Psychiatric Advanced Directives Face Obstacles : Infrastructure to uphold plans' legitimacy oftendoes not exist or is circumvented by conflicting laws.


ATLANTA – The potential benefits of advanced directives and other plans for future treatment during psychiatric incompetency have not received the attention they deserve from the mental health community, speakers said at the American Psychiatric Association's Institute on Psychiatric Services.

Plans for future treatment that take the form of psychiatric advanced directives, crisis cards, and joint crisis plans are well accepted in many circumstances by psychiatric patients at risk for future hospitalization. But the infrastructure to uphold the legitimacy and continuity of such plans often does not exist or is circumvented by conflicting laws.

Psychiatric advanced directives (PADs) are “very often not something that the person thinks up themselves. It's often something that we as advocates invite a person to consider,” said Peter Stastny, M.D., of the department of psychiatry at Albert Einstein College of Medicine, New York.

A PAD can be a written instruction, a health care proxy, or both, and sometimes a living will. New York state requires that one person be the proxy for a patient's physical and mental health care.

Crisis cards allow patients to document their own wishes independent of a clinical team. On the other hand, patients collaborate with their personal contacts and treatment teams to create joint crisis plans to provide for care when the patients are not well. Patients who are offered a PAD typically have some psychotic symptoms in addition to a schizophrenia spectrum disorder or mood disorder.

Patients Generally Support PADs

In face-to-face interviews with 1,100 patients in five states, 73% said that they would want to complete a PAD. Yet only 7% of patients had already done so, reported Jeff Swanson, Ph.D., of the department of psychiatry and behavioral science at Duke University, Durham, N.C.

Patients were more likely to want an advanced directive if they were female, were of a racial or ethnic minority, had a history of self-harm, were under heavy external pressure to take medications, had police involved in a prior crisis, and had a low level of personal autonomy or mastery.

Patients who had none of these six characteristics had only a 55% probability of wanting a PAD. But patients who had all six had a 98% probability of desiring a PAD, Dr. Swanson said.

In interviews with 20 psychiatric patients who received training in how to create a PAD in New York, Dr. Stastny and his associates discovered that the patients understood the meaning of advanced directives and the important responsibility they give to patients.

The PAD was often seen as helpful rather than as antagonistic, Dr. Stastny said.

Half of the patients chose to create a PAD; the other half did not. The patients had been in the care of state-run or nonprofit mental health clinics for 10–20 years and had been hospitalized many times.

Patients with a PAD could select psychiatric medications they preferred to receive and those medications that they specifically did not wish to receive. They had to make a special effort to indicate that they preferred to receive no psychiatric medications since this was not one of the options stated on the PAD form.

They also could indicate which treatment facilities and doctors they preferred. Another section allowed patients to list approaches that helped them when they were having a hard time. “Everyone seemed to be concerned with improving their treatment and their chances of getting the best possible treatment,” Dr. Stastny said.

The training included how to select a health care proxy and determine what authority that person might have.

The patients completed the training by selecting a proxy. Many of the patients selected a sibling, an uncle, or a more distant family member, since they did not want to burden their parents further. Some patients wanted their primary health care provider to be their proxy, but this might present a conflict of interest.

The 20 patients in Dr. Stastny's study were among 6,000 patients in New York who were trained in writing PADs for 1.5 years as part of Kendra's Law, which was enacted in 1999. Kendra's Law provided about $1 million in funding for written PAD training. Kendra's Law permits court-ordered, assisted outpatient treatment in New York to individuals with mental illness who may deteriorate in the future because of a history of lack of compliance with treatment for their illness. Their lack of compliance may have caused them to be hospitalized, receive treatment services in a correctional facility, or act violently toward themselves or others.

The booklet that New York patients received as a part of PAD training was taken out of circulation because the New York State Office of Mental Health considered the PAD forms to be too complex for patients, Dr. Stastny said. The state no longer funds the PAD training project.


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