Ethically Relevant Differences in Advance Directives for Psychiatric and End-of-Life Care

BACKGROUND: Psychiatric advance directives (PADs) represent a shift from more coercive to more recovery-oriented care and hold the promise of empowering patients while helping fill the gap in treatment of non-dangerous patients lacking decision-making capacity. Advance directives for end-of-life and psychiatric care share an underlying rationale of extending respect for patient autonomy and preventing the harm of unwanted treatment for patients lacking the decision-making capacity to participate meaningfully in planning their care. OBJECTIVE: Ethically relevant differences in applying advance directives to end-of-life and psychiatric care are discussed. DESIGN: These differences fall into three categories: (1) patient factors, including decision-making capacity, ability to communicate, and prior experience; (2) decisional factors, including expected outcome and the nature of the decisions; and (3) historical-legal precedent. RESULTS: Specific recommendations are offered. CONCLUSIONS: Clinicians need to appreciate the ethical implications of these differences to effectively invoke PADs or assist patients in creating PADs.