Commentary: Psychiatric Advance Directives and Recovery-Oriented Care

Frontline public-sector clinicians, in the face of sorely strained clinical resources, can be skeptical about "recovery-oriented" or "patient-centered" care. To some, these terms lack specificity and guidance for practice. Two articles in this issue offer empirically supported direction for promoting a recovery orientation and for thinking about treatment decisions and planning from the patient's point of view.

Adams ( 1 ) explored preferences for shared decision making among a relatively small group of persons with severe mental illnesses and found, not surprisingly, that these individuals expressed a clear desire for patient-centered decisions—especially medication decisions—affecting their treatment.

Srebnik and Russo ( 2 ) examined whether the psychiatric advance directive leads to more patient-centered crisis care. These legal documents are designed to direct care during incapacitating psychiatric crises ( 2 ). The authors found that when directives were accessed, two-thirds of subsequent treatment decisions were consistent with them. Because most directives are consistent with standard clinical practice, interpreting their influence on clinical decision making during these crises may be difficult. The authors also reported lower rates of consultation with proxy decision makers, typically authorized by a health care power of attorney. This latter finding is somewhat disappointing because a tangible benefit of directives is the ability of the treatment team to involve trusted others in decision making when a consumer is unable to make such decisions.

Lack of clinician familiarity with directives and lack of ready access to them in crises prevent wider use ( 3 ). To increase awareness, understanding, and assistance in completing directives, the MacArthur Foundation is supporting a new National Resource Center on Psychiatric Advance Directives (nrc-pad.org). At least one national electronic directory, the U.S. Living Will Registry (www.uslivingwillregistry.com), provides online storage and secure access to care planning documents. Also, more states have set up online directories.

Twenty-five states have enacted statutes for authorizing mental health advance instructional documents or proxy decision making and providing a legal means for competent individuals to consent to or refuse future mental health treatment during decisional incapacity. About 66% of consumers consistently express interest in completing psychiatric advance directives ( 3 ). All states permit competent adults to use generic health care decision laws to make at least some psychiatric treatment choices in advance, typically through a health care power of attorney.

Mental health administrators and hospital compliance officers increasingly recognize their legal obligations to implement psychiatric advance directives under the provisions of the federal Patient Self-Determination Act of 1991, which requires hospitals to inform patients of their rights under state law to prepare a directive, to inquire and document whether patients have executed one, to ensure compliance with state laws by respecting advance directives, and to educate health care providers regarding these legal instruments. Moreover, the Centers for Medicare and Medicaid Services recently reiterated that patients have the right to formulate advance directives and staff must comply with the 1991 federal guidelines or risk loss of funding ( 4 ).

Beyond the pressures to comply with the Patient Self-Determination Act, clinicians should see psychiatric advance directives as an opportunity to collaborate with consumers in planning for treatment and, through a health care power of attorney, to engage consumers' trusted social networks in making good decisions in periods of decisional incapacity. Directives are a legal right for consumers as well as practical tools for clinicians to deliver better care.