1. Sofer, Dalia


They can enhance the lives of patients with mental illness, but multiple obstacles impede their implementation.


Article Content

The psychiatric advance directive, an offshoot of the medical advance directive, has yet to reach the popularity of its forebear. The reasons why point to a maze of systemic, logistical, and cultural barriers that, proponents argue, are nonetheless worth overcoming. A psychiatric advance directive is a legal document that outlines the future mental health treatment preferences of a currently competent person. These directives, which are authorized by law in 25 states and can be incorporated into health care directives in most of the remaining states, can help direct treatment when an acute episode of psychiatric illness hinders a person's capacity to give or withhold informed consent.

Figure. Steve Singer... - Click to enlarge in new window Steve Singer, who has bipolar and borderline personality disorders, is shown with his service dog, Tiger. Singer completed a psychiatric advance directive after his efforts to seek help at a hospital were met with placement on a locked ward under the watch of an armed guard until a social worker was able to release him. The psychiatric advance directive allows him to specify which treatments he wants and which he doesn't. Photo by Travis Dove / The New York Times / Redux.

There are two types of psychiatric advance directives-instructional and proxy. Instructional directives describe treatment preferences regarding, for instance, medication (including types, dosages, and timing); hospitals; and the use of restraints, seclusion, or sedation. They may also specify the names of both authorized and unwelcome visitors and identify who will care for a child or pet. Proxy directives allow a designated agent to make decisions on behalf of a person who is temporarily incapacitated. Directives are often a combination of these two types, although laws vary by state. For state-specific information and forms, see


Although psychiatric advance directives haven't been fully embraced by clinicians and patients, efforts are underway to embed them in health care. In 2011, the Joint Commission mandated that organizations serving adults with serious mental illness do the following: document the existence of a psychiatric advance directive; share resources with patients to help them formulate a directive, upon request; and ensure that clinical staff are aware of the existence of psychiatric advance directives and know how to access them. In addition, the Centers for Medicare and Medicaid Services, invoking the 1990 Patient Self-Determination Act, requires facilities receiving Medicaid and Medicare funding to implement procedures for handling advance directives, including psychiatric advance directives, which are also referred to as PADs. They are also required to inform patients about their rights under state law to use these directives.


"PADs can be beneficial from both an ethical and clinical point of view," says Douglas P. Olsen, PhD, RN, associate professor at the Michigan State University College of Nursing, contributing editor of AJN, and former nurse ethicist at the National Center for Ethics in Health Care at the U.S. Department of Veterans Affairs. "An essential component of mental health treatment is respect for humanity, and PADs, by engaging patients in their own care, can be helpful tools."


A 2014 Frontiers in Public Health literature review of the effectiveness of psychiatric advance directives found that while results are mixed, directives can empower patients, minimize coercion, and improve coping strategies, all of which may reduce the frequency of inpatient admissions. Another study in the November 2007 Psychology, Public Policy, and Law, in which people with mental illness drafted a psychiatric advance directive with the help of a facilitator, found that the information in directives could be of use to clinicians, particularly because patients' preferred treatment methods can vary greatly. The authors note that whereas many patients refused the use of the antipsychotic haloperidol in their directive, others said they preferred the medication when they felt out of control. Listing the reasons for a preference was also beneficial. Clinicians who encounter patients during acute psychotic episodes often know little about them or what works and doesn't work for them. Research suggests that providing a rationale for preferences increases the likelihood that the patients' wishes will be honored.


This leads to the question: how legally binding is a psychiatric advance directive? "PAD instructions don't trump safety," Olsen says. "If clinicians deem that a patient may harm himself or others, instructions may be overridden. There is a lot of gray area surrounding their legality, which varies by state and jurisdiction."



Legal ambiguity is among the primary factors holding back clinicians from embracing psychiatric advance directives. Although most state laws allow clinicians to disregard instructions when a patient's wishes are not feasible or are in conflict with the current standards of care, anxiety over liability persists. This apprehension was strengthened by the 1999 case of Hargrave v. State of Vermont, in which Nancy Hargrave, a Vermont resident who had a diagnosed mental illness, filed a class action lawsuit against the Vermont Department of Developmental and Mental Health Services, because she was medicated against her wishes, which had been documented in a durable power of attorney. The court, deeming that the Americans with Disabilities Act had been violated, ruled in favor of Hargrave and the other plaintiffs. Still, proponents of psychiatric advance directives-including the Substance Abuse and Mental Health Services Administration (SAMHSA)-maintain that as long as providers act in good faith and within standards of care, they won't be subject to criminal prosecution, civil liability, or professional discipline.


Anxiety over liability isn't the only hindrance. Olsen says multiple misgivings can add to a clinician's hesitation. For example, he explains, it may be difficult at times to abide by patients' instructions. "You may get a patient whose PAD says, 'Admit me only if I'm talking about the FBI or the Mafia.' Do you honor that even if you think the patient should be admitted? At the same time, you want to be careful not to go back to the old days of involuntary commitment." Added to that is a resistance to the shift in power, with clinicians who have traditionally made unilateral treatment decisions perhaps not willing to relinquish control and allow patients to have a say. The last but not least hindrance, says Olsen, is stigma. "Clinicians are often skeptical of psychiatric patients, so the desire to honor their wishes may not be there. They may also feel that psychiatric patients hinder the treatment plan."


These concerns are exacerbated by implementation challenges. A July 2014 Psychiatric Services study at St. Luke's-Roosevelt Hospital Center in New York City found that obstacles to the introduction of psychiatric advance directives included "traditional paternalism" and the need for collaboration among several units within the hospital, including the departmental chair's office, the chief of psychiatric inpatient and emergency services, hospital legal counsel, and the software designer of the facility's electronic health record. In a January 2015 study, also in Psychiatric Services, of Virginia's efforts to make the completion of psychiatric advance directives a part of routine mental health services, a lack of collaboration across systems was similarly found to impede the adoption of this practice. Furthermore, the study found that fragmented health and mental health care systems and limited in-patient services can make it difficult to respect patient preferences, such as requests to be admitted to particular hospitals. Cultural resistance was also highlighted. Without clear and persistent emphasis on the benefits of psychiatric advance directives, the study concludes, overworked staff are likely to perceive this as "just another uncompensated task."



Despite these difficulties, psychiatric advance directives, when implemented thoughtfully and with persistence, can become useful tools for both patients and clinicians. The creation of training manuals and curricula can help with the dissemination of these documents, as can the appointment of a designated person to coordinate implementation across agencies and systems. Other recommendations include filing psychiatric advance directives in multiple health settings, having patients wear bracelets alerting clinicians of the existence of such a directive, and including psychiatric advance directives on a portable thumb drive.


Complex though this process may be, psychiatric advance directives have strong support among many health organizations. In addition to SAMHSA, these include the National Alliance on Mental Illness, Mental Health America, and the American Psychiatric Nurses Association.-Dalia Sofer