Wednesday, December 05, 2007

Do psychiatric advance directives help?

The Wall Street Journal ran an interesting story earlier this week about Psychiatric Advance Directives (PADs) which points out some of the strengths and weaknesses of using them as a planning tool for treating severe mental illnesses:

With PADs, patients with mental illness can state preferences for, or dislikes of, specific treatments, designate a proxy decision-maker or make other advance decisions about care, says Jeffrey Swanson, associate professor at Duke University, who has researched PADs. Twenty-five states, including Illinois, currently have laws authorizing such directives, and more are considering them, according to the National Resource Center on Psychiatric Advance Directives.

…Most state laws contain such an "override" clause, according to Swanson, but to actually force a treatment or hospitalize patients involuntarily for being a danger to themselves or others requires following state law regarding involuntarily treatment, which often involves a court hearing.

Many clinicians worry that PADs allow patients to refuse all treatment or make unreasonable or unsound demands. There are also questions about how to judge if patients are well enough to create PADs, and what to do if they change their minds later if they appear to be getting more symptomatic.

PADS are one more tool for helping individuals who have capacity to make decisions about the mental health treatment they will get if they become incapacitated. But, PADs are not a replacement for treatment laws. For individuals with chronic and persistent symptoms, PADs only work AFTER someone is stabilized and recovered enough to properly execute a PAD. Sometimes, this might require hospitalization or outpatient commitment. Thus, the treatment laws and PADs are tools to be used for situations that require different treatment solutions.

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