Abstract
The psychiatric advance directive (PAD) is a proven technique for improving care for persons with mental illness that empowers rather than coerces patients.
They are also a tool in enhancing treatment and so possibly in reducing violence. Many states in the United States and other countries including the United Kingdom, New Zealand, Canada, India, and Australia have the legal structure in place for PADs. Other countries including Belgium, Germany, and Ireland have shown interest in the technique. 1,2 However, they are not being used to the degree that patients desire. 3
The need to improve psychiatric care has been a recent topic of interest to the public, partly because of reports describing the deplorable state of care in the United States and partly because of a series of senseless mass killings by persons with an apparent mental disorder. In addition, Weller 4 suggests that United Nations Convention on the Rights of Persons with Disabilities supports the use of PADs. While there is a clear need for improved policy, using PADs is something that can be done without changing the law. The PAD can be used for clinical benefit even before given legal support.
An advance directive is a written statement of treatment preferences in the event that a person is unable to speak for himself or herself. Advance directives also usually name a surrogate decision-maker to work with clinicians on the patient’s behalf. Advance directives are activated when a clinician determines that the patient lacks decision-making capacity. Advance directives were developed to anticipate end-of-life care or severe medical illness, and this is still their most common use.
However, the principle of extending the right of patients to have their treatment goals and preferences guide decision-making when they cannot speak in their own best interest applies to any type of treatment including psychiatric care.
There are two ways to think about psychiatric advance directives:
A Ulysses contract, which refers to the incident in the Odyssey, when Ulysses asks to be tied to the mast, so he can hear the Sirens’ irresistible song, but not be free to respond and face certain death. He instructs his crew to ignore his requests for release until he is safely away from the Sirens’ influence. Patients with mental illness can document in advance that treatment should proceed despite their refusal if certain criteria are met. The criteria to invoke the PAD are that the person is exhibiting signs of mental disorder as anticipated in the PAD; a clinician determines the lack of decision-making capacity and that treatment will be beneficial; and the person’s designated surrogate agrees with the need for treatment. This use requires legal support. A traveling plan of care is a document providing clinicians with information regarding treatments that are preferred and effective when the patient lacks the capacity to convey that information. This use can be implemented for clinical benefit without a supporting legal structure. There is a technique similar to the PAD called the joint crisis plan emphasizing the traveling care plan aspect.
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PADs can make use of both the Ulysses contract and traveling care functions. The Joint Commission, 6 the chief accrediting agency in US health care, recognized the utility of PADs in 2011 by including new PAD-related standards for accreditation of organizations serving adults with serious mental illness.
It has always been a challenge to balance caring-concern and civil rights in the effort to help people, who, as a result of their mental illness, are unable to perceive either the need or possibility of treatment. Current legal structures in the United States result in a treatment gap because they require most coerced psychiatric treatment to be justified by a patient’s dangerousness to self or others. Too many people, who are suffering and disabled with psychiatric disorders, but not dangerous, go untreated.
Research indicates that use of a PAD lowers the need for coercive treatment, 7,8 increases a patient’s sense of control, 9 lowers acts of violence, 8 and more often results in treatment consistent with patient preference. 10 Further from an ethical perspective, if coercion is required for a patient with a PAD, it is done knowing that the patient, when in a better state of mind, sanctioned the action and helped direct the care.
Sometimes, it is necessary to force treatment, especially if there is a potential for harm to the patient or others, but force is a last resort. Mental-health treatment is more humane and effective when the patient is engaged in the treatment. Ultimately, patient engagement is even the goal in forced treatment. This has been called the “thank you theory” which justifies forced treatment presuming that as a result of treatment patients will regain the insight to see that the forced treatment was needed and “thank” the clinician. 11
In the discourse regarding mental-health policy to improve care and lower incidents of violence, the public may choose to adopt increases in the ability to compel some patients into treatment. Unfortunately, coercive treatment, unsanctioned by the patient, is paternalistic and frequently experienced as such by the patients themselves.
Research shows that there are best practices in the use of PADs, such as working with a clinician who knows the patient to develop the PAD 3,7 and barriers to their use such as clinician unfamiliarity. 9,12 –14 Therefore, to get the most benefit out of PADs, clinicians and patients should be trained in their use.
PADs empower persons with mental illness and show a basic respect of their humanity. Compassion requires that instances of forced treatment be reduced to a minimum. The use of PADs can help, and clinicians can start using them immediately, while advocating their governments to support their use in law and policy.