Psychiatric advance directives

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.

Another point of controversy relates to when patients may revoke directives. A competent individual can revoke a psychiatric advance directive at any time. But problems can occur when a patient tries to revoke the document during a psychiatric crisis. Some patients insert a clause that explicitly states that the document should not be revoked during a period of incapacity.

Regardless of these controversies, the Harvard Mental Health Letter notes an important side benefit of filling out the documents: the process enhances patient-doctor communication. 

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