Advanced Search

Psychiatric Services, VOL. 58, No. 9

Article | September 01, 2007

Commentary: Psychiatric Advance Directives and Recovery-Oriented Care

Marvin S. Swartz; Jeffrey W. Swanson

Psychiatric Services 2007; doi: 10.1176/appi.ps.58.9.1164

Article

References

text A A A

Dr. Swartz and Dr. Swanson are with the Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 238 Civitan Bldg., Box 3173, Durham, NC 27710 (e-mail: marvin.swartz@duke.edu).

Frontline public-sector clinicians, in the face of sorely strained clinical resources, can be skeptical about "recovery-oriented" or "patient-centered" care. To some, these terms lack specificity and guidance for practice. Two articles in this issue offer empirically supported direction for promoting a recovery orientation and for thinking about treatment decisions and planning from the patient's point of view.

Adams (1) explored preferences for shared decision making among a relatively small group of persons with severe mental illnesses and found, not surprisingly, that these individuals expressed a clear desire for patient-centered decisions—especially medication decisions—affecting their treatment.

Srebnik and Russo (2) examined whether the psychiatric advance directive leads to more patient-centered crisis care. These legal documents are designed to direct care during incapacitating psychiatric crises (2). The authors found that when directives were accessed, two-thirds of subsequent treatment decisions were consistent with them. Because most directives are consistent with standard clinical practice, interpreting their influence on clinical decision making during these crises may be difficult. The authors also reported lower rates of consultation with proxy decision makers, typically authorized by a health care power of attorney. This latter finding is somewhat disappointing because a tangible benefit of directives is the ability of the treatment team to involve trusted others in decision making when a consumer is unable to make such decisions.

Lack of clinician familiarity with directives and lack of ready access to them in crises prevent wider use (3). To increase awareness, understanding, and assistance in completing directives, the MacArthur Foundation is supporting a new National Resource Center on Psychiatric Advance Directives (nrc-pad.org). At least one national electronic directory, the U.S. Living Will Registry (www.uslivingwillregistry.com), provides online storage and secure access to care planning documents. Also, more states have set up online directories.

Twenty-five states have enacted statutes for authorizing mental health advance instructional documents or proxy decision making and providing a legal means for competent individuals to consent to or refuse future mental health treatment during decisional incapacity. About 66% of consumers consistently express interest in completing psychiatric advance directives (3). All states permit competent adults to use generic health care decision laws to make at least some psychiatric treatment choices in advance, typically through a health care power of attorney.

Mental health administrators and hospital compliance officers increasingly recognize their legal obligations to implement psychiatric advance directives under the provisions of the federal Patient Self-Determination Act of 1991, which requires hospitals to inform patients of their rights under state law to prepare a directive, to inquire and document whether patients have executed one, to ensure compliance with state laws by respecting advance directives, and to educate health care providers regarding these legal instruments. Moreover, the Centers for Medicare and Medicaid Services recently reiterated that patients have the right to formulate advance directives and staff must comply with the 1991 federal guidelines or risk loss of funding (4).

Beyond the pressures to comply with the Patient Self-Determination Act, clinicians should see psychiatric advance directives as an opportunity to collaborate with consumers in planning for treatment and, through a health care power of attorney, to engage consumers' trusted social networks in making good decisions in periods of decisional incapacity. Directives are a legal right for consumers as well as practical tools for clinicians to deliver better care.

Acknowledgments and disclosures

Acknowledgments and disclosures | References

The authors report no competing interests.

References

Acknowledgments and disclosures | References

Adams JR, Drake RE, Wolford GL: Shared decision-making preferences of people with severe mental illness. Psychiatric Services 58:1219—1221, 2007

Srebnik DS, Russo J: Consistency of psychiatric crisis care with advance directive instructions. Psychiatric Services 58:1157— 1163, 2007

Swanson JW, Swartz MS, Elbogen EB, et al: Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. American Journal of Psychiatry 163:1943—1951, 2006

42 CFR Part 482 Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients' Rights; Final Rule. Federal Register 71:713771—71428, 2006

Adams JR, Drake RE, Wolford GL: Shared decision-making preferences of people with severe mental illness. Psychiatric Services 58:1219—1221, 2007

Srebnik DS, Russo J: Consistency of psychiatric crisis care with advance directive instructions. Psychiatric Services 58:1157— 1163, 2007

42 CFR Part 482 Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients' Rights; Final Rule. Federal Register 71:713771—71428, 2006

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.

Submit a Comments

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of JBJS editorial staff.

* = Required Field

Comment Author(s)*(if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
E-mail

Recipient(s) will receive an email with a link (good for 72 hours) to 'Commentary: Psychiatric Advance Directives and Recovery-Oriented Care' and do not need to have Psychiatric Services account to access the content.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*
Separate multiple email address with semi-colons (up to 5).

Subject:* 's Psychiatric Services: 'Commentary: Psychiatric Advance Directives and Recovery-Oriented Care'
Subject for your email.

Message:
(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The American Psychiatric Association (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that you are requesting the material solely for personal, non-commercial use, and that it is subject to The American Psychiatric Association's Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The American Psychiatric Association's Privacy Policy for further information.

Copyright © American Psychiatric Association. All rights reserved.
Share
Get Citation

Marvin Swartz, M.D., Jeffrey Swanson, Ph.D.; Commentary: Psychiatric Advance Directives and Recovery-Oriented Care. Psychiatric Services. 2007 Sep;58(9):1164-1164.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © American Psychiatric Association. All rights reserved.
Reprints