Clinicians, Case Managers Can Influence Decisions About Advance Directives

Psychiatric “advance directives”—documents composed in advance of a psychiatric relapse to outline treatment preferences in the event that a patient becomes incompetent—are favored by patients with severe psychiatric illness when they have a case manager or clinician who actively supports use of the documents.

That was the conclusion from a survey of 303 adults with serious mental illness who were receiving community mental health services and who had experienced at least two psychiatric crises in the preceding two years. The survey was published in the July Psychiatric Services.

“The majority of consumers, when approached systematically and asked if they are interested in advance directives, say they are interested in creating the document,” study author Debra Srebnik, Ph.D., told Psychiatric News.

She is an assistant professor of psychiatry in the department of psychiatry and behavioral sciences at the University of Washington School of Medicine.

In the study, associations were examined between level of interest in creating the document and a variety of variables: demographic characteristics, psychiatric symptoms, level of functioning, diagnosis, history of hospitalization, history of outpatient commitment orders, support for the directives by case managers, and site differences.

Of the survey participants, 161 (53 percent) expressed an interest in the directives. Variables significantly associated with interest were the support of the case manager for the document and no history of outpatient commitment.

Before introducing information about the directives to the participants, case managers rated themselves, using a Likert scale, on four questions assessing support for the concepts of psychiatric advance directives:

• How useful do you think psychiatric advance directives would be for consumers during mental health crises?

• How useful do you think psychiatric advance directives would be for service providers during mental health crises?

• How do you feel, personally, about psychiatric advance directives?

• How useful would it be for consumers to have service providers help them complete psychiatric advance directives?

Srebnik told Psychiatric News that the idea that patients with no history of outpatient commitment orders were more likely to be interested in advance directives ran counter to a research hypothesis: The researchers had assumed that those with such a history might prefer to have a written advance directive as a substitute for commitment.

Srebnik explained, however, that the theoretical foundation of that assumption overlooks the real preferences and tendencies among such patients. Having an outpatient commitment order may serve as a proxy for unmeasured variables, such as treatment engagement, adherence, or appreciation that one has a mental illness requiring treatment.

“For those who discount the need for treatment, psychiatric advance directives will predictably be of little interest, except possibly as a vehicle for refusing future treatment,” Srebnik and colleagues wrote in the article. “The directives may be valuable only to individuals who perceive value in the treatment that the documents direct.”

In the article “Implementing Psychiatric Advance Directives: Service Provider Issues and Answers” in the May 13 Journal of Behavioral Health Services and Research, Srebnik and Lisa Brodoff, J.D., of the School of Law at Seattle University outlined questions raised by service providers about psychiatric advance directives.

Among these issues are access to directives, competency to execute directives, the relationship of directives to standards of care, and liability for honoring and not honoring directives.

Srebnik said that anecdotally “there are very few of these documents in circulation.” And even when they exist, it may be difficult or impossible to access them in an emergency situation.

“Imagine the situation where a patient is having a crisis and has to go to the emergency room,” she said. “The staff has never seen the patient before, and the patient may or may not even remember that a directive exists. That’s the end of the discussion. The service provider may never know the directive exists, and in some systems it may be difficult to get their hands on the documents.”

Jeffrey Metzner, M.D., chair of APA’s Council on Psychiatry and Law, said that among the problems with psychiatric advance directives is that they might be used to indicate a preference for no treatment.

“Under ordinary circumstances, if a patient were incompetent, that patient would meet civil commitment criteria,” he said. “If a directive indicates no treatment, I don’t think anyone is going to follow that directive.”

Metzner said that advance directives might be most useful to clinicians when they indicate a preference for or against a particular treatment over a range of options.

“If there is a choice of treatments, and you’ve expressed a preference for one, the psychiatrist will be more likely to use that one than another,” he said.

“The study was not about the pros and cons of using advance directives, though it implies that they are good and that they are underutilized,” said Metzner, a clinical professor of psychiatry at the University of Colorado Health Sciences Center. “The real conclusion is that patients are more likely to use advance directives if the case manager or clinician thinks it is a good idea and conveys it to the patient. The message is that people working with severely mentally ill people ought to educate themselves about psychiatric advance directives and talk with patients about them.”

The study, “Interest in Psychiatric Advance Directives Among High Users of Crisis Services and Hospitalization,” is posted on the Web at http://ps.psychiatryonline.org/cgi/content/full/54/7/981?. ▪