Psychiatric advance directives can help patients express treatment
preferences and guide physicians in moments of crisis, but both groups need
more help understanding and using them, said a panel of researchers at APA's
2005 annual meeting in May.
A psychiatric advance directive (PAD) is an alternative to coercion, a
document that allows competent persons to state their psychiatric treatment
preferences for times when they are not competent, said Marian Butterfield,
M.D., M.P.H., an associate professor of psychiatry at Duke University. The
directive covers hospital admission, medication administration, use of other
interventions such as electroconvulsive therapy, and may authorize a surrogate
agent to act on the patient's behalf. Twenty states now have laws authorizing
some form of PAD.
"A psychiatric advance directive is completed before a mental health
crisis in which the patient loses the capacity to make decisions," said
Butterfield. "The PAD is then consulted by treating physicians when the
patient is in an impaired condition."
PADs are intended to help patients by giving them a voice in their
treatment and support in times of crisis. Physicians, too, could benefit by
better coordinating care with family and primary care doctors and targeting
treatment more exactly, knowing what has or hasn't work in the past.
That's the theory. In practice, complications arise in creating and
implementing PADs. Patients may need help in understanding their value and in
filling them out. Some physicians fear that a PAD will restrict their
treatment choices. Law-enforcement and hospital authorities may be unfamiliar
with them and ignore them in the very times of crisis when they are intended
PADs bear similarities and differences with general medical advance
directives, said former APA President Paul Appelbaum, M.D., chair of the
Department of Psychiatry at the University of Massachusetts and chair of APA's
Council on Psychiatry and Law. Both types of documents meet with general
approval by the public, but few individuals actually have them. Neither can
cover every contingency, so that designating a health care proxy may be just
as important. They are also often unavailable when they are most needed, and
it may be hard to get officials or medical personnel to even read them, much
less follow their directions, he noted.
Unlike general health directives, the question of patient competence hangs
over a PAD, although there is a presumption that the patient was competent
when signing it.
Physicians also fear that the content of a PAD will be "crazy"
and that patients will use them to refuse treatment. "In fact, patients
are doing a good job of filling them out, especially if facilitators are
involved," said Appelbaum.
Picking the right time to fill out a PAD is another key issue. Following
passage of the federal Patient Self-Determination Act of 1990, hospitals began
asking patients to complete advanced directives at admission, the worst time
for any patient but especially for psychiatric patients, said Appelbaum.
Completing a directive at the first outpatient visit or upon hospital
discharge would be better.
A team from Duke University School of Medicine studied 1,000 outpatients in
mental health clinics in Chicago, Tampa, San Francisco, Durham, N.C., and
Worcester, Mass., and found that few (4 percent to 13 percent) had PADs but
that 65 percent to 77 percent said they wanted one, once the idea was
explained to them, said study leader Jeffrey Swanson, Ph.D., an associate
professor of psychiatry at Duke. The study will be published shortly, he
"There's a large, latent demand," said Swanson. "The PAD
gives patients some sense of empowerment at very vulnerable moments in their
Patients interested in PADs tended to be female, nonwhite, suicidal, with a
low sense of mastery, and a history of feeling pressured to take medications
and an arrest in the prior six months, according to the Duke study.
Patients in the study who had completed a directive were more likely to
have high insight (odds ratio, 1.9), a representative payee managing their
money for them (3.0), been transported by the police to treatment (2.3), and
feel pressure from clinicians and others to keep their appointments at
community mental health clinics (1.8).
Eric Elbogen, Ph.D., an assistant professor of psychiatry at Duke, has
studied 121 advanced-instruction documents produced by patients randomized
from public-sector settings. The patients were assigned a bachelor's-level
facilitator who helped explain their options in completing a PAD.
Most of the patients made clear the options they preferred, Elbogen
For instance, 98 percent alerted doctors to at least one crisis symptom."
I want to hurt myself because the television is talking to me,"
said one. "I have racing thoughts and become aggressive, especially in
the emergency room," wrote another. This kind of prior knowledge of
violent history can help hospital staff and reduce risk when the patient
appears again, said Elbogen.
Seventy-five percent of the patients said they wanted to be treated with
respect and listened to if brought to the hospital. Eighty-eight percent
mentioned at least one hospital to which they were willing to go, while 62
percent documented a refusal to go to a specific hospital, usually giving
reasons for doing so.
PADs may help guide treatment as well. All subjects mentioned at least one
factor likely to cause a relapse. Also, 77 percent rejected at least one
medication, but 94 percent gave advanced consent for treatment with at least
one drug. "No one refused all medications, but no one liked
Haldol," said Elbogen.
Half of the patients studied instructed staff on how to avoid use of
restraint and seclusion, and three-quarters listed side effects they
experienced on particular medications. Sixty-two percent refused to have
electroconvulsive therapy. All gave emergency contacts, usually family
The facilitators helped focus the documents by asking open-ended questions,
"There were few medically inappropriate treatment requests in the
directives, and they included much relevant information that would be valuable
to clinicians," said Elbogen. The most unrealistic response was,"
I need a cigarette in intake because I can't calm down without a
The authority of the PAD, however, is not absolute, said Elbogen. It does
become part of the patient's chart, and if one section of the PAD can't be
carried out, the rest is not invalidated. Furthermore, involuntary commitment
overrides the PAD.
Clinicians have little experience with PADs so far, and they are ambivalent
about them, said Marvin Swartz, M.D., professor and head of social and
community psychiatry at Duke. Swartz and Elbogen are co-investigators with
Swanson on the Duke study.
"About two-thirds of psychiatrists say they would honor a PAD,
although many think that patients would use it to inscribe treatment
refusal," he said, drawing from his random sample of psychiatrists in
North Carolina, where PADs have been authorized since 1997.
Responses from the psychiatrists surveyed varied depending on hypothetical
circumstances, said Swartz. Asked if they would follow a PAD if a patient were
concerned about drug side effects, 70 percent of the doctors said yes. But if
the PAD as written sounded "psychotic," and the patient had a
history of violence, only 40 percent said they were likely to follow it.
Public-sector psychiatrists were less positive about PADs and more certain
that they would have no impact on their practice.
In the end, the value of a PAD may lie as much in its role as a form of
communication with future clinicians as in the fact that it is a legally
binding document, said Appelbaum. A purely informational system does exist in
the United Kingdom, he said, where "crisis cards" serve as
nonbinding directives, telling clinicians in effect: "If I get in
trouble, here's what helps me...."