Psychiatric Advance Directives: What Psychiatrists Need to Know Now

Psychiatric Advance Directives: What Psychiatrists Need to Know Now

CME credit for this article is now expired. It appears here for informational purposes only.

At the end of this article, readers should be able to:

1. Describe the benefits of psychiatric advance directives (PADs) and the problems with their implementation.

2. Distinguish between the 3 types of PADs: the instructional directive, the proxy directive, and the combination directive.

3. Assess the limitations associated with PADs.

Psychiatric advance directives (PADs) are similar to medical advance directives except the focus is on mental health treatment decisions. PADs are increasing in favor among patients but are considerably underused compared with medical advance directives.

PADs were created as a result of several court cases from the 1970s and 1980s that focused on patient self-determination regarding medical and psychiatric care. These cases ultimately led to the Patient Self-Determination Act of 1990 (PSDA).1,2 This federal law requires Medicare and Medicaid providers to inform patients of state laws concerning advance directives; to ask whether the patient has an advance directive; and to inform the patient of his or her right to complete an advance directive. Since the PSDA was enacted, 25 states and the District of Columbia have added statutes to assist mentally ill persons in guiding their care when facing possible future decision-making incapacity.

PADs are a means to empower persons with mental illness by increasing autonomy and decreasing coercion in the treatment they receive. PADs allow an individual with mental illness, while competent, to describe early indicators of relapse; specify preferences for or against certain medications; weigh in on other treatment options that may or may not have worked previously; articulate acceptable trade-offs in treatment; give advance informed consent for treatment (including hospitalization when appropriate); and designate a surrogate to make future health care decisions on his or her behalf.3,4

Elements of PADs

The specific aspects of a PAD differ from state to state, but they generally contain the following guidelines1:

• Choice of medications, route of administration, dosage limitations

• Designation of treatment plan

• Preferences for a lengthier hospital stay versus more aggressive treatment considerations (or vice versa)

• Desires regarding unusual or experimental treatments

• Choices with respect to the use of nonpharmacological modalities (eg, electroconvulsive therapy)

• Designation of treatment setting and choice of physician

• Preferences regarding the management of emergency situations (eg, use of physical restraints, seclusion, chemical sedation)

• Plans for post-hospital discharge services and support services (eg, housing management)

PADs provide a means for patients to express their personal choices and make advance decisions about the treatment they want to receive during times of acute illness.3 PADs contribute to improved communication with providers, allow patients to have a role in their treatment, and allow for better relationships with family and caregivers. This can improve patient self-esteem, improve treatment compliance, and enhance the patient’s quality of life. Family members can better understand a patient’s illness, which may help them recognize early signs of illness.

There are 3 types of PADs: the instructional directive (eg, living wills), the proxy directive (eg, health care power of attorney), and the combination directive. Each type has its own strengths and weaknesses.

The strength of the instructional directive is that the patient’s wishes are written out clearly before he becomes incapacitated. The patient has a relative amount of reassurance that his wishes will be followed. This increases a sense of continued autonomy even in times of vulnerability. A weakness is that it might be too restrictive in scope and flexibility. A patient may be left with an outdated treatment regimen because the document has not been updated. In addition, unforeseen problems may arise for which solutions have not been clearly spelled out, thus leading to improvisation and potential conflicts between the patient, his family, and the physician.

The strength of the proxy directive is that it has more flexibility and it is easier to meet the changes or challenges that can arise during treatment. The patient appoints a surrogate that he knows and trusts, which enables a smoother transition of care if the patient loses decision-making capacity. However, a problem can occur if the surrogate’s decisions are not altruistic. In addition, there may not be a close family member or friend to serve as a proxy. In this case, a patient’s physician could serve as a proxy, but there is the potential for conflict of interest. Because the advance directive does not have the immediate oversight of a judge, some states explicitly forbid a psychiatrist to act as proxy.1

The combined directive has all the strengths of the other two directives and minimizes the weaknesses of each. The proxy portion gives broad decision-making authority to the patient’s substitute decision maker, who can use the instructional portion of the directive as proof of the patient’s wishes.3


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