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Psychiatric Advance Directives: Pros and Cons

Natalie Staats Reiss, Ph.D.

I read an article today on Washingtonpost.com discussing the pros and cons of "psychiatric advance directives". These documents are special legal documents used to communicate wishes about psychiatric medical care should someone become incapacitated and unable to communicate their wishes. You have likely heard about the more traditional form of advance directives called "living wills", which deal with someone's wishes about end-of-life care.

Psychiatric advance directives can allow someone to communicate what medications and/or other types of treatments they prefer (or absolutely do not want, e.g., electroconvulsive therapy), where they prefer to be treated, and who they wish to provide the treatment. In addition, most states' mental health advance directives allow someone to appoint a "proxy" or another person to make decisions on their behalf should they become incapacitated. Some states (e.g., Ohio) allow people to communicate other information on the directive, such as: who is allowed to visit the patient if they are hospitalized and who is authorized to look after the patient's relatives, pets, and/or property while they are being treated.

About two dozen states have psychiatric advance directive statutes that specifically allow for those with mental illness to develop these types of documents.

Researchers' and clinicians' reactions to psychiatric advance directives are mixed. Those who support the use of these documents suggest that:

  1. They are a step forward in terms of being an active health care consumer and having a say in the medical decision-making process.

  2. These documents can prompt discussions between doctors and patients. People who discuss these issues with their doctor (or, at the very least, give a copy of the directive to their doctor) are having open and honest conversations about their situations, which is a healthy coping strategy for dealing with the symptoms and outcomes of having a mental illness.

  3. The directives can help shorten the time delay between a worsening of symptoms and obtaining effective treatment. If, for example, you know that you react negatively to Haldol (an antipsychotic medication often used for schizophrenia), but you have had tremendous success with Risperidone in the past, it can help doctors when you are unable to share this information.

Those who oppose the use of the documents say that:

  1. Some people with mental illnesses may not be rational enough to outline appropriate plans for treatment in advance. Or, they may be unaware of available treatment options that could help them get better, faster.

  2. Because there is currently no central registry (or statewide registries) for these documents, doctors and hospitals may not know about or have access to these directives.

  3. The forms may be confusing in cases of emergency, when someone has two separate directives (one for general medical conditions, and one for mental illnesses).

  4. The directives may increase the number of malpractice suits by those claiming the documents were not properly honored.

  5. The documents provide a false sense of security, because they are not always honored. For instances, in some states, the directives become invalid if someone is experiencing a psychotic crisis (i.e., a loss of touch with reality). Some states also allow doctors to override instructions if they have made reasonable efforts to follow the directives. Also, in most states, involuntary commitment (i.e., hospitalizing someone "against their will" because they are a danger to themselves or others) laws supercede the advance directives.

  6. They promote inequality, stigmatization and discrimination by separating mental illness from other types of illnesses.

  7. They detract from using health-care proxies (i.e., substitute decision-makers), which is a better way to communicate wishes about someone's care in the event they become incapacitated.

  8. Even though they are available, they are still seldom used. Less than 10% of people with mental illnesses have filled out this type of documents. Many of the people who do not fill them out have very little understanding of how the documents work, and simply do not believe that their wishes would be followed.

I am very interested in your opinions regard psychiatric advance directives. Would you use these types of documents? Why or Why Not?

For an example mental health advance directive from Ohio, see http://www.olrs.ohio.gov/other/AdvanceDirectivesWorkbook.pdf