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Psychiatric advance directives: Pros and cons
Patients and providers tend to avoid them
While psychiatric advance directives are not new in concept, patients tend not to take advantage of these tools.
Psychiatric advance directives are intended to be developed by patients with behavioral health disorders or diseases prior to a potential necessary hospitalization, in which it could be possible for that patient to be declared incompetent to make his or her own treatment decisions.
"In psychiatry, the idea that someone might be incompetent at one point in time, but they make decisions about how they would like to be treated and who they would like to be involved, and all that at a point prior to [hospitalization] — when they are viewed as competent," says Mark Salzer, PhD, associate professor and director, UPENN Collaborative on Community Integration of Individuals with Psychiatric Disabilities at the University of Pennsylvania in Philadelphia.
And while the concept is not new for psychiatric advance directives, the laws pertaining to them are new in certain states, Salzer says.
By completing a psychiatric advance directive, patients can determine in advance such things as what doctors they want to treat them, and which they don't; what medications they want to be placed on, and those they don't wish to be given; and who they want to be informed of their hospitalization — such as friends and family members — and those they don't.
Patients also can stipulate which hospitals they will be admitted to, and again, those they don't.
"Part of my work . . . is in the area of community integration for people with psychiatric disabilities, and part of my work is promoting self-determination and patient rights as much as possible — ensuring that people's rights aren't violated, to see that they have opportunities to make decisions that affect their lives, as much as possible," Salzer tells Medical Ethics Advisor. "Psychiatric advance directives are actually a nice tool — a nice way for patients to express their rights to make decisions about their treatment.
Salzer appreciates such directives both from an "empowerment standpoint" and also "from a crisis planning perspective" by allowing patients to choose in advance of a crisis what health decisions and issues are important to them.
"For some individuals who are hospitalized frequently, that can be helpful therapeutically," he says.
Challenges for psychiatric directives
While the benefits are many, there also are problems with psychiatric advance directives from both a patient and provider perspective, according to Salzer.
From the patient perspective, they often are wary of the fact that such directives carry the weight of law, he says.
"Some people don't want to do a psychiatric advance directive, partly because — or I think primarily because — they fear these are actually legal documents, and they fear that if they express certain desires in this legal document, that at a later point in time, when they are hospitalized, they will be held to those decisions that they might have made six months earlier, or a year earlier, or whatever," Salzer says.
While such directives are legally binding, a thorny issues exists regarding whether a patient has a right to change his or her mind and refuse the treatment that he or she earlier laid out in an advance directive.
From the provider side, Salzer says a "huge issue" for psychiatrists who treat such patients is that they fear the dictates contained in an advance directive will affect their own decision-making regarding the patient's care.
"They're concerned that this document will tie their hands in a way that might force them to make medical decisions — clinical decisions — that they don't agree with [and] that they think aren't in the patient's best interest," Salzer says.
Due to this fear, providers "don't seem to be promoting them" to patients, he says.
And even when a physician does offer the opportunity to the patient, patients often refuse.
Logistical challenges exist, as well
If a patient does exercise his or her right to create a psychiatric advance directive, the question becomes — how does this directive get into the appropriate health care providers' hands?
"There isn't currently a good system for disseminating and getting these documents to the right place and the right time," Salzer notes.
Theoretically, he says, advance directives could be placed in a person's file with their insurer, if they had private insurance, for example. When the hospital calls the insurer to secure authorization to admit the patient, the insurer could then — ideally — advise the hospital that the patient had an advance directive on file and send that to the hospital.
But for patients on Medicaid, the process may not work at all, or might be very different, because such as system "hasn't been put in place very well," Salzer says.