed incompetent to make decisions, but few patients complete these documents. This Open Forum reports on factors that have helped or hindered completion of PADs in New Zealand. Perceived barriers to completion include resource limitations, procedural issues, access and storage problems, and mistrust between clinicians and service users regarding implementation. Having management and nursing "champions" of the process and organizing outreach meetings for all interested parties appear to aid completion. Targeted education and training promote creation and use of PADs, address negative attitudes, and assist service users in creating these documents. Information technology support is vital to having PADs uploaded and accessed in medical records.

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.

ADVANCE CARE PLANNING FOR MENTAL HEALTH TREATMENT: THE PERSPECTIVES OF AUSTRALIAN MENTAL HEALTH CLINICIANS

BackgroundInternational research highlights that the successful implementation of Advance Care Planning (ACP) for mental health treatment can depend on clinicians' attitudes and knowledge of Psychiatric Advance Directives (PADs). With proposed...

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

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.

Communication Commentary: Psychiatric Advance Directives

Communication Commentary: Psychiatric Advance Directives

P02-151 - Psychiatric advance directives: A stakeholders’ analysis on a multistage scenario

IntroductionInvoluntary admissions for the treatment of mental disorders affect 10% of mental health services users. Psychiatric Advance Directives (PADs) are documents that allow users notifying treatment preferences for crisis relapses. PADs have been experienced in several countries to improve users’ empowerment and reduce involuntary treatment. However, PADs take-up rate remains low and its effectiveness inconsistently evaluated. A hypothesis is that PADs should be considered as a process including its completion, registration, and honouring.AimA Multi-Criteria Stakeholders’ Survey was carried out to understand what an optimal PAD process should be, and what the main hurdles are in implementing it.Method102 Belgian stakeholders were selected among users and non-users groups, and face-to-face interviewed. Each interviewee scored 20 different options in designing, completing, registering and honouring a PAD. Four criteria were assessed: patient's autonomy, therapeutic relationship, mental care continuity and feasibility.ResultsOverall, the PAD options aiming at improving access to the document and honouring statements received lower scores than options aiming its design or completion. Therapeutic relationship was a more important criterion than autonomy for the non-users than for the users group (p = 0.03). Options with the highest scores emphasized that PADs should be requested by the user, drafted in an outpatient setting, include de-escalating methods, justify treatment preferences, allow appointing a surrogate decision-maker, and need health providers training or a case-coordinator to be honoured.ConclusionPAD access and honouring are problematic steps of the process and should be developed to improve the use of PADs and its possible effectiveness

Jail Administrators' Perceptions of the Use of Psychiatric Advance Directives in Jails

Jail Administrators' Perceptions of the Use of Psychiatric Advance Directives in Jails

Jail Administrators' Perceptions of the Use of Psychiatric Advance Directives in Jails

Jail Administrators' Perceptions of the Use of Psychiatric Advance Directives in Jails

Jail Administrators' Perceptions of the Use of Psychiatric Advance Directives in Jails

Individuals with serious mental illnesses are at high risk of incarceration. Jails are often unable to obtain information needed to provide appropriate care. Psychiatric advance directives may be useful tools to communicate treatment information to jails. This study explored their use as a novel intervention for individuals with mental illnesses in jails. Eighty jail administrators in North Carolina were surveyed to determine their support for psychiatric advance directives in jails. Relationships between respondents' job type (jail administrator or medical administrator) or jail census and support for the directives were examined by using chi square tests. Open-ended responses were analyzed using qualitative methods. Seventy-three percent of respondents indicated they supported psychiatric advance directives. Respondents from jails at or below a median census of 120 were significantly more likely to support psychiatric advance directives than those from larger jails. Psychiatric advance directives' informational function may prove valuable in jail settings. Additional research assessing directives as interventions for individuals with mental illnesses at risk of incarceration is needed.

Use of Psychiatric Advance Directives During Psychiatric Crisis Events

Use of Psychiatric Advance Directives During Psychiatric Crisis Events

Use of Psychiatric Advance Directives During Psychiatric Crisis Events

This paper presents the first empirical data regarding the rates and predictors of using psychiatric advance directives. Directives were accessed in only 20% of crisis events for the 69 participants selected on the basis of frequent use of psychiatric emergency and hospital services. Directives were 10 times more likely to be accessed when a surrogate decision-maker was involved in the crisis event. Directives were also more likely to be accessed over time and for people who had repeated crises, fewer prior hospitalizations, no substance use, and no prior outpatient commitment orders. Creation of more directives to increase clinician and system familiarity and more consistent appointment of surrogate decision-makers could increase use of directives.

Refusing Care: Forced Treatment and the Use of Psychiatric Advance Directives

ABSTRACT This article discusses recommendations regarding forced treatment proposed in Refusing Care: Forced Treatment and the Rights of the Mentally Ill (2002). Two of these recommendations are discussed. First, the work proposes that on a first, serious psychotic break individuals should be committable under lesser standards than ordinary civil commitment standards (likewise for involuntary medication). Each element of this recommendation is discussed: Why the break should be psychotic, why it should be a first–and only a first–break, and why it should be serious. In addition, certain counterweights are raised and answered–e.g., will this proposal discourage voluntary admissions? The second recommendation is that after a first psychotic break, patients should self-bind (i.e., give an advance directive) to care under similar circumstances as in the case of the first break–or self-bind to no treatment undertaken for the patients' own benefit. The use of self-binding in this context is discussed, in addition to some puzzles concerning its use. Most important, what we should do if a patient self-binds to no treatment, and then, when impaired, says he or she wants treatment? The last part of the article discusses practical dimensions of the recommendations proposed, e.g., how do we ensure that advance directives are truly voluntary?

Implementing psychiatric advance directives: service provider issues and answers.

Psychiatric advance directives (PADs) are an emerging method for adults with serious and persistent mental illness to document treatment preferences in advance of periods of incapacity. This article presents and responds to issues most frequently raised by service providers when planning for implementation of PADs. Issues discussed include access to PADs; competency to execute PADs; the relationship of PADs to standards of care, resource availability, and involuntary treatment; roles of service providers and others in execution of PADs; timeliness and redundancy of PAD information; consumer expectations of PADs; complexity of PADs; revocation and "activation"; legal enforceability of PADs; the role and powers of agents; liability for honoring and not honoring PADs; and use of PADs to consent for release of health care information. Recommendations are made for training staff and consumers, consideration of statute development, and methods to reduce logistical, attitudinal, and system barriers to effective use of PADs.

Psychiatric Advance Directives

Psychiatric advance directives (PADs) have been legally defined in 12 states and implemented in all but 9. PADs may prevent unwanted treatment and identify preferred treatment. They may also allow mentally ill persons to exercise autonomous control over care even during periods of illness-induced incompetence. PADs can be beneficial for intermittently psychotic patients who have a trusted health care provider and a surrogate decision maker. Because of the growing interest in the use of PADs, nurses should be informed about the intended purposes, benefits, and drawbacks of them.

Psychiatric Advance Directives: An Alternative to Coercive Treatment?

Psychiatric Advance Directives (PADs) are a legal means by which persons with mental illness, while competent to make healthcare decisions, may specify their preferences for treatment and may designate a surrogate decision-maker to act on their behalf in the event of an incapacitating mental health crisis. PADs have been advocated as a strategy to increase autonomy and decrease coercion in the treatment of severe psychiatric illness, but there has been little research on the actual use and effects of PADs. This article develops a conceptual model for how PADs might work, both directly and indirectly. According to the model proposed here, PADs might provide an effective tool for managing psychiatric crises but might also help to improve participation in regular outpatient treatment. This article further examines arguments for and against PADs and looks optimistically toward their use as an alternative to more coercive approaches to mental health treatment such as outpatient commitment (OPC).