Psychiatric Advance Directives and Social Workers: An Integrative Review (original) (raw)
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Commentary: Psychiatric advance directives as tools for enhancing treatment of the mentally ill
The journal of the American Academy of Psychiatry and the Law, 2006
In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely accepted and utilized if they are viewed as tools for maximizing individual autonomy, with an emphasis on optimizing rather than merely restricting care.
Psychiatric Advance Directives, a Possible Way to Overcome Coercion and Promote Empowerment
Frontiers in Public Health, 2014
Psychiatric advance directives (ADs) allow an individual to state their preferences for future treatment at times when they may be unable to make considered decisions. There are differences in their form and legal value and the process associated with their use and completion. Several studies have now been completed to assess the impact of ADs on service use and coercion. Their results give a mixed picture but directives nevertheless have the potential to support the empowerment process, minimize experienced coercion, and improve coping strategies. These may in turn reduce the frequency of in-patient service use. Further studies on the different processes of facilitation involved and on different populations are necessary to improve our knowledge and use of these potentially powerful interventions.
2007
Psychiatric advance directives (PADs) are legal tools that allow competent individuals to declare preferences for future mental health treatment when they may not be capable of doing so as a result of a psychiatric crisis. PADs allow individuals to maintain self-determination during times when they are most vulnerable to loss of autonomy and in need of assistance to make their preferences known and honored. This article describes the content of twenty-eight open-ended, semi-structured qualitative interviews of adults with PADs who have experienced psychiatric crises. The qualitative analysis revealed three major themes from the interviews: (1) PADs as tools for empowerment and self-determination, (2) limited knowledge of PADs among service providers; and (3) difficulties communicating PADs to inpatient staff. In general, many participants expressed enthusiasm of the implementation of PADs but concern regarding clinicians' general lack of awareness about them. Additionally, some consumers discussed discomfort in even mentioning that they had a PAD to clinicians for fear of a negative response from them, or some type of involuntary treatment during their hospitalization. However, participants consistently viewed PADs as a positive tool to promote autonomy with the potential to facilitate stronger patient-provider relationships. Therefore, when working with individuals in psychiatric crisis who have a PAD, and who have never before experienced a sense of control over their own treatment, clinicians must recognize the potential troubling disequilibrium this sense of control may engender. In sum, though the most significant challenges facing the implementation of PADs involve clinicians' familiarity with and education about PADs, much promise for the future growth of PADs lies in the benefits perceived by the patients. Kim et al.
Psychiatric advance directives and reduction of coercive crisis interventions
Journal of Mental Health, 2008
Background: Psychiatric advance directives are intended to enable self-determined treatment for patients who lose decisional capacity, and thus reduce the need for coercive interventions such as police transport, involuntary commitment, seclusion and restraints, and involuntary medications during mental health crises; whether PADs can help prevent the use of these interventions in practice is unknown. Aims: This study examined whether completion of a Facilitated Psychiatric Advance Directive (F-PAD) was associated with reduced frequency of coercive crisis interventions. Method: The study prospectively compared a sample of PAD completers (n ¼ 147) to non-completers (n ¼ 92) on the frequency of any coercive interventions, with follow-up assessments at 6, 12, and 24 months. Repeated-measures multiple regression analysis was used to estimate the effect of PADs. Models controlled for relevant covariates including a propensity score for initial selection to PADs, baseline history of coercive interventions, concurrent global functioning and crisis episodes with decisional incapacity. Results: F-PAD completion was associated with lower odds of coercive interventions (adjusted OR ¼ 0.50; 95% CI ¼ 0.26-0.96; p 5 0.05). Conclusions: PADs may be an effective tool for reducing coercive interventions around incapacitating mental health crises. Less coercion should lead to greater autonomy and self-determination for people with severe mental illness.
Psychology, Public Policy, and Law, 2007
Statutes on psychiatric advance directives (PADs) allow competent individuals to document instructions for future mental health treatment in the event of an incapacitating crisis. PADs are aimed at promoting a stronger sense of patient self-determination, considered a central tenet of psychosocial rehabilitation and recovery; however, it is unknown what factors (if any) lead psychiatric patients with PADs to experience this benefit long term. The current study involves examination of 1 year effects on perceived treatment self-determination among 125 people with mental disorders who completed PADs via a 1-on-1 facilitated PAD intervention. Descriptive analyses showed participants documented medically relevant information that would assist doctors in a crisis and participants reported a high level of satisfaction with the facilitated PAD intervention. Multivariate analyses demonstrated that increased sense of autonomy at 1 year was predicted by race, understanding PADs, and verbal memory. Results provide useful guidance for administrators and clinicians, suggesting that PADs show promise in helping empower people with mental illness, especially African-American clients. Further, findings indicate that optimal implementation of PADs will be achieved when facilitated intervention assists people with mental illness to better understand what PADs are and to remember they have a PAD at the time they are experiencing a psychiatric crisis.
In an exploratory context, a qualitative approach was used to document perceptions of psychiatric advance directives (PADs) among legal professionals (n=50) and mental health professionals (n=150) in Ontario and Quebec. A Web survey was administered and a qualitative analysis approach was used to explore attitudes towards PADs. It was found that legal and mental health professionals hold diff erent values related to clinical, ethical and legal issues, which may be related to their professional training. Among the advantages associated with PADs include their ability to document a mentally ill individual's clear wishes, respect autonomous choices and foster collaborative treatment. Reported disadvantages of PADs include the possibility of new circumstances arising, mentally ill individuals may not comprehend completing a PAD, and whether a mentally ill individual should be permitted to refuse treatment on ethical grounds.
Issues in the development of advance directives in mental health care
Journal of Mental Health, 2003
Background: Interest in advance directives in mental health care is growing internationally. There is no clear universal agreement as to what such an advance directive is or how it should function. Aim: To describe the range of issues embodied in the development of advance directives in mental health care. Method: The literature on advance directives is examined to highlight the pros and cons of different versions of advance directive. Results: Themes emerged around issues of terminology, competency and consent, the legal status of advance directives independent or collaborative directives and their content. Opinions vary between a unilateral legally enforceable instrument to a care plan agreed between patient and clinician. Conclusion: There is immediate appeal in a liberal democracy that values individual freedom and autonomy in giving weight to advance directives in mental health care. They do not, however, solve all the problems of enforced treatment and early access to treatment. They also raise new issues and highlight persistent problems.