Strengthening the psychiatric advance directive system in New Zealand: Allowing the mentally ill to help themselves

<p>Psychiatric advance directives (PADs) are an emerging method for adults with serious and persistent mental illness to manage their treatment by documenting treatment preferences in advance of periods of incapacity. However, the application of PADs has largely been neglected by the legal and psychiatric discourse in New Zealand. This paper presents some of the key purposes and unrealised benefits of PADs, and explains why New Zealand’s law and policy surrounding advance directives in the mental health arena is unclear compared to other jurisdictions. Though interviews conducted with New Zealand clinicians and consumer advocates, key practical and legal dilemmas around forming, monitoring, and enforcing PADs were extracted and dissected. Interviews elucidated that, while attitudes were generally positive attitude towards PADs in the mental health system, the lack of a focused PAD strategy stifled its promulgation where it could most benefit service users. This paper proposes that PADs should be promoted, and articulates a normative PAD strategy for New Zealand.</p>

Strengthening the psychiatric advance directive system in New Zealand: Allowing the mentally ill to help themselves

<p>Psychiatric advance directives (PADs) are an emerging method for adults with serious and persistent mental illness to manage their treatment by documenting treatment preferences in advance of periods of incapacity. However, the application of PADs has largely been neglected by the legal and psychiatric discourse in New Zealand. This paper presents some of the key purposes and unrealised benefits of PADs, and explains why New Zealand’s law and policy surrounding advance directives in the mental health arena is unclear compared to other jurisdictions. Though interviews conducted with New Zealand clinicians and consumer advocates, key practical and legal dilemmas around forming, monitoring, and enforcing PADs were extracted and dissected. Interviews elucidated that, while attitudes were generally positive attitude towards PADs in the mental health system, the lack of a focused PAD strategy stifled its promulgation where it could most benefit service users. This paper proposes that PADs should be promoted, and articulates a normative PAD strategy for New Zealand.</p>

Opportunities and Risks of Self-Binding Directives: Results from Interview Studies with Stakeholders in Germany and The Netherlands

"Self-binding directives (SBDs) are a special type of psychiatric advance directive in which service users agree in advance to (coercive) treatment they might late refuse during a mental health crisis. SBDs aim to empower and protect service users by enabling them to state their values and to plan their (coercive) treatment in advance in consultation with the treating psychiatrist. SBDs have been widely discussed in the ethics literature. Topics include ethical issues surrounding competence, revocation and the ethical justification of involuntary commitment and treatment based on SBDs. Little empirical research on SBDs has been conducted thus far. The Netherlands is to the best of our knowledge the only country with explicit legal provisions for SBDs. On the 1st of January 2020, the new Dutch Law on Compulsory Mental Health Care (Wvggz) entered into force. The implications of this law for the use of SBDs are still unclear. In this presentation, we will present insights from a qualitative interview study on stakeholders’ experiences with SBDs under the new law and their views on the ethical opportunities and challenges of SBDs. Based on the results, we give recommendations for the implementation of SBDs in other European countries. "

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.

Psychiatric advance directives: reconciling autonomy and non-consensual treatment

This paper examines the potential for advance directives to be used by people with mental illness. Also known as a ‘living will’, an advance directive enables a competent person to make decisions about future treatment, anticipating a time when they may become incompetent to make such decisions. In Englishlaw, if “clearly established” and “applicable to the circumstances”, an advance directive assumesthe same statusas contemporaneous decisions made by a competent adult. A psychiatric advance directive, anticipating relapse of a psychosis, develops the concept of the living will. We argue it could reconcile two apparently contradictory themes in the current practice of psychiatry - on the one hand, the call to provide for non-consensual treatment outside hospital, and on the other, the promotion of patient autonomy.

The Use of an Advance Directive in Consultation-Liaison Psychiatry: A Case Report

Objective: The following case report illustrates the use of a psychiatric advance directive in a surgical setting. Method: The case of a woman with breast cancer and debilitating pre-operative anxiety is presented. Her anxiety was so severe that it resulted in repeated refusal to have necessary surgery. An advance directive facilitated proceeding with surgery despite her objections in the immediate pre-operative period. Conclusion: Consultation-Liaison psychiatrists should consider the use of an advance directive when preoperative anxiety interferes with decision-making capacity.