Psychiatric advance directives: qualitative study of informed deliberations by mental health service users

BackgroundEstablished legal mandates and high expectations for psychiatric advance directives are not matched by empirical evidence documenting their actual implementation.AimsTo explore the interests, concerns and planning activities of informed mental health service users contemplating such directives.MethodStandard qualitative research techniques were used: field observations, interviews, focus groups, archival research and key informant interviews; 33 persons participated in the interviews and focus groups. Transcripts were coded and analysed for thematic content, and results were member-checked.ResultsTraining set in motion labour-intensive projects: conceptualising how a psychiatric advance directive would work in one's life, mobilising resources, reviewing past experiences and assessing risks. Especially meaningful was the prospect of being treated as a responsible agent in future interactions with the mental health system.ConclusionsAdvance directives are best thought of as complex planning tools for future psychiatric crisis management, rather than focal interventions to enhance compliance. Research is needed to explore the institutional response to this prospective decision-sharing initiative.