Psychiatric Advance Directives and reduction of coercive crisis interventions

Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.
Journal of Mental Health (Impact Factor: 1.01). 06/2008; 17(3):255-267. DOI: 10.1080/09638230802052195
Source: PubMed


BACKGROUND: Psychiatric advance directives are intended to enable self-determined treatment for patients who lose decisional capacity, and thus reduce the need for coercive interventions such as police transport, involuntary commitment, seclusion and restraints, and involuntary medications during mental health crises; whether PADs can help prevent the use of these interventions in practice is unknown. AIMS: This study examined whether completion of a Facilitated Psychiatric Advance Directive (F-PAD) was associated with reduced frequency of coercive crisis interventions. METHOD: The study prospectively compared a sample of PAD completers (n=147) to non-completers (n=92) on the frequency of any coercive interventions, with follow-up assessments at 6, 12, and 24 months. Repeated-measures multiple regression analysis was used to estimate the effect of PADs. Models controlled for relevant covariates including a propensity score for initial selection to PADs, baseline history of coercive interventions, concurrent global functioning and crisis episodes with decisional incapacity. RESULTS: F-PAD completion was associated with lower odds of coercive interventions (adjusted OR=0.50; 95% CI=0.26-0.96; p < 0.05). CONCLUSIONS: PADs may be an effective tool for reducing coercive interventions around incapacitating mental health crises. Less coercion should lead to greater autonomy and self-determination for people with severe mental illness.

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Available from: H. Ryan Wagner, Dec 14, 2014
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    • "However, though welcomed at a theoretical level, this is not reflected in practice and, even where provision exists, their use is uncommon (Backlar, 1998; Gallagher, 1998; Jeste & Saks, 2006, p. 624; Sarin, 2012; Srebnik & Kim, 2006; Swanson et al., 2003; Varekamp, 2004). A frequently cited aim of PADs in general is to reduce the need for coercion through, for example, improving crisis management recommendations based on patients' past experiences and preferences (Henderson et al., 2004; Khazaal, Chatton, Pasandin, Zullino, & Preisig, 2009; Swanson et al., 2008; Thornicroft et al., 2013). By contrast, a primary outcome of SBDs is to enable the individual to request introduction of coercive interventions in the earlier stages of illness, in order to prevent themselves from engaging in damaging and risky behaviour as they deteriorate (Gremmen, Widdershoven, Beekman, Zuijderhoudt, & Sevenhuijsen, 2008). "
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    ABSTRACT: For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician-patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.
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    • "Propensity scoring also allows for the examination of how well the covariates are ''balanced'' after inclusion of the propensity weight (Rosenbaum and Rubin 1984). The use of propensity scoring approaches in studies of adult mental health outcomes is becoming more common (Swanson et al. 2007, 2008; Swartz et al. Under Review). "

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    • "In US, a study on F-AD (24) compared a sample of completers to non-completers and found a statistically significant association between F-AD completion and lower rates of coercive interventions at follow-up. The study could not however exclude possible bias from initial differences between completers and non-completers. "
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    ABSTRACT: Psychiatric advance directives (ADs) allow an individual to state their preferences for future treatment at times when they may be unable to make considered decisions. There are differences in their form and legal value and the process associated with their use and completion. Several studies have now been completed to assess the impact of ADs on service use and coercion. Their results give a mixed picture but directives nevertheless have the potential to support the empowerment process, minimize experienced coercion, and improve coping strategies. These may in turn reduce the frequency of in-patient service use. Further studies on the different processes of facilitation involved and on different populations are necessary to improve our knowledge and use of these potentially powerful interventions.
    Full-text · Article · Apr 2014 · Frontiers in Public Health
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