Psychiatric Advance Directives and their relevance to improving psychiatric care in Asian countries

People with mental illness may be unable to provide critical input about the care they wish to receive during a psychiatric crisis because of altered mental states. It is therefore imperative that clinicians seek to understand service users' wishes for care while they are well and able to provide meaningful input into the discussion. Achieving such an end may be done by discussing and completing a psychiatric advance directive. However, very few Asian countries have legislation that supports such advance directives. The present article seeks to give physicians more information about advance psychiatric directives and the potential role they could play to improve the healthcare provided in Asia to people at risk of losing capacity due to a mental illness. The degree to which mental health legislation supports psychiatric advance directives is documented for each country of South East Asia and Eastern Asia.     

Between self-determination and role abdication: opinions about euthanasia -- results of a study of Thuringians palliative tumour patients

This study reports the degree to which terminally ill tumour patients wish to be involved in medical decisions about their care and death. In addition, the study aimed to examine euthanasia from the patient's perspective. 272 tumour patients with a life expectancy of less that 1 year took part in a face to face survey. The survey examined attitudes, beliefs and desires with respect to euthanasia, where one would like to die and who should be present as well as attitudes to advance directives. The majority of tumour patients (75 %) wanted to die at home and in the presence of family members (90 %). A multidimensional scaling analysis generated two clusters which were interpreted as self-other determination and integration-non-integration as a patient within the health system. The central theme for the tumour patients is to protect their autonomy in the decision making process at the end of their lives. Desires expressed by these tumour patients did not reflect public discussions about active, passive or indirect assisted suicide. The results demonstrate that doctors should communicate especially sensitively with tumour patients and their relatives.     

Models of advance directives in mental health care:

OBJECTIVE: The aim of this study was to examine perceptions of the place of advance directives in mental health care. METHODS: Postal survey of stakeholders was carried out to assess their views on different models of advance directives in mental health care. A total of 473 responded. RESULTS: In all, 28% of psychiatrists thought advance directives were needed compared to 89% of voluntary organisations and above two-thirds of the other stakeholder groups. There were clear tensions between patient "autonomy" and "right to treatment" which underpin many of the concerns raised. Autonomy provided by advance directive can be contrasted with a co-operative partnership approach to advance planning. The legal status of advance directives is important for some people in relation to treatment refusal. There was general concern about the practical issues surrounding their implementation. CONCLUSION: There is a wide range of views in all stakeholder groups about the possible form advance directives should take. Although there is a widespread desire to increase patient involvement in treatment decisions, which advance directives could possibly help to realise, they may also have unwanted consequences for mental health services and individuals.     

Advance directives for health care and research: prevalence and correlates

Patients suffering from Alzheimer disease and other types of dementia gradually lose their decision-making capacity. Advance directives have been widely promoted as a means to maintain some control over one's life in the event of decisional incompetence. This study used data from a recent postal survey conducted in Quebec, Canada to: 1) estimate the prevalence of formal and informal advance directives for health care and research among community-dwelling older adults presumed free of cognitive deficits; and 2) characterize those who have communicated their preferences regarding health care and research participation. Prevalence rates vary from 7.4% (formal advance directives for research) to 42.3% (informal advance directives for health care). Following multivariate logistic regressions, individuals who have communicated their wishes regarding future health care were found to be older, predominantly women, and to more often know someone with cognitive impairment. Those who have expressed their wishes regarding future research involvement were more inclined to participate in research. They were also more likely to have discussed or written advance directives for health care. The finding that only a small proportion of older adults have discussed future research participation with their families points to the need to find effective ways to promote advance directives for research in this population.     

A messy necessary end: Health care proxies need our support

OBJECTIVE: To promote development of written advance directives and appointment of a proxy for health care by patients who are under the care of a neurologist. BACKGROUND: since 1989, the American Academy of Neurology (AAN) has endorsed but not actively promoted advance directives. In the years since publication of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), much published material has contradicted the notion that creating advance directives offers patients a useful means of extending their autonomy. METHODS: The author reviewed the post-SUPPORT literature, in which numerous articles criticize and others continue to uphold the use of advance directives. He also conducted a pilot study concerning the health care proxy. Additionally, he reexamined his experiences as an ethics consultant, mindful of the medical literature unfavorable to advance directives, to challenge his own opinion that creating directives and appointing a health care proxy are valuable activities for all adults to engage in and for neurologists to promote. RESULTS: Very few articles focus on advance directives and neurology. This literature is not present in neurology specialty journals. Only two of the five neurologists approached by the author were positive about advance directives and collaborated fully in the pilot study. Reviewing his experiences provided the author with numerous examples of the actual or potential usefulness of health care proxies. CONCLUSIONS: Increasing the advance directives literature in neurology specialty journals may lead to the creation of health care documents by more neurologic patients and the development of innovative ways of extending the autonomy of previously competent individuals. The author has recently formed a volunteer organization, Patient Advocates to Preserve Autonomy (PAPA), to increase effectiveness of advance directives. It is hoped that the reservations of some neurologists about advance directives and proxy decision-making may be lessened if they improve their knowledge of the subject and convince themselves that addressing it is one of the obligations attendant on providing "principal care" for many of their patients. The focus initially needs to be on attitudes, rather than methods. However, this pilot project showed that a passive approach is ineffective. A campaign within the AAN to promote advance directives as an aspect of principal care would be helpful. Patients who have lost the capacity to make their own health care decisions often benefit from advance directives and, especially, from having an appointed health care proxy. Those benefits may improve if patient, proxy, and physician are carefully prepared for their roles.     

Psychiatric wills of mental health professionals: a survey of opinions regarding advance directives in psychiatry

Pscychiatric wills are advance directives for an eventual involuntary treatment in psychiatry. We attempted to determine psychiatric professionals' knowledge and opinion about this legal option and obtain their formulations of advance directives for themselves. A total of 101 psychiatric nurses and psychiatrists at the Department of Psychiatry of the University of Vienna responded to a questionnaire about psychiatric wills and anonymously drafted advance directives for themselves concerning psychiatric treatment in case of an acute psychosis. Fifty-four percent knew about this legal option, 55% considered it an appropriate legal possibility, and 29% considered it inappropriate. The study also found that 75% of respondents reject certain methods of therapy, e.g. 30% want to exclude the use of neuroleptic medications, and 46% reject ECT. We conclude that although there is little experience so far with advance directives for psychiatric patients, there is an interest and predominance of positive attitudes towards this legal option among mental health professionals. Concerning their preferences, professionals felt inclined to make very specific statements as to which available treatment strategies they would reject and which they would request for their treatment. This bodes well for the widespread use of advance directives in mental health settings. Accepted: 20 March 1998     

A Survey of Stakeholder Knowledge, Experience, and Opinions of Advance Directives for Mental Health in Virginia

An innovative Virginia health care law enables competent adults with serious mental illness to plan for treatment during incapacitating crises using an integrated advance directive with no legal distinction between psychiatric or other causes of decisional incapacity. This article reports results of a survey of 460 individuals in five stakeholder groups during the initial period of the law’s implementation. All respondents held favorable views of advance directives for mental health care. Identified barriers to completing and using advance directives varied by group. We conclude that relevant stakeholders support implementation of advance directives for mental health, but level of baseline knowledge and perception of barriers vary. A multi-pronged approach will be needed to achieve successful implementation of advance directives for mental health.     

Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness

OBJECTIVE: Studies show a high potential demand for psychiatric advance directives but low completion rates. The authors conducted a randomized study of a structured, manualized intervention to facilitate completion of psychiatric advance directives. METHOD: A total of 469 patients with severe mental illness were randomly assigned to a facilitated psychiatric advance directive session or a control group that received written information about psychiatric advance directives and referral to resources in the public mental health system. Completion of an advance directive, its structure and content, and its short-term effects on working alliance and treatment satisfaction were recorded. RESULTS: Sixty-one percent of participants in the facilitated session completed an advance directive or authorized a proxy decision maker, compared with only 3% of control group participants. Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the advance directive to refuse some medications and to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment. At 1-month follow-up, participants in the facilitated session had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the mental health services they believed they needed. CONCLUSIONS: The facilitation session is an effective method of helping patients complete psychiatric advance directives and ensuring that the documents contain useful information about patients' treatment preferences. Achieving the promise of psychiatric advance directives may require system-level policies to embed facilitation of these instruments in usual-care care settings.     

Psychiatric advance directives

Psychiatric advance directives are gaining attention as the number of consumers seeking metal health services increases. Even though medical advance directives have existed for years, psychiatric advance directives are in their infancy. The goal of these directives is to increase patient autonomy and decrease coercive treatment. Although this concept sounds simple, advance directives have generated heated debates that encompass ethics, law, and medicine. Psychiatric advance directives are also not universally accepted--only 14 states currently recognize such directives. This review article discusses the premise behind psychiatric advance directives and explores possible benefits and obstacles to the use of such directives.     

Patientenverfügungen von Menschen mit psychischen St?rungen

Since 1 September 2009, advance directives are regulated by law in Germany. This article discusses ethical challenges of advance directives in patients with mental disorders. Besides concrete information on the preferred medical treatment in concrete clinical situations, the mental capacity of the patient at the time of issuing the directive is essential. The "Decisional Competence Assessment Tool for Psychiatric Advance Directives" and empirical studies from the USA on advance directives in patients with mental disorders and the assessment by the treating psychiatrists of these patient directives are discussed. Ethical conclusions are drawn for handling advance directives in psychiatric practice.     

Attitudes concerning involuntary treatment of mania: results of a survey within self-help organizations.

PURPOSE: - The objective of the study was to determine the level of involuntary treatment that mood disorder patients and their families wish in the event of a manic or hypomanic episode. METHOD: - A survey was conducted within two self-help organizations during two conventions gathering over 500 patients, along with families and caregivers. A clinical vignette depicting an uncollaborative hypomanic patient beginning to endanger his professional and financial situation and to put undue stress upon his family was presented and followed by an eight-item questionnaire. The level of coercive treatment seen as appropriate was measured by visual analogue scales. RESULTS: - The 503 respondents disagreed partially with the statement that the patient should decide by himself about his hospitalization and partially favored some involuntary treatment over treatment refusal. There was no difference between patients, relatives and caregivers related to acceptance of coercive hospitalization and treatment. Respondents assigned a major role to treating teams and family members in decisions for coercive treatment. CONCLUSION: - Most respondents (including a majority of patients) support a moderate degree of coercive treatment in the event of a hypomanic or manic state. Surveys of opinions from concerned people could influence, practice, legislation and possibly advance directives that could be written by patients or patients organizations.     

Interest in psychiatric advance directives among high users of crisis services and hospitalization

OBJECTIVES: This study examined rates of interest in creating psychiatric advance directives among individuals at risk of psychiatric crises in which these directives might be used and variables associated with interest in the directives. METHODS: The participants were 303 adults with serious and persistent mental illnesses who were receiving community mental health services and who had experienced at least two psychiatric crises in the previous two years. Case managers introduced the concepts of the directives and assessed participants' interest. The associations between interest in the directives and demographic characteristics, psychiatric symptoms, level of functioning, diagnosis, history of hospitalizations, history of outpatient commitment orders, support for the directives by case managers, and site differences were examined. RESULTS: Interest in creating a directive was expressed by 161 participants (53 percent). Variables significantly associated with interest were support for the directives by a participant's case manager and having no outpatient commitment orders in the previous two years. Reasons for interest included using the directives in anticipation of additional crises and as a vehicle to help ensure provision of preferred treatment. CONCLUSIONS: Substantial interest in psychiatric advance directives was shown among individuals with serious and persistent mental illness. The results strongly suggested that attitudes of clinicians about psychiatric advance directives are associated with interest in the directives among these individuals. Therefore, it is important to educate clinicians and address their concerns about the directives so that they can more comfortably support creating the documents. A shift in values may also be necessary to more consistently recognize and honor patients' treatment preferences as specified in the directives.     

End-of-life decisions, powers of attorney, and advance directives

In modern medicine, decisions about the kind of treatment at life's end are often inevitable. According to German law, powers of attorney and advance directives can be of help in these decisions. When a patient in a state of competence has issued a lasting power of attorney, there is no need for courts to appoint a proxy, and physicians immediately have a legally empowered decision-maker they can address. According to current German law, advance directives are legally valid and binding expressions of a patient's will. They are, however, more powerful when issued after consultation with a physician. If treatment at life's end no longer complies with the patient's will or loses its medical indication, the goal of treatment should be redirected towards palliation. This implies that life-sustaining treatment may be withdrawn or withheld, which is best accomplished with sensitivity to the needs of patients, relatives, and health care professionals.     

Einstellungen zur Patientenbetreuung in der letzten Lebensphase

In view of the increasing importance of palliative medicine and end-of-life care of neurological patients, a survey from the American Academy of Neurology was translated in a validated fashion and sent to all medical directors of neurological departments in Germany. The topics of the survey comprised-based on clinical scenarios-the withdrawal or withholding of life-sustaining measures, physician-assisted suicide (PAS) and euthanasia, advance directives and health care proxies, principles of palliative care, and ethical and legal questions in end-of-life care. Of 411 directors of departments, 152 participated in the survey. Almost all respondents support a patient's right to refuse life-sustaining treatment. Thirty-two percent think it is illegal to administer analgesics in doses that risk respiratory depression. Forty-five percent believe that treating terminal dyspnea with morphine is the same as euthanasia. Despite the fact that 88% of the respondents regard advance directives as helpful, only an average of 4% of their patients have completed one. About one third of the respondents have been confronted with a request by patients for PAS or euthanasia. Thirty-five percent believe that PAS should be made explicitly legal for terminally ill patients. Forty-six percent of the respondents believe that their training in end-of-life care was insufficient, and 91% express interest in education programs on palliative care.     

Clinical decision making and views about psychiatric advance directives

OBJECTIVES: Psychiatric advance directives allow competent persons to document advance instructions or designate a health care agent to communicate their preferences for future mental health treatment in the event of an incapacitating crisis. Although laws authorizing psychiatric advance directives have proliferated, little is known about clinicians' understanding and perceptions of these legal tools. METHODS: A total of 597 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey about their attitudes toward psychiatric advance directives and decision making about following such directives. RESULTS: Approximately half the sample (47 percent) agreed that advance instructions would be helpful to consumers with severe mental illnesses, and a majority (57 percent) endorsed health care agents as beneficial. Regardless of profession, clinicians had more positive attitudes about psychiatric advance directives when they correctly recognized that they were not required by state law to follow directives that note the patient' s refusal of appropriate medical treatment. In multivariate analyses, the decision to abide by a patient' s advance refusal of treatment in a hypothetical scenario was predicted by knowing the laws associated with these directives, valuing family opinions about treatment, and respecting patient autonomy. CONCLUSIONS: Clinicians correctly apprised of the state law were more likely to endorse psychiatric advance directives. Thus clinicians may be more willing to use directives if they are educated about the legal parameters of their implementation. The clinicians' profession had only an indirect influence on whether clinicians would follow an advance instruction that noted the patient's refusal of appropriate treatment; rather, clinicians' values and legal knowledge had the greatest effect, highlighting the potentially complex ethical dilemmas faced by mental health professionals who encounter these directives.     

Effect of patients' reasons for refusing treatment on implementing psychiatric advance directives

OBJECTIVE: Clinicians have raised concerns that psychiatric advance directives may be used to refuse all treatment. However, people writing psychiatric advance directives can explicitly state their reasoning underlying treatment decisions. This study examined whether patients' reasons for refusing treatment influenced clinician decision making about implementing psychiatric advance directives. METHODS: A total of 597 mental health professionals completed a questionnaire that presented two scenarios: one in which the patient wrote a psychiatric advance directive refusing all medication because of paranoid delusions and one in which the patient wrote a psychiatric advance directive refusing all medication because of concerns about side effects. RESULTS: Twenty-two percent of clinicians reported that they would respect the former psychiatric advance directive, whereas 72% reported that they would respect the latter. After multivariate regression was used, the reason for treatment refusal remained the single significant predictor of clinicians' decision to honor a patient's psychiatric advance directive. CONCLUSIONS: Results show reasons for treatment refusal in psychiatric advance directives are likely to affect clinicians' decisions to implement the directives.     

Competency for creation, use, and revocation of psychiatric advance directives

Psychiatric advance directives help promote patient involvement in treatment and expedite psychiatric care. However, clinicians are unsure of how to use directives, partly due to poor clarity regarding standards for capacity to create, use, and revoke them. This article recommends possible capacity standards. Capacity to create directives is a legal presumption, supported by empirical data. Standards are discussed for the subset of cases in which capacity assessment is needed. Use of directives may be triggered by incapacity to provide informed consent to treatment, although tailored, individualized points of activation may also be considered. In many states, revocation of a psychiatric advance directive requires adequate decision-making capacity. Setting a capacity standard for revocation presents challenges, however, in light of obstacles to providing treatment when revocation is attempted and the fact that many patients prefer revocable directives. As more directives are created and used, additional research and statutory refinements are warranted.     

Advance directives for clinical research in dementia

In this paper the author raises a number of general and specific doubts concerning the employment of advance directives in clinical research.From a general point of view, they are little used even in the countries in which they are legally recognised. From the specific point of view of the demented patient, the profoundly regressive personality changes during the course of the disease make it difficult to believe that there is a continuity between the person who expressed precise opinions when he was in good health or only slightly affected and the same person in an advanced phase of the disease. Especially in non-therapeutic studies, in which any benefit to participants is missing, the author's opinion is that the directly expressed consent of the participants should be absolutely required.     

Aktive Sterbehilfe bei Menschen im Wachkoma?

An examination was made concerning doctors' and nursing staff's attitudes towards active euthanasia of patients suffering from coma vigil (2652 doctors and 5785 nursing staff were interviewed). This investigation made clear that most of the persons asked about this group of patients voted for a change in German laws following the Dutch example. There were noticeable differences observed between the professional groups. A majority (64.79%) were convinced that under certain circumstances it is justified to end intentionally the life of persons in a coma vigil. Of the nursing staff, 70.38% were in favour of this attitude, and 51.53% of the doctors share this opinion. Certain groups supported the question of active euthanasia more clearly than others. These were young participants in the investigation, first-time employees, nondenominational interviewees, those who are dissatisfied with their job situation, who are from the newly-formed German states, and who are divorced. The attitudes expressed by all these people originate in many different motives: thoughts about the patients, aspects concerning jobs, and personal aspects had an influence on results of the investigation. This single investigation which was restricted to patients suffering from coma vigil and to employees of the public health service, does not prove that the total population has generally changed its attitude toward active euthanasia. It is impossible to justify the necessity of new laws about euthanasia based on the above results.     

Attitudes towards professional euthanasia in the range between grement in the society and personal preferences--results of a representative examination of the German general population

Several surveys of the German population concerning the attitude towards euthanasia in patients with terminal illness yielded contradictory results, ranging from high acquisition to high refusal rates. After a critical discussion of the methodological concepts of these investigations, we present the results of a representative study of 1957 German persons (age range: 14 - 96 years) which was performed by the institute USUMA in February 2001. Four different types of euthanasia were included in the study: active, passive, and indirect euthanasia as well as physician's assisted suicide. The affirmative response categories were "declared will and unbearable pain", "declared will", "referred will", and "in the responsibility of the physician". Additionally, we asked to state the personal preference in the case of an own incurable illness. The resulting frequency distributions stress the autonomy of the patients (declared will) and the legal forms of professional euthanasia (passive and indirect euthanasia), independent from the degree of pain. The rank order of the hypothetic personal preferences was: passive euthanasia (26.1 %), active euthanasia (21.1 %), indirect euthanasia (13.1 %) and assisted suicide (6.2 %). For each category the hypothetic personal will to utilize euthanasia personally is markedly lower than the consent to legalize euthanasia in the society. This points to a diminished readiness of the population to seek for euthanasia. Persons aged 60 years and above deny all types of euthanasia significantly more often than younger persons. Persons with subjectively bad health status prefer the category "in the responsibility of the physician" more often than healthy subjects. The representative study proves that there is no polarized public opinion concerning euthanasia, rather there is a picture of high complexity.