Psychiatry Advance Directives
A person with any illness should be empowered to have a say in their treatment plans and choices. And mental health should not be any different. Dr. Ramesh Kumar of SCARF explains what a Psychiatry Advance Directive is and why it must be executed despite the concerns.
Psychiatry advance directives (PADs) is a document which outlines the patients’ preference in his treatment. This is executed when the patient has capacity, so that these directions can guide his treatment at a later date when he is unwell.
The PADs empowers the patient by allowing him to have a say in his treatment and validates his/ her treatment choices. It has been shown to improve motivation to continue with treatment (improves treatment adherence) and thereby improve the final outcome of the illness.
The major concerns about PADs fall in the following areas:
- Competence to execute PADs,
- Conflict of PADs and good clinical practice,
- Access to completed PADs,
- PADs and resource availability, and
- Legal issues.
1. Competence to execute PADs
Regarding the issue of competence, there are concerns that this issue is overblown. We seem to have different set of standards of competence for executing PADs and medical directives thus placing our patients at a disadvantage. This also perpetuates the stigma related to mental illness. There is evidence to say that patients who may be unwell are still capable of executing meaningful PADs.
2. Conflict of PADs and good clinical practice
The other concern frequently raised by clinicians is of PADs inconsistent with currently accepted treatment. This raises the larger issue of personal autonomy versus nonconsensual treatment (Holpern and Szmuckler, 1997). The usual approach would be to follow good clinical practices with adequate documentation by the clinician outlining the reasons for overruling PADs.
3. Access to completed PADs
Another issue that the clinician has to deal with is regarding whether a patient has executed PADs or not.
4. PADs and resource availability
The other area of concern is the resources available to help with the execution of PADs. The involvement of mental health clinicians in this process has its own advantages and disadvantages.
5. Legal issues
Last is the concern about legal issues. These include competence for execution and revocation of PADs, PADs activation, conflict resolution structures and concerns about its misuse (including coercion).
A study has been conducted about the feasibility of executing PADs at Schizophrenia Research Foundation. The major themes which emerged were in the areas of site of treatment, type of treatment and nominated decision makers. Many of the patients were rated by their clinician as being symptomatic when they completed PADs, and 1/3 rd of patients were either from rural areas or not exclusively urban.
Our experience from this study makes us believe that PADs are feasible in India with suitable adaptations in our patients. With the growing trend in modern medicine towards a more consumer oriented approach, we think it is imperative to incorporate the patient’s opinions in his/her treatment.