Implementing psychiatric advance directives: service provider issues and answers

Promoting and hindering factors in the use of advance statements by Australian mental health clinicians

WHAT IS KNOWN ON THE SUBJECT?: Australia is a commonwealth of federated states and territories with each having unique mental health legislation. Victoria implemented advance statements based on legislation from overseas jurisdictions such as Scotland. The aim of this Victorian legislation was to underpin an individual's autonomy and decision-making in relation to treatment, particularly compulsory treatment. Advance statements allow individuals within the healthcare setting to document preferences for care and treatment during times of decompensated mental health, including informing nominated persons and preferences for recovery-oriented care; however, advance statements continue to attract barriers in their implementation and use. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: This paper focuses on legislation within one jurisdiction, Victoria, highlighting that several barriers to uptake exist, including uncertainty around the legal status of advance statements, the ideal setting to implement advance statements and concern around perceived consumer capacity to contribute to developing advance statements. There are substantial differences of opinion regarding adherence to treatment and recovery preferences contained within the advance statement, especially when decisions are made in the context of decompensated mental health. The Theoretical Domains Framework (TDF) model has been used to formulate recommendations in several other health studies, but to date has not been used to provide recommendations for greater implementation of advance statements. Implementation science is a contemporary research translation movement that seeks to identify factors and strategies that influence the adoption and integration of interventions like advance statements in real world settings. For this study it has been useful to identify barriers, consider implementation strategies and link this with policy frameworks to support practice change. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our study revealed that real challenges exist for mental health clinicians in adopting advance statements despite them having a strong held intention to empower service users to play a greater role in their own treatment and care decisions. The facilitators identified in this study highlight the notion that advance statements, and the concept of supported decision-making are needed in contemporary mental health care. Implementation science can assist in identifying barriers and suggesting facilitators including enhanced training, incentivization of advance statement creation, and greater awareness of the overarching purpose and principle of advance statement creation. Continued support and training in implementing and maintaining advance statements is required if mental health clinicians are to drive the uptake of this important reform to mental health legislation. Training needs to be provided that will address attitudes, and strongly held beliefs that pose barriers to the use of advance statements.

ABSTRACT

INTRODUCTION: Advance statements, also known as advance directives or psychiatric wills, provide individuals the opportunity to document care and recovery preferences during a period of mental ill health. Although the use of advance statements has gained momentum, little research has explored the factors that promote or hinder further uptake.

AIM

To determine the factors that promote or hinder the uptake of advance statements.

METHOD

Cross-sectional online survey of healthcare workers (n = 190).

RESULTS

Promoting factors include high perceived value of advance statements, particularly their role in recovery focussed care, while hindering factors include disagreement or responsibility for advance statement creation and legal status.

DISCUSSION

This study indicates that several hindering factors or barriers to advance statement uptake remain, and until these factors are addressed future implementation is arguably hindered. In this paper, we have used the Theoretical Domains Framework (TDF) model to outline suggestions to address hindering factors to implementation and guide future implementation strategies for advance statement uptake and practice change.

IMPLICATIONS FOR PRACTICE

The ongoing uptake of advance statements requires tailored implementation strategies address hindering factors. Strong promoting factors, such as the shared belief in the advance statement model and its role in recovery focused care, should be considered a strong foundation for implementation strategies.

What do we know about the experience of seclusion in a forensic setting? An integrative literature review

Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma-related harm and re-traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer-reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex-specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.

Mental Health Professionals' Positions in Relation to Advance Statements: A Foucauldian Discourse Analysis

Advance Statements enable mental health patients to have their preferences considered in treatment decisions in the event of losing capacity, but their uptake is poor. This is for complex and often conflicting reasons and factors related to service user, clinician, and institutional priorities, which influence clinical practice. A Foucauldian discourse analysis approach was used to explore how 13 mental health clinicians positioned their role in relation to Advance Statements. Five positions emerged from the data: taking account of peoples' wishes, enabling people to have their say (to a point), we know what's best, firefighting with risk, and leverage and liability. Discursive practices demonstrated and reinforced power relations between patients, clinicians, and wider systems. These findings highlight the challenge of legitimizing the knowledge of patients and need for a cultural shift at a systems level, which recognizes the ways Advance Statements meet the needs of all stakeholders.

The PACT advance decision-making template: preparing for Mental Health Act reforms with co-production, focus groups and consultation

BACKGROUND

Advance decision making (ADM) in mental health is supported by stakeholders but faces significant barriers. These must be overcome, not least to support the UK government's commitment to introduce statutory mental health ADM in England and Wales.

AIMS

To build understanding and address the gap between aspirations for ADM and actuality, with feasible co-produced ADM resources.

METHODS

We used focus groups and consultation to explore experience and views of stakeholders on ADM processes and materials. Discussions included feedback on an ADM template which was adapted accordingly throughout the research process.

RESULTS

Between September 2017 and December 2019, 94 individuals, representing stakeholders advised on design and process of ADM, alongside wider discussion at stakeholder events. Collaborative ADM was universally supported. Valued outcomes were diverse and combining aspirations with practicality required resolving dilemmas. A prototype template and guidance, the PACT (Preferences and Advance decisions for Crisis and Treatment) was co-produced, designed to help manage fluctuating mental capacity through collaborative decision making. The PACT enables direct engagement with medico-legal frameworks, with provision to facilitate person-centred assessments, treatment refusals and requests. Resources including supported engagement and cross-agency awareness and accessibility were seen as essential.

CONCLUSION

Our research confirms high stakeholder motivation to engage in ADM is hampered by multiple barriers. We identified enabling conditions for ADM and co-produced an ADM template and guidance which supports achievement of a range of valued outcomes. Further developments to support and evaluate the process of implementation are now needed to prepare for statutory change.

Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial - DAiP study

BACKGROUND

Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France.

METHODS

A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis.

SETTING

Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews.

PARTICIPANTS

400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French.

INTERVENTIONS

The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care.

MAIN OUTCOMES AND MEASURES

The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs.

DISCUSSION

Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

Psychiatric Advance Directives: Origins, Benefits, Challenges, and Future Directions

Psychiatric advance directives (PADs) are legal documents that allow individuals with psychiatric illness to designate decisions, while competent, about their future psychiatric care were they to lose competency due to psychiatric illness in the future. Among other items, these documents often include preferences regarding a surrogate decision-maker, types of medications, doses and routes of medications, seclusion and restraints, electroconvulsive therapy, and instructions for care of their property while incapacitated. While the concept and legal recognition of PADs has existed in the United States for several decades, use of PADs by patients and familiarity with PADs among mental health providers remain limited. This column reviews the origin of PADs, discusses several commonly considered arguments for and against the use of these documents, and concludes with a discussion of how PADs are currently used in the United States and their potential future role in mental health treatment.

Users' and health professionals' values in relation to a psychiatric intervention: the case of psychiatric advance directives

Although clinical and organisational benefits have been expected from Psychiatric Advance Directives (PADs), their take-up rates remain low and their evaluation disappointing. The endorsement of PADs by stakeholders is decisive for their use and understanding stakeholders' preferences for implementation is crucial. A Multinomial Discrete Choice analysis was carried out of options for designing, completing, and honouring PADs, with a view to enhancing user autonomy, therapeutic alliance, care coordination, and feasibility. Although autonomy underlies the whole process, the criteria determining options varied with the stage of the intervention. These criteria should be taken into account in future PAD intervention and evaluation processes.

[Advanced directives in psychiatry: A review of the qualitative literature, a state-of-the-art and viewpoints]

BACKGROUND

Advance Directives are written documents, which are used for people to notify their preference for a future situation when they are unable to give their consent. In psychiatry, psychiatric advance directives (PADs) can be used for patients with chronic psychotic disorders such as schizophrenia, or a bipolar disorder. PADs give the patient an opportunity to state wishes in advance about his/her treatment when he/she is in an acute state of illness. PADs were initially developed as a way for patients to defend themselves against the power of the psychiatrists, but are likely to become a useful tool in psychiatric care. PADs may contain information about medication, non pharmaceutical devices, and the name of a proxy decision maker. The main objective is to reduce the number of compulsory hospitalisations.

OBJECTIVE

This article is a qualitative review which carries out a state-of-the-art on the use of PADs for people with chronic psychotic disorders and defines suggestions to include this intervention in the French psychiatric context.

METHOD

We used the keywords psychiatric advance directives, crisis card, Ulysse directives, joint crisis plan (JCP) in the MEDLINE database to propose a qualitative review. We selected original clinical studies about the use of PADs for people with psychotic disorders.

RESULTS

We included 36 articles. The qualitative analysis identified seven main themes: different types of PADs, effectiveness of PADs, practical use of PADs, patient's views, clinician's views, economical aspects, and legal aspects. The content of the PADs is consistent with psychiatric standard care in nearly all cases, regarding medical instructions, pre-emergency interventions, non-hospital alternatives and non-medical personal care. Patients use their PADs to describe prodromal symptoms of relapse and to suggest a treatment and a hospitalisation in advance. PADs are not used to refuse all treatments. Patients show a strong interest in creating a directive and a high level of satisfaction when using it. They feel they have more control over their mental health problem and are more respected and valued as a person. Thirty-six to fifty-three percent of clinicians had positive opinions regarding PADs. They valued the increase of the patient's autonomy and the prevention of relapse, but were concerned about difficulties for accessing the documents, and about the lack of training of the medical teams. Clinicians also feared the pressure of relatives or partners on treatment decisions. The qualitative analysis revealed the specific benefit of the JCP, a particular type of PADs negotiated with the medical team, on the reduction of the general number of admissions. We can identify practical problems such as the lack of accessibility to PADs in emergency situations, and the clinician's reluctance to use PADs. The only economical evaluation showed a non-significant decrease in total costs.

DISCUSSION

PADs are used in a few countries, although their benefits in terms of patient's perceptions and compulsory admissions are promising. The JCP proposes a specific clinical approach based on therapeutic alliance. Its creation also involves the clinician, family members and a neutral mediator in a negotiated process. The JCP is likely to be the most efficient PAD model in reducing compulsory admissions. The use of the JCP appears to be relevant in the context of the new French legislation, establishing outpatient commitment orders and could be an effective way to improve the relationships with patients.

Psychiatric Advance Directives as a complex and multistage intervention: a realist systematic review

Psychiatric Advance Directives (PADs) are documents that allow users with severe and chronic mental illnesses to notify their treatment preferences for future crisis relapses and to appoint a surrogate decision-maker for a period of incompetence. Despite many supposed clinical and organisational benefits, their take-up rate has remained very low and their clinical evaluation has given contradictory results for organisational outcomes. Intermediary results are available, however, which rely on different theoretical views about how PADs are supposed to work. We carried out a realist systematic review that considered the PAD as a multistage intervention including the definition of the document, its completion and its access and honouring. We identified the theoretical frameworks underlying this kind of intervention and examined the available evidence that supported or contradicted the expectations at each stage of the intervention. Forty-seven references were retrieved, ranging from 1996 to 2009. Three frameworks underlie a PAD intervention: enhancement of the autonomy of the user, improvement of the therapeutic alliance and integration of care through partnership working. Although designed in the first place with a view to sustaining the user's autonomy, results indicate that the intervention is more efficient within a therapeutic alliance framework. Moreover, much is known about the completion process and the content of the document, but very little about its access and honouring. The mixture of expectations makes the purpose of PADs unclear, for example, crisis relapse prevention or management, advance planning of long-term or emergency care, or reduction in the resort to coercion. This may explain their low take-up rates. Hence, frameworks and purpose have to be clarified. The shape of the whole intervention at each stage relies on such clarification. More research is needed, particularly on the later stages of the intervention, as the evidence for how PADs should be implemented is still incomplete.

Advance agreements for mental health care: an examination of process and outcomes

OBJECTIVE

Despite high demand for anticipatory planning tools in mental health there is little Australian research about their implementation. This study examines the processes and outcomes of the introduction of structured mental health advanced agreements in the Australian Capital Territory.

METHOD

Thirty-three patients with serious mental illness collaborated with a key clinician to develop an advanced agreement. Patients and clinicians were provided with appropriate education, workbooks and materials. The process and outcomes associated with developing and completing an agreement were evaluated with patient and clinician interviews and self-report measures.

RESULTS

The process was strongly accepted by the patients with only 16% discontinuing for reasons related to the advanced agreement. Participants strongly endorsed benefits both to themselves and to the management of patients' illnesses. Service level impediments, particularly clinician acceptance, limited treatment options, and the lack of legal force of the agreement were identified.

CONCLUSIONS

When supported, mental health patients can work collaboratively with clinicians to produce anticipatory treatment requests which are beneficial, feasible and consistent with good care. Implementation of anticipatory planning in mental health will require service-level changes to promote clinician acceptance and to embed practices which facilitate these tools as part of routine care.

[Psychiatric advance directives and the role of autonomy]

Although psychiatric advance directives (PADs) are grounded in the ethics of autonomy, the relationship between the two is unclear. PADs are legal documents that allow individuals with mental illness to record their treatment preferences should they become incompetent in the future. The relationship between autonomy and PADs has been discussed in ethical, legal, and philosophical terms, but has not been clearly operationalized for clinical purposes. Autonomy is a fundamental ethical value that includes having the independence from outside controlling influences and the mental capacity to direct one's personal actions. Individuals with mental illness sometimes require assistance to understand their ethical and legal rights with respect to autonomous choice, and professional stakeholders need education regarding the importance of autonomy for clinical practice. Competency to consent to treatment is the mental prerequisite that ensures individuals with mental illness are able to complete PADs with insight, whereas autonomy is the value that empowers individuals to work towards their recovery.

Reducing barriers to completing psychiatric advance directives

OBJECTIVE

Psychiatric advance directives (PADs) allow individuals to plan for future mental health treatment. However, little is known about barriers to PAD completion. This paper examines an intervention's effect in reducing barriers to PAD completion.

METHOD

Patients were randomly assigned to a facilitated PAD session or control group. Barriers associated with (1) the PAD documents and (2) external support for PADs were assessed at baseline (n = 462), 6 months (n = 380) and 1 year (n = 362).

RESULTS

There were no significant baseline between-group differences on the two barriers. However, at follow-up both barriers were significantly lower in the experimental group. Further, barriers were predictive of PAD completion.

CONCLUSIONS

Structured facilitation can significantly reduce barriers to PAD completion. However, the intervention did not eliminate barriers. Findings are discussed in the context of possible system-level changes to further reduce barriers to PAD completion.

Do psychiatric advance directives protect autonomy?

A psychiatric advance directive (PAD) is a legal resource that allows a person to document his or her wishes about receiving mental health services in the event that he or she is unable to provide consent at a future time. Advantages for completing a PAD include promoting the person's autonomy and authentic self, minimizing harms, and promoting beneficence. However, more research is needed to describe the positive and negative consequences associated with completing and implementing a PAD in the clinical setting.

Psychiatric advance directives and the right to refuse treatment in Canada

OBJECTIVE

To provide a Canadian perspective on psychiatric advance directives (PADs) and assess whether these documents can be implemented as an adjunct to mental health services to empower people with mental illness.

METHOD

We reviewed Canadian jurisprudence over the past 15 years related to people with mental illness and the right to refuse medical treatment. Provincial mental health legislation is explained to discern PADs' possible effect in Canada.

RESULTS

Evidence is accumulating that legal and mental health professionals see PADs as useful documents to promote patient autonomy. Canadian jurisprudence, mental health legislation, and psychological research suggest that PADs could be implemented by legal and mental health professionals. Mental health legislation has the power to prohibit or facilitate choices regarding the right to refuse medical treatment.

CONCLUSIONS

This review suggests the need for greater empirical research to be conducted in Canada to determine stakeholders' perceptions of whether PADs could successfully be implemented and their interaction with legislation.

Overriding psychiatric advance directives: factors associated with psychiatrists' decisions to preempt patients' advance refusal of hospitalization and medication

Psychiatric advance directives (PADs) are intended to support patients' treatment decisions during a crisis. However, PAD statutes give clinicians broad discretion over whether to carry out patients' advance instructions. This study uses data from a survey of psychiatrists (N=164) to examine reasons for overriding PADs. In response to a hypothetical vignette, 47% of psychiatrists indicated that they would override a valid, competently-executed PAD that refused hospitalization and medication. PAD override was more likely among psychiatrists who worked in hospital emergency departments; those who were concerned about patients' violence risk and lack of insight; and those who were legally defensive. PAD override was less likely among participants who believed that involuntary treatment is largely unnecessary in a high-quality mental health system.

Psychiatric advance directives: a tool for consumer empowerment and recovery

Individuals with psychiatric disabilities identify choice and self-direction as central elements of recovery. During times of psychiatric crisis people may experience a frightening loss of choice and self-direction, which can be damaging and traumatic. Psychiatric advance directives (PADs) are legal documents created to address this loss of autonomy and choice during crises by allowing individuals to communicate in the present wishes for care during a future crisis. This paper examines the ways in which PADs support and can be a tool for recovery and discusses future recovery-oriented directions for PAD research and intervention.

Clinicians' attitudes regarding barriers to the implementation of psychiatric advance directives

OBJECTIVE

Psychiatric advance directives (PADs) may include documenting advance instructions (AIs) and/or designating health care agents (HCAs). Laws authorizing PADs have proliferated in the past decade, but there has been little research regarding perceptions of barriers to the implementation of PADs among groups of mental health professionals.

METHODS

A total of N=591 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey regarding their perceptions of potential barriers to the effective implementation of PADs.

RESULTS

Across the three professional groups barriers related to operational features of the work environment (e.g., lack of communication between staff, lack of access to the document) were reported at a higher rate than clinical barriers (e.g., inappropriate treatment requests, consumers' desire to change their mind about treatment during crises). However, psychiatrists were more likely to report clinical barriers to implementation than both psychologists and social workers. In multivariable analyses, legal defensiveness, employment in public sector mental health services, and a belief that treatment refusals will outweigh the benefits of PADs were associated with more perceived barriers, whereas age and endorsing positive perceptions of PADs were associated with fewer perceived barriers.

CONCLUSION

Psychiatrists, psychologists and social workers tend to perceive significant potential barriers to PADs, related to operational aspects of these professionals' work environment as well as certain clinical features of PADs for persons with severe mental illness. Additionally, legal defensiveness and general endorsement of PADs appear to shape perceptions of barriers to the effective implementation of PADs.

Psychiatric advance directives: qualitative study of informed deliberations by mental health service users

BACKGROUND

Established legal mandates and high expectations for psychiatric advance directives are not matched by empirical evidence documenting their actual implementation.

AIMS

To explore the interests, concerns and planning activities of informed mental health service users contemplating such directives.

METHOD

Standard qualitative research techniques were used: field observations, interviews, focus groups, archival research and key informant interviews; 33 persons participated in the interviews and focus groups. Transcripts were coded and analysed for thematic content, and results were member-checked.

RESULTS

Training set in motion labour-intensive projects: conceptualising how a psychiatric advance directive would work in one's life, mobilising resources, reviewing past experiences and assessing risks. Especially meaningful was the prospect of being treated as a responsible agent in future interactions with the mental health system.

CONCLUSIONS

Advance directives are best thought of as complex planning tools for future psychiatric crisis management, rather than focal interventions to enhance compliance. Research is needed to explore the institutional response to this prospective decision-sharing initiative.

Ulysses directives in The Netherlands: opinions of psychiatrists and clients

In this article we present a study on the opinions of Dutch psychiatrists and clients on Ulysses directives. In-depth interviews were conducted with 18 clients and 17 psychiatrists. Most respondents were proponents of Ulysses directives. The most frequently mentioned objective of these directives was to secure timely admission to hospital, although a large minority was mainly interested in giving patients influence on treatment decisions. Psychiatrists differed on how much autonomy they preferred with regard to decisions about the moment of admission and kind of treatment. Clients also differed in this respect. Pressure from others to execute a Ulysses directive, and premature admission to the hospital were mentioned as risks of Ulysses directives. Crisis cards were seen as an alternative by many psychiatrists and some clients. Recommendations are made for a good functioning of Ulysses directives, and the appropriateness of crisis cards as an alternative for a number of patients is discussed.