Advance Directives
Advance Directives
Definition
An advance directive is a written document in which people clearly specify how medical decisions affecting them are to be made if they are unable to make them or authorize a specific person to make such decisions for them. These documents are sometimes called “living wills.” Psychiatric advance directives serve the same purpose as general medical advance directives, but are written by mental health consumers as a set of directions for others to follow prior to the onset of a period in which their decision making is impaired or an incapacitating crisis arises.
Description
According to the National Mental Health Association (NMHA), it has become increasingly accepted over the past 30 years that consumers of mental health services know which treatments work best for them, and their opinions have become increasingly valued by those providing services. However, when mental health consumers become unable to make decisions or to give informed consent for treatments offered, others (including family, friends, judges, or care providers) make the decisions for them in crisis. In these kinds of crisis situations, advance directives may be beneficial for people receiving care, because the advance directive is a legal document that may protect them from unwanted treatment or involuntary hospitalization. Many states have passed laws related to advance directives and psychiatric advance directives. In some cases, the laws detail the content of these psychiatric advance directives, which may include instructions about antipsychotic medication, electroconvulsive therapy, or hospital admission, and the naming of people who can act as surrogate decision makers if necessary.
Psychiatric advance directives usually fall into two categories: instruction directives and agent-driven directives.
Instruction directives
An instruction directive is a written document that specifies which treatments individuals do and do not want, in the case that they become unable to make decisions about their care. These documents may indicate the affected individual’s preferences about many aspects of treatment, including:
- people who should be contacted at a time of psychiatric crisis
- activities that reduce (and heighten) anxiety for the individual
- effective alternatives to restraint or seclusion for the individual
- acceptable and unacceptable medications and dosages
- other interventions that might be considered during a time of crisis (such as electroconvulsive therapy)
Agent-driven directives
An agent-driven directive may also be called a durable power of attorney. This directive is a signed, dated, and witnessed document that authorizes a designated person (usually a family member or close friend) to act as an agent or proxy. This empowers the proxy to make medical decisions for patients when they are deemed unable to make these decisions for themselves. Such a power of attorney frequently includes the person’s stated preferences in regard to treatment. Several states do not allow any of the following people to act as a person’s proxy:
- the person’s physician, or other health care provider
- the staff of health care facilities that is providing the person’s care
- guardians (often called conservators) of the person’s financial affairs
- employees of federal agencies financially responsible for a person’s care
- any person that serves as agent or proxy for 10 people or more. The person who is to act as the proxy should be familiar with the individual’s expressed wishes about care, and should understand how to work within the mental health system.
These two distinct documents may, in some cases, be combined into one form.
Special concerns
In the United States, each state has laws about general medical advance directives and how those laws apply to psychiatric advance directives; a few states exclude psychiatric advance directives from their statutes. The specific form the advance directive should take, the language it should use, and the number of witnesses required to make the document legal and binding vary from state to state. In general, according to the National Mental Health Association, physicians and other health care professionals are expected to comply with the instructions of an advance directive, as long as those instructions are within the guidelines of accepted medical practice. It is recommended that people speak to their attorneys or physicians to ensure that their wishes are communicated in a form that is legally acceptable in their state.
Some other considerations associated with advance directives center on how they are implemented and whether or not a person who wants to complete one actually does so. Various solutions have been proposed to address these problems, including a proposal for video-based advance directives in which patients would produce videotapes documenting their directives. In addition, even though as many as two-thirds of people with mental illness report that they would complete a psychiatric advance directive, only 4-13% of outpatients receiving mental health treatment through public sector resources report having done so. One proposal put forward to address this disconnect is the implementation of facilitated psychiatric advance directives involving a guided discussion and review of choices for completing an advance directive. One study assessing the efficacy of this approach found that completion of psychiatric advance directives in the group that received the facilitated intervention was 61%, compared to the 3% of participants who did not receive facilitated intervention.
Resources
BOOKS
Clayman, Charles A., M.D. American Medical Association Home Medical Encyclopedia. New York: Random House, 1989.
Doukas, David J., and William Reichel. Planning for Uncertainty, A Guide to Living Wills and Other Advance Directives for Health Care. Baltimore, MD: Johns Hopkins University Press, 1993.
National Mental Health Association. Psychiatric Advance Directives Issue Summary. Mental Health America, 2002.
PERIODICALS
Moseley, Ray, Aram Dobalian, and Robert Hatch. “The Problem with Advance Directives: Maybe It Is the Medium, Not the Message.” Archives of Gerontology and Geriatrics 41 (2005): 211–19.
Srebnik, Debra S., and others. “The Content and Clinical Utility of Psychiatric Advance Directives.” Psychiatric Services 56 (2005): 592–98.
Swanson, Jeffrey W., and others. “Facilitated Psychiatric Advance Directives: A Randomized Trial of an Intervention to Foster Advance Treatment Planning among Persons with Severe Mental Illness.” American Journal of Psychiatry 163 (2006): 1943–51.
ORGANIZATIONS
Advance Directive Training Project. Resource Center. Albany, NY. Telephone: (518) 463-9242. <http://www.peer-resource.org>.
American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Telephone: (888) 357-7924. Fax: (202) 682-6850. Web site: <http://www.psych.org/>.
Judge David L. Bazelon Center for Mental Health Law. Washington, DC. Telephone: (202) 467-5730. <http://www.bazelon.org/advdir.html>.
Mental Health America. (Produces a Psychiatric Advance Directives Toolkit). Telephone: (800) 969-6642.
National Association of Protection and Advocacy Systems. Washington DC. Telephone: (202) 408-9514. <http://www.protectionandadvocacy.com>.
OTHER
Caring Connections. Part of the National Hospice and Palliative Care Organiation. Toll-free helpline: (800) 658-8898 (also available in Spanish at Telephone: (877) 658-8896). <http://www.caringinfo.org/i4a/pages/index.cfm?pageid=1>.
National Library of Medicine. National Institutes of Health. “Advance Directives.” <http://www.nlm.nih.gov/medlineplus/advancedirectives.html>.
Joan Schonbeck,
RN Emily Jane Willingham, PhD