Advance Directives

To the Editor: Srebnik and La Fond provide a useful review of the potential role of psychiatric advance directives in their article in the July issue. We would like to add a few points.

First, although we endorse the authors' list of possible practical benefits of psychiatric advance directives, the strongest argument in their favor is ethical: such directives made while a patient has the capacity, or competence, to make treatment decisions provide the soundest ethical basis for nonconsensual treatment when capacity is lost. Indeed, when capacity becomes the determinant of whether a patient receives psychiatric treatment without consent, the question arises whether it should not become the justification for all involuntary treatment. A radical revision in mental health legislation would logically follow; for example, an "Incapacity Act" might replace a "Mental Health Act" (1).

Thus for advance directives, capacity assumes center stage. Three levels need to be defined: first, the patient must have a certain level of capacity to make an advance directive; second, capacity must fall below a certain level to trigger the advance directive; and third, the patient must have a level of capacity greater than the second level and possibly the same as the first level to revoke the directive (2). Few mental health professionals are experienced in thinking about capacity, and it will take some time for us to acquire the requisite skills. The fact that patients will have previously lost and regained capacity, often in a stereotyped way, will facilitate individual specification of the relevant levels.

Our second point is that crisis planning that is not legally binding has the potential to achieve many of the benefits being sought through advance directives. The results of a pilot study of the use of "crisis cards" conducted by our team in London support this view (3). Such cards can be carried by the patient and may contain information ranging from persons to contact to details of treatment shaped by various contingencies.

Third, if, as many have suggested, one of the major benefits of an advance directive is clearer communication between the patient and the clinical team, then computer-assisted guides to making a directive are not desirable. We suggest that there are two types of both crisis cards and advance directives. The first follows a plan of treatment agreed to by the patient and the clinical team; the second is drawn up by the patient without discussion with the team (3). The latter is likely to prove less satisfactory.

Finally, important conceptual issues must be sorted out concerning advance consent to treatment rather than the more conventional advance refusal. An advance directive carries the same weight as a contemporaneous request for a specific treatment. Just as a clinician will not comply with an inappropriate treatment request by a patient who has capacity, neither would the clinician comply with an advance directive asking for inappropriate treatment. Here again, prior agreement with the clinical team would be highly advantageous.

Dr. Szmukler is joint medical director at Maudsley Hospital, Denmark Hill, London. Dr. Henderson and Dr. Sutherby are research fellows in the section of community psychiatry at the Institute of Psychiatry in London.