Psychiatric Advanced Directives Face Obstacles : Infrastructure to uphold plans' legitimacy oftendoes not exist or is circumvented by conflicting laws.

Lack of Support Stymies PADs

The reform of advanced directives in psychiatry is not a progressive movement that is gathering support and growing in practice, said Kim Hopper, Ph.D., an anthropologist at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, N.Y.

Reform is a defensive maneuver against a set of coercive measures in the community, he said.

Some states have loopholes that allow civil commitment statutes to trump PADs in practice. In some cases, the PAD may be circumvented if the directions it contains go against community standards of care.

If patients don't expect the system to respond, Dr. Hopper asked, then why should they go through the work of actually creating the PAD when they may be setting themselves up for bitter disappointment? “That's the highest risk of this kind of intervention,” he said.

PADs, crisis cards, and joint crisis plans will face obstacles in becoming legitimate means of directing future treatment unless they are given official endorsement, are authorized and archived by respected sources, and can be easily accessed at treatment centers. PADs, crisis cards, or joint crisis plans carried by a patient will not be taken seriously by emergency departments if the staff have no interest in these programs or if bureaucratic support is lacking, Dr. Hopper said.

An ongoing randomized study in North Carolina has shown that 79% of 123 patients who received help from a trained facilitator were able to complete a PAD within 1 month. In contrast, only 6% of 60 patients who received a referral, information on PADs, and PAD forms–but no facilitator–completed a PAD within 6 months, Dr. Swanson said.

The provision of a facilitator would, in itself, represent an investment by a mental health system to provide the service of creating plans for future treatment, Dr. Hopper noted.

The PADs were placed on the U.S. Living Will Registry (located at www.uslivingwillregistry.com

Overall, 15% of the 123 patients have refused to have a facilitated PAD session, while another 4% met with their facilitator and then refused to create a PAD. All of the patients had some psychotic symptoms.

Plans in England Face Trouble, Too

In England, plans for future treatment also have largely been developed as a reaction to an increasing demand for fewer restrictions on involuntary hospitalization or outpatient commitment for noncompliant patients who may be dangerous to themselves or others.

Highly publicized cases of violent crimes committed by mentally ill individuals in England have brought about several draft bills for mental health reform that take away some of the rights of patients to direct their future treatment when they are unable to do so on their own behalf.

Currently, a draft bill on mental health reform includes a very broad definition of a mental disorder that involves “virtually any disturbance of psychological functioning” and a broad definition of minimal treatment that includes rehabilitation and habilitation (training, social skills, and education). The bill says that if patients pose a substantial risk of harm to others, the patients must be hospitalized against their will, even if there is an alternative, lawful treatment, noted George Szmukler, M.D., dean of the Institute of Psychiatry at King's College, London.

PADs currently cannot be used in England. Dr. Szmukler and his colleagues introduced two alternatives to a PAD–crisis cards and joint crisis plans–in a pilot study conducted in a community psychiatric service of 106 patients with psychosis who were at high risk of crisis. Many of the patients were reluctant to participate, but after 9 months 40% had agreed. All of these patients opted for a joint crisis plan.

The patients who chose to participate were more likely to have an affective disorder, a history of suicidal ideation, fewer hospital admissions, and nonblack ethnicity. Although the patients had guidance, the choice of information included in the plan was up to the patients themselves. The joint crisis plans provided important information to health care providers when the patient was too ill to do so and reduced hospital admissions by 30% in the follow-up year. The plans were used in 73% of patient crises and 81% of hospital admissions (Acta Psychiatr. Scand. 1999;100:56–61).

After the pilot study, Dr. Szmukler, Claire Henderson, M.B., also of the Institute of Psychiatry, and their associates conducted the first randomized, controlled trial to assess the impact of joint crisis plans. But only 36% of the eligible patients in the study were ultimately randomized in the single-blind trial (BMJ 2004;329:136–40). Of 160 patients who had a psychotic illness or nonpsychotic bipolar disorder, significantly fewer of those who completed a joint crisis plan required compulsory hospital admission (13%) than did patients who received a control intervention (27%).