Psychiatric advance directives: Controversies and benefits

In theory, psychiatric advance directives provide a way to improve medical decision making during a mental health crisis. Directives indicate, in advance, what treatments a patient prefers or who should make decisions if he or she becomes incapacitated. However, two key controversies surround these directives, reports the December 2007 issue of the Harvard Mental Health Letter. Psychiatric advance directives differ from general advance care directives in two ways. First, general directives dictate decisions about end-of-life treatments that the patient has never actually experienced. In contrast, psychiatric patients are generally dealing with chronic illnesses and have experience with the treatments. Second, the goal of a general advance care directive is to help life end in comfort; the goal of a psychiatric advance directive is to maximize the chances of recovery, while minimizing unwanted interventions. The Harvard Mental Health Letter notes that controversy may arise when clinicians are given license to override a psychiatric advance directive. Most state laws give clinicians discretion to override a directive when a patient is involuntarily committed to a facility, when a patient's wishes are not feasible, or when the directive conflicts with the current standard of care. However, clinicians are expected to honor other preferences expressed in the documents.
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