Transcript What Information Consumers Include in their Psychiatric

Facilitating Advance Directives
for Mental Health Care
Christine M. Wilder, M.D.
Department of Psychiatry
Duke University School of Medicine
NRC•PAD
Why Use Advance Directives for
Mental Health Care?
• Enhance autonomy and self-directed
mental health care
• Provide ER and inpatient doctors with
transportable documentation of a patient’s
treatment preferences and history
 Medical disorders, emergency contact
information, side effects of medication
• Improve therapeutic alliance and treatment
adherence
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AD Completion Rates by Study
Group
Control
Group
(n=230)
F-PAD
Group
(n=239)
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Baseline 2 months
1 (0.5%) 8 (3%)
3 (1%)
149 (62%)
After Swanson et al 2006, Am J Psychiatry 163:1943-51
Excerpts from Unfacilitated AD:
“I do not consent to the administration of the
following medications . . . [lists 9 meds]”
“. . . Episodes are to be managed at home where my
special foods are prepared by me or health care aide as
no hospital can afford my expensive diet. . .”
“. . . DO NOT NOTIFY my son ________ or his
family, as they are hostile relatives.”
“I do not consent to being admitted to. . .[lists 4
hospitals] where abusive treatment has occurred . . .I
would want a legal aid attorney to see me ASAP.”
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Facilitated AD from Same Participant
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AD Content: Medications
• 94% gave advance consent to
treatment with at least one psychotropic
medication (mean = 2.4)
• 77% refused at least one psychotropic
medication (mean= 1.5)
• No participant refused all medications
• On average, participants gave advance
consent to twice as many medications
as they refused
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Sample Medication Choices
“I refuse Haldol because it makes me stiff,
I get blurred vision, and feel like a
zombie.”
“I don’t want Depakote because one time I
had it and I got Pancreatitis.”
“They’ve given me Ativan before but I
absolutely do not want any medications I
could become addicted to.”
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AD Content: Hospitals
• 88% gave advance consent to hospitalization
in at least one specified facility
• 62% documented advance refusals of
admission to particular hospitals
• 51% gave reasons for refusal
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Sample Hospital Comments
“I want to go to [hospital X] because it is
closest to my parents and they treat me
well there.”
“I do not wish to go back to [hospital Y], I
was thrown in a dark room and am scared
and was hurt by another patient last time.”
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AD Content: Emergency
Contacts
• Includes family, friends, doctors and
counselors that participant would want to
have contacted in the event of crisis
• Provides prior consent for communication
between inpatient and outpatient treatment
providers
• On average, participants listed 3
emergency contacts
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Facilitator Role
• Providing information and education about
ADs, including their limitations
• Helping consumers identify appropriate
agents to act in their stead during a period of
incapacity
• Eliciting preferences and advance consent or
refusal for psychotropic medications, hospital
treatment, or ECT
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Facilitator Role
• Gathering information about crisis
symptoms, relapse and protective factors,
instructions for inpatient staff, and other
relevant information the consumer thinks
is important
• Providing assistance for filing ADs at local
health care facilities and storing them in
the U.S. Living Will Registry
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Beginning a Facilitation
• Orient the consumer to the purpose of
your meeting
• Explain what an AD is and why s/he might
want one
• Review the limitations of an AD
• Determine if the consumer would like to
complete an AD
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Identifying an Agent
• Clarify what an agent is and why the
consumer might want one
• Determine if the consumer wants to
identify an agent
• Elicit the consumer’s preferred agents
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Demonstration and Small Group
Practice: Identifying an Agent
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Eliciting Preferences
• You are acting as a facilitator, not a
provider
• Consumer has ultimate control over
his/her AD
• It is appropriate to test feasibility with
consumer, clarify consumer statements,
and explore reasons for preferences
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Challenges in Eliciting Preferences
• Consumers who have trouble expressing
preferences
• Consumers who have too many
preferences
• Consumers who have unrealistic
preferences
• Conflict between clinical and facilitator
role: when you know too much
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Demonstration and Small Group
Practice: Eliciting Preferences
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Overcoming Logistical Barriers to
Completing ADs
• If consumer wants to sign the “Ulysses clause,”
a co-signature from a psychiatrist or clinical
psychologist is required
• ADs need to be witnessed by two adults; the
facilitator can act as one witness
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Ensuring ADs Are Read by
Providers and Family
• Make copies of AD and send to relevant
outpatient and inpatient facilities
• Encourage consumer to discuss AD
preferences with health care agents,
clinicians, and other family members
• Consumers should keep a copy of their ADs
with them at all times
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Conclusion
•
ADs can help empower consumers with
mental illness when they experience
crises
AD facilitation is most helpful when:
•
1. consumers are educated about how these
legal documents work, and
2. efforts are made by the facilitator to both
honor consumers’ preferences and assist in
writing a feasible AD
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National Resource Center on Psychiatric Advance Directives
http://www.nrc-pad.org
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