Psychiatric Advance Directives in India: What will the future hold?

Stakeholder perspective on barrier to the implementation of Advance Care Planning in a traditionally paternalistic healthcare system

Background

Advance psychiatric agreements could guide medical teams in providing care consistent with the incapacitated service user’s wishes. However, these types of agreements are rarely completed in Asian settings. What challenges can a traditionally paternalistic healthcare system expect to encounter when attempting to implement psychiatric advance directives?

Methods

We answered this research question by exploring the cultural, administrative and logistical challenges that might impede the implementation of the system supporting the service. We interviewed key stakeholders, 28 service users and 22 service providers, to seek their views and interests in the implementation of directives. We structured our analyses along a literature-review-based framework designed to guide further implementation studies, proposed by Nicaise and colleagues (2013). Accordingly, we divided our inductively generated themes into four longitudinal categories: pre-development stage, development stage, implementation stage, post-implementation stage.

Results

Overall, the findings indicated that many service users and service providers are interested in advance care planning. They believed that foreseeable challenges could be overcome with appropriate measures. However, the multiple challenges of implementation led some service providers to be ambivalent about their implementation and led service users to dismiss them. Specifically, factors related to the local culture in Singapore necessitated adjustments to the content and structure of the directives. These include language barriers in a multicultural society, conflicting wishes in a collectivist society, taboos for speaking about undesirable outcomes in a traditionalist society, and time limitations in a fast-paced society.

Conclusion

While culture-specific changes may be required to enable service users in a small Asian country to employ existing advance psychiatric agreement approaches, service providers and service users see their benefits. However, service providers must be mindful not to assume that service users are willing to defer every decision to their physician.

Psychiatric Advance Directives and their relevance to improving psychiatric care in Asian countries

People with mental illness may be unable to provide critical input about the care they wish to receive during a psychiatric crisis because of altered mental states. It is therefore imperative that clinicians seek to understand service users' wishes for care while they are well and able to provide meaningful input into the discussion. Achieving such an end may be done by discussing and completing a psychiatric advance directive. However, very few Asian countries have legislation that supports such advance directives. The present article seeks to give physicians more information about advance psychiatric directives and the potential role they could play to improve the healthcare provided in Asia to people at risk of losing capacity due to a mental illness. The degree to which mental health legislation supports psychiatric advance directives is documented for each country of South East Asia and Eastern Asia.

Advance statements in adult mental healthcare: an update

In this article we re-examine the conclusions of our article on advance statements in adult mental healthcare that was published in 2010 in the light of new literature published in the intervening decade. We explore the results of studies on the implementation and effectiveness of advance statements in adult mental health services, and then summarise recommendations for legislative changes from the Independent Review of the Mental Health Act 1983 that are relevant for England and Wales.

EAT-PAD: Educating about psychiatric advance directives in India

BACKGROUND

With India enacting the Mental Health Care Act (MHCA; No. 10 of 2017a), Psychiatric Advance Directives (PADs) have been legalised and have become binding orders for psychiatrists treating patients. There is a paucity of research into acceptability of PADs in Indian mental health care, likely due to a lack of awareness. There are no educational measures about PADs provided for in this Act. Facilitators and facilitation methods have not been elaborated upon as well.

AIM

The aim of this study is (a) to develop/evaluate the effectiveness of a structured Education-cum-Assessment Tool (EAT) in providing information regarding PADs and (b) to evaluate modes of facilitation required by patients to complete PADs.

METHODS

A tool was developed as per provisions regarding PADs in the Mental Health Care Bill of 2013. This tool was administered to patients ( n = 100), purposively sampled from the adult psychiatry review out-patient department (OPD). Patients were evaluated on retention of information, completion of PADs, modes of facilitation and time taken to write one.

RESULTS

Mean years of education was 8.28 (±5.74) years and mean duration of illness was 8.30 (±7.04) years. In all, 65% had Below-Poverty Line (BPL) status. All participants completed valid PADs in an average of 15 minutes. About 93% required facilitation via assistance in writing and reminding. The mean EAT scores implied above 70% retention but did not relate to types of facilitation.

CONCLUSIONS

EAT scores can be used as an approximate measure of the patient's ability to understand and retain information which is a part of decisional capacity. Types of facilitation can help in understanding patient's ability to communicate their choices. Service providers may find EAT a time-effective tool for uniformly educating service users regarding PADs and indirectly assessing competence.