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Columns   |    
Special Report: Highlights of the 2004 Institute on Psychiatric Services
Deborah Christie-Smith; Connie Gartner
Psychiatric Services 2005; doi: 10.1176/appi.ps.56.1.16
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The 2004 Institute on Psychiatric Services, held October 6-10 in Atlanta, drew 1,475 participants to a varied program of more than 375 lectures, symposia, plenary sessions, workshops, and poster sessions. The American Psychiatric Association's (APA's) fall conference on clinical care and service systems has been held annually for 56 years.

In her address at the institute's opening session, APA President Michelle B. Riba, M.D., M.S., discussed issues related to the institute's 2004 theme—"Mental Health Disparities in the Community." She cited the National Institutes of Health's definition of disparities as "differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups." Racial and ethnic minority populations tend to receive lower-quality care regardless of access-related factors, such as insurance coverage and income, she noted. Social stigma and past cases of gross inequitable treatment still linger in the minds of many individuals, and prejudices continue to have an impact. In addition, community mental health systems are increasingly dependent on Medicaid, which funds more than 60 percent of their services, Dr. Riba noted. Minority populations are major users of public mental health systems, where they may not be able to find high-quality and culturally competent care.

Dr. Riba told the audience that approval in 2003 of psychosomatic medicine as the newest psychiatric subspecialty is encouraging. Efforts to eliminate disparities in health will be aided by better knowledge about the intersection of physical and mental illness, she said. Many patients in the public health system have medical problems, such as hypertension, heart disease, and diabetes, in addition to psychiatric problems, such as depression and anxiety. Stressors related to poverty and discrimination can adversely affect health by causing negative emotional states, such as anxiety and depression, that can directly influence biological processes or patterns of behavior that affect disease risk. Developments in the subspecialty of psychosomatic medicine will improve diagnosis and treatment of patients with complex medical conditions, Dr. Riba said.

Dr. Riba described efforts already undertaken by APA to eliminate disparities. APA's office of minority and national affairs (OMNA), under the guidance of Annelle Primm, M.D., is developing "OMNA on Tour." The tour will visit states with the highest proportions of underserved minority groups to engage stakeholders, including APA district branch members, primary care physicians, legislators, employers, social service providers, and mental health care providers, in discussions of disparities in mental health and mental health care. The tour will educate audiences about the impact of such disparities on overall health, economic productivity, and societal well-being.

Dr. Riba also drew attention to a new video developed by OMNA—"Real Psychiatry: Doctors in Action"—to increase overall recruitment to the field, with an emphasis on students from minority groups. The 27-minute video, which is available free of charge to medical students, medical schools, and interested organizations, follows the day-to-day practice of four psychiatrists from different racial and ethnic groups, who describe how their experiences as psychiatrists have enriched their lives. Dr. Riba urged audience members to take every opportunity in their organizations and their communities to raise awareness of disparities and to work to eliminate them.

At a well-attended plenary session, A. Kathryn Power, M.Ed., who is director of the Center for Mental Health Services, spoke about her work as the chief federal official responsible for transforming the mental health system as called for in the report of the President's New Freedom Commission on Mental Health. She began by quoting Martin Luther King, Jr.: "Our nettlesome task is to discover how to organize our strength into compelling power."

Ms. Power described progress made by the Federal Partners Workgroup, an association of 21 federal agencies that was created after the report's release to take an inventory of mental health programs and funding in each agency and to assess whether the programs support the goals described in the report. The workgroup developed an action agenda of time-limited, realistic priorities for the first year of a five-year "arc for transformation." The agenda is awaiting final approval.

A transformed system is one that provides consumer-driven care focused on recovery, according to the New Freedom Commission's report. Ms. Power told the audience that she requires all her staff to read two books to better understand the processes of change and of recovery. In the first, The Tipping Point, science writer Malcolm Gladwell contends that when small numbers of people change their behavior, the behavior can ripple outward until a critical mass or tipping point is reached, changing the world. In The Anatomy of Hope: How People Prevail in the Face of Illness, Jerome Groopman, M.D., deconstructs the concept of hope and describes the important responsibility that clinicians have to convey hope to counter their patients' despair.

Ms. Power told the audience of clinicians that because they provide care at the most basic and personal level, they have the greatest opportunity to implement real changes. Consumer-driven care is based on the belief that individuals can take charge of their own lives, their own wellness, and their own case management on the basis of their personal goals for recovery. This single belief, she said, has important implications for the consumer-clinician relationship. It demands that both consumers and psychiatrists be able and willing to be equal partners in determining what constitutes optimal care. Consumer-driven care means building treatment around the totality of the individual. Ms. Power pointed out that this concept is fully in line with APA's understanding of care: that it should be based on continuous healing relationships and engagement with the whole person.

According to Gladwell, tipping points occur as a result of a handful of exceptional people—called connectors—who have the power to inspire others to embrace a common idea. Ms. Power exhorted audience members, "Be connectors for transformation. You are leaders in your practices, your organizations, and your field. You, right here in this room, can become the compelling power that will help transform mental health care for all Americans."

"Psychoanalysis and Eastern Cultures: Adversaries or Allies?" was the topic of a well-attended lecture delivered by Salman Akhtar, M.D. Dr. Akhtar is professor of psychiatry at Jefferson Medical College in Philadelphia as well as training and supervising analyst at the Psychoanalytic Center of Philadelphia. Before the lecture began, Dr. Akhtar was presented with APA's Kun-Po Soo Award, which recognizes individuals who have made significant contributions to the understanding of the impact and import of Asian cultural heritage in areas relevant to psychiatry.

Dr. Akhtar opened his discussion by giving examples of human experiences that are universal—falling in love, losing a loved one to death, taking pride in a child's achievement. He then noted that all human beings, regardless of nationality or culture, fundamentally struggle with only two problems in life: some things are impossible, and some things, although possible, are prohibited. What divides the mentally ill and the mentally healthy is the degree to which each group succeeds at dealing with these two universal problems, Dr. Akhtar said. But, he asked, if all human beings have similar emotions and struggle with the same problems, why can't we apply one model of the human mind to people from all cultures?

Dr. Akhtar's view is that the psychoanalytic model "is applicable but not applicable" to all cultures. Areas of difficulty arise as we approach a confluence of Eastern cultures and psychoanalysis, but there are solutions to these difficulties.

Dr. Akhtar reminded the audience that psychoanalysis has four components: the theory of mental function, the developmental model, the theory of psychopathology, and the technique used to conduct psychoanalysis itself. Only one of these components—the theory of mental function—is universally applicable, Dr. Akhtar said. Psychoanalysis has traditionally been conducted with people who are mostly white, mostly Jewish, and mostly male, he noted—although this situation is changing. With such a limited sample, how do we know what is "normal"? In terms of the developmental model, for example, we can't say that it is normal for a child to have a transitional object, such as a special blanket or toy—children in India and rural Japan don't have them and don't need them, because they are constantly surrounded by family members and other people, and there is no "transition" as such. Eastern and Western cultures also differ on questions such as how often an adult should call his or her parents, or how long it is acceptable for parents to stay in their grown children's homes.

Dr. Akhtar pointed to numerous other aspects of psychoanalysis that could be problematic if transported to other cultures. Psychoanalytic concepts such as phallic exhibitionism and castration anxiety would be difficult to discuss for people whose language does not include words for certain bodily functions and organs other than obscene words, which is true of many Eastern languages. In any case, he noted, these are limited male-centric notions. Isn't it possible that one would want to exhibit a beautiful waist, or beautiful eyes? And would it not be better to think of castration anxiety in much broader terms, to include fear of any form of mutilation? In addition, Dr. Akhtar pointed out, psychoanalysis—particularly early psychoanalysis—has tended to use anatomy-centric terms, at the expense of acknowledging the mind. Yet "the body is only the servant of the mind," he said.

Another example is that in some cultures, there is a very different concept of self than in Western society—or perhaps no concept of self at all—which presents a challenge given that psychoanalysis is about the self. It is important to remember that there are many mental models, just as there are many religions, and no single one is better than any of the others, Dr. Akhtar said. Although people sometimes expect psychiatrists to have all the answers, "psychiatrists and psychoanalysts are not experts at living; we barely know a little bit about how not to live. There are so many different ways of living."

Thus problems arise when we try to transport assumptions and when we try to transport language, Dr. Akhtar noted. He believes that Eastern cultures need to detoxify and demystify their languages, to come up with nonobscene names for the genitals. They need to rid themselves of the idea that some things are too sacred to talk about, and that certain things shouldn't even be thought about, much less spoken about. "We should not be afraid of our thoughts," he said. "It is OK to prohibit or avoid certain actions, but not thoughts."

Similarly, psychoanalysis can benefit from incorporating Eastern concepts, which it has already done to some extent—for example, the recognition of "gut feelings" and of humans' affinity with animals. However, some things that are viewed positively in Eastern cultures are sometimes considered to be pathological by Westerners—for example, silence, inactivity, and thoughts of death. Dr. Akhtar tentatively suggested that whereas in Eastern cultures death is an integral part of life, many Westerners refuse to acknowledge death, some even harboring a belief that, with the right lifestyle, they can avoid it altogether!

In concluding, Dr. Akhtar expressed his belief that there are many possibilities for mutual dialogue between Western practitioners of psychoanalysis and people from Eastern cultures, "provided that Eastern people give up their defensiveness and Western people give up their colonial tendencies."

The American Association of Community Psychiatrists (AACP) held a symposium titled "Helping Systems Develop Recovery-Oriented Services" at which several presenters described recovery not only as a personal process for consumers but also as an organizational transformation in which systems "recover" from traditional perspectives through a process of self-evaluation and culture change.

One of the symposium presenters, Wilma Townsend, president of WLT Consulting in Gahanna, Ohio, described how two Ohio county mental health systems have implemented a recovery model through collaboration with consumers, family members, clinicians, and others. "Emerging Best Practices in Mental Health Recovery" (available at www.mhrecovery.com) was developed in Hamilton County. One component is a workbook designed to engage clinicians and consumers in recovery through the completion of four activities together. Consumers evaluate where they are on the recovery continuum and select goals and best practices to support their goals. Tools are available to help organizations introduce a recovery model. SOAR (Systems Operating to Achieve Recovery) comprises two toolkits, "Establishing a Recovery System" and "Consumer Operated Services," that were developed by the mental health system in Licking and Knox counties in Ohio (www.lickingknoxcmhrb.org).

In the next presentation, Dr. Sowers, who is medical director of the office of behavioral health services of the Allegheny County Department of Human Services in Pittsburgh, discussed guidelines for recovery-oriented services that were developed in 2003 by the AACP (available at www.comm.psych.pitt.edu). He pointed out that many professionals were trained to regard people with severe mental illness as individuals who have perpetual needs—and to provide care accordingly. The guidelines were designed to help organizations make a major cultural shift, from a paternalistic illness-oriented perspective to collaborative autonomy-enhancing approaches. The AACP is also developing the ROSE (Recovery-Oriented Services Evaluation), which is completed by individuals at every level of an organization—administrators, clinicians, and consumers—to identify organizational strengths and weaknesses. (A preliminary version is available at www.comm.psych.pitt.edu.)

The title of the presentation given by Kenneth Thompson, M.D., was "Training Service Providers to Facilitate Recovery: Use of Dialogue." Dr. Thompson, who is director of the Institute for Public Health and Psychiatry at the Western Psychiatric Institute and Clinic in Pittsburgh, described dozens of dialogue meetings between consumers and providers that he and others have been convening in Pennsylvania communities for several years. Such dialogues are needed now more than ever, he said, because of the dramatic growth in the amount of feedback that clinicians are receiving from consumers. "Clinicians are starting to hear that there is more to the experience of being healed—and participating in the experience of healing—than we have allowed ourselves to listen to," Dr. Thompson noted. Dialogue is essential to recovery because it is the way that providers can understand the perspectives of consumers—and vice versa, he explained. Dialogue is a way to "get outside the box of the doctor-patient relationship."

The dialogues in Pennsylvania involve inviting up to 20 people—an equal number of consumers and providers—to sit in a room together for periods ranging from several hours to two days. The dialogue session usually begins with a question about each person's perspective on recovery. In one of the first dialogue meetings several years ago, the psychiatrists admitted that they had no idea what recovery was, Dr. Thompson said. Several consumers said that they did not feel that their therapist supported recovery: "Why are you so reluctant to let us do what we want?" they asked. One psychiatrist responded, "Have you ever heard of 'Do no harm?' " None of the consumers had heard of this tenet of a physician's oath. An exchange ensued in which both consumers and providers discussed their fears of making bad judgments and mistakes, their fears of "something bad happening."

"People will accept that others have different roles and different things that they're expected to do," Dr. Thompson noted, "but people don't have to be rigid about these roles, to refuse to discuss them, or to impose them on others in some way," he said. The problems encountered during the dialogue sessions are usually related to trainees and insecure treatment providers, Dr. Thompson explained. "They say 'I'm a doctor, you're a patient. I can't allow myself to imagine that we are more the same than not.'"

In summarizing, Dr. Thompson said, "The issue for our profession is how we tolerate being people in the work that we do. How do we tolerate our own emotional life while taking care of people and working in that partnership? Because, ultimately, in order to do this work you have to be touched."

A large audience was present for a lecture on celebrity stalkers and presidential assassins, delivered by Robert T. M. Phillips, M.D., Ph.D., a renowned forensic psychiatrist who has served as an expert witness in prominent civil and criminal proceedings nationwide. Dr. Phillips is adjunct associate professor of psychiatry at the University of Maryland Schools of Medicine and Law in Baltimore and serves as a consultant to the protective intelligence division of the U.S. Secret Service.

Both legally and clinically, stalking is said to have occurred when one or more of the following conditions is met, Dr. Phillips said: the behavior is repeatedly directed toward a specific individual, the actions are unwelcome and intrusive to the target of the attention, and the behavior induces fear or concern in the target. Dr. Phillips noted the irony of the fact that celebrities want attention and enjoy having "groupies" to some extent; however, there is a fine line between adulation and irritation. The psychiatrist's interest is in the unwelcome aspect of the behavior.

Dr. Phillips explained that in discussing celebrity stalking, the existing stalking nomenclature—specifically, the prototypes developed by Paul Mullen—needs to be modified slightly. He outlined various prototypes of celebrity stalkers with reference to Mullen's original prototypes, presenting some notorious cases as examples. However, he reminded the audience that these prototypes should be used only as guidelines to help shape independent assessments—it is important that psychiatrists or others who find themselves working with stalkers—or with those who report that they are being stalked—not be fooled or limited by specific prototypes.

One prototype is the "celebrity intimacy seeker," who has erotomanic delusions of reciprocated love, wants to establish a relationship with the celebrity, and becomes enraged by rejection. Psychiatric intervention is usually necessary, although these stalkers do not tend to be very responsive to treatment; they are sometimes responsive to court order but most often only to incarceration. One example is Margaret Ray, who stalked Late Show host David Letterman. She broke into Letterman's Connecticut home on five occasions, drove his car, watched his television set, ate his food, and slept in his bed.

Some celebrity stalkers fit the "rejected intimacy seeker" prototype. These individuals feel rejected after initially feeling that they had a real relationship with the celebrity. They harbor a mixture of desire for reconciliation and desire for revenge. An example is Robert Bardo, who stalked and eventually killed Rebecca Schaeffer, who starred in the television show My Sister Sam in the 1980s. Schaeffer had responded to a fan letter and become the object of Bardo's delusional fantasy. When she rebuffed his in-person approaches, he came back with a gun and killed her, explaining "Her behavior was callous, and I expected more of someone like her." Psychiatrists who treat intimacy-seeking and rejected intimacy-seeking stalkers need to remember that perceptions, not reality, are key, Dr. Phillips noted. Repetitive exposure through the media feeds the delusional thought processes of the stalker. Frequently, the stalkers believe that the celebrity is speaking directly to them. "You cannot shake it when you confront them with your reality," Dr. Phillips warned. Psychiatrists need to try and put themselves in the stalker's shoes, to see the situation as the stalker sees it.

Dr. Phillips also described "predatory celebrity stalkers," such as Jonathan Norman, a 31-year-old bodybuilder who in July 1997 was found running through the woods adjacent to the home of Steven Spielberg. A body search yielded photographs of Spielberg's seven children and a shopping list of tools that Norman apparently intended to use on Spielberg, including eye masks, handcuffs, nipple clips, and dog collars. A police officer who gave evidence at Norman's trial said that Norman claimed to have written a screenplay about a man raping another man, and he wanted to show the screenplay to Spielberg. These stalkers take pleasure in the sense of power that comes from frightening their victims, Dr. Phillips noted. They are usually—at least initially—the least intrusive of all the stalkers. They are "good at it," so there is usually no warning of the danger.

Dr. Phillips used the case of John W. Hinckley, Jr.—an example of "pathological celebrity infatuation"—to illustrate the concept of the "zone of risk." In such cases, it is not just the target but individuals around the target who are in danger. In Hinckley's case, the love object—Jodie Foster—was not threatened; he wanted to get her attention by harming a third party, and ultimately injured several individuals. Dr. Phillips pointed out that Hinckley was in psychotherapy at the time. It is not uncommon for stalkers to be in established therapeutic relationships while engaging in stalking behavior without the issue ever coming up, he said. "They are very, very good at making sure that information remains contained."

Turning to political assassinations, Dr. Phillips noted that one important difference between the stalking of celebrities and the stalking of the president—the ultimate celebrity—is the existence of a large force of individuals employed to keep the president safe. Yet this does not deter some stalkers, he reminded the audience. As with celebrity stalkers, the various stalking prototypes can be observed among presidential stalkers. Dr. Phillips also noted an additional category of political stalkers—"nuisance and attention-seeking presidential stalkers," whose motive is usually to make some type of political statement. He also outlined the recent (2002) case of Mei Ling Lin, a "presidential intimacy seeker." In this case, the victim was not the president himself but someone close to the president—former Press Secretary Ari Fleischer. Lin obtained Fleischer's home address through the Internet, having developed a romantic fixation on him, and stalked him on several occasions.

Dr. Phillips summarized his lecture by emphasizing that the behaviors observed among celebrity stalkers and among presidential stalkers are indistinguishable—these are individuals who have fascinations driven by the various stalking typologies. "Their belief systems are deeply rooted, and their actions—positive or negative—can have a profound effect on the lives of the individuals they have targeted," he said.

Marc D. Feldman, M.D., drew a large audience to his lecture titled "Childhood Betrayed: Understanding Munchausen by Proxy Maltreatment." Dr. Feldman is clinical professor of psychiatry at the University of Alabama at Tuscaloosa and attending psychiatrist at the Pain and Rehabilitation Institute in Birmingham, Alabama. He is also author of the book Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder.

He opened by noting that as recently as 1991, a majority of U.S. family physicians and social workers who were surveyed were not familiar with the term "Munchausen by proxy" (MBP). Today, it is a "hot topic," often discussed on television news programs. A book about the syndrome, Sickened," by Julie Gregory, is an international bestseller.

DSM-IV calls MBP "factitious disorder by proxy," Dr. Feldman noted. It is his belief that MBP is a form of child abuse, not a mental illness, and that it therefore should not be included in DSM—just as a person can't "have" shaken-baby syndrome, for example. "It may be the most lethal form of childhood maltreatment," he said.

Dr. Feldman pointed out that the hallmark of MBP is deceit. This aspect of the syndrome means that its incidence is underestimated, although hundreds of cases are nevertheless reported in the literature. Its victims are usually infants or toddlers, but not always—for example, a case involving a mentally disabled 26-year-old was reported. In 75 percent of cases, the perpetrators are the mothers; the remaining 25 percent of cases involve other female caretakers—the father is rarely the perpetrator. Studies have shown a death rate of about 10 percent among MBP victims.

Among children who have been the victims of MBP, symptoms include seizures, apnea, diarrhea, bleeding, fever, rash, and psychological or behavioral symptoms. Of these, apnea is the most common—it is easy to disrupt a child's breathing to the point of unconsciousness. A startling proportion of cases involve misuse of ipecac, Dr. Feldman noted; in his view, this product should be withdrawn from drugstores. Dr. Feldman told the audience that the lengths to which some mothers go to try to convince professionals that their child is ill are "worthy of an Academy award," whereas some mothers use very primitive methods, such as presenting a stone from a river as a kidney stone. Psychological or behavioral symptoms are not often considered as part of MBP but should be, he suggested—for example, a mother who falsely claims that her child has attention-deficit hyperactivity disorder.

MBP may be more difficult to detect than other forms of child abuse, said Dr. Feldman, because gross evidence of abuse—such as burns and bruises—is uncommon. Warning signs that a child may be the victim of this syndrome include episodes of illness that begin when the mother has been alone with the child and end when the mother is separated from the child, unexplained illnesses among other children in the family, the provision of false information to clinicians, symptoms that do not respond to appropriate treatment, and a disease pattern that is extremely rare—it is not uncommon for physicians who encounter MBP to exclaim, "I've never seen a case like this before!"

Dr. Feldman suggested reasons behind the behavior of mothers who engage in MBP, including a need to control, feelings of being anonymous in life, and reenactment of their own childhood abuse. Many have personality disorders, especially borderline personality disorder and narcissism.

Dr. Feldman explained that MBP is not a "characteristic" to be identified during an interview but, rather, something that is usually established by a meticulous review of clinical information. Specimens need to be retained, and the child needs to be separated from the parent or caregiver and asked gentle, nonthreatening questions. Sometimes covert video surveillance is used, he noted, although it is important that an institutional protocol for such surveillance be in place well before such an approach is even considered.

Dr. Feldman cautioned that "false-positives" do happen. However, in such cases there is not a pattern of behavior. Also, the parents are reassured by negative test results and provide accurate information and histories, he said.

Once MBP is suspected, it is usual for the father to side with the mother and become defensive. The staff is often divided on whether they side with the mother or with the clinician who has broached the possibility of MBP. In addition, the family physician is "our worst enemy," noted Dr. Feldman, because he or she must admit personal error by acknowledging the existence of MBP and is often reluctant to do that.

Dr. Feldman emphasized how important it is for physicians who have been involved with cases of MBP to testify during court proceedings. A written report does not get the same attention from the judge as direct examination does, he said. It is important that the child be protected from further invasive medical procedures and that the child's siblings also be protected. The child's removal from the parent or caregiver usually becomes "the issue" but in most cases is necessary. The first priority in all legal proceedings is to protect the child, not the parent, he said. "The risks to the child are simply too great."

At a symposium titled "Taking Charge of Future Treatment: Collaboration or Confrontation?" some presenters noted that the process of creating a psychiatric advance directive can have substantial benefits not only for the consumer but also for the consumer-provider relationship. A psychiatric advance directive is a legal instrument whereby a competent person specifies future treatments if he or she becomes incompetent. Twenty states now have laws authorizing psychiatric advance directives.

Peter Stastny, M.D., associate professor at Albert Einstein College of Medicine, described a one-year project undertaken in New York City that trained nearly 6,000 people to create advance directives and to help others to do so. The trainers were provided with an extensive information package that included an advance directive form from the Bazelon Center for Mental Health Law that was modified in accord with New York statutes. The form does not invite a person to reject all treatment, Dr. Stastny noted, but to choose among treatments. Individuals were asked to make a list of treatments that had worked before. An important part of the process is choosing a proxy to ensure that providers abide by the directive.

Consumers with serious mental illness who were later interviewed reported feeling that it was an extraordinary responsibility to execute an advance directive and to define oneself as a responsible person in charge of one's treatment. Several consumers reported that choosing a proxy was an exercise that appealed to their imagination—finding "the right person" who would be a diplomatic and helpful advocate. In addition, some consumers felt that thinking about their past experiences with the mental health system in order to make a list of treatments that worked helped them to view their relationship to the system in a new way and to consider the system's commitment to them.

Dr. Stastny noted that consumers who were simply given the materials and not provided with help by a trainer to create an advance directive had a low rate of completion. He urged audience members to consider the positive message that inviting a client to create an advance directive can convey and to become involved in the process. However, he cautioned that creation of a directive is voluntary and that clients should not be pushed.

Jeffrey Swanson, Ph.D., associate professor at Duke University Medical Center, presented preliminary findings from an ongoing study in North Carolina, which has found that although many consumers expressed a desire for a psychiatric advance directive, very few actually had completed one. Many consumers reported not understanding what an advance directive is, which suggests a strong need for educational materials and program components.

Kim Hopper, Ph.D., of the Nathan Kline Institute for Psychiatric Research, provided additional practical advice. He strongly recommended use of an online depository for the directives, because crisis care personnel take the online form more seriously than a piece of paper. A possible "latent function" of an advance directive, he said, is to "set the patient up for another disappointment" if the directive is ignored. Therefore, organizations within a system should work together to help ensure compliance with advance directives.




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