Tuesday, October 30, 2007
The Wall Street Journal's Health Blog reports on a recent development in the area of advanced directives:
Psychiatric advance directives, or PADs, are legal documents that patients can prepare to state in advance of an acute psychiatric crisis what medications, hospitals and other treatments they would prefer or like to avoid.
Twenty-five states have laws allowing PADs. In North Carolina, a sample form includes such items as preferences about electroconvulsive therapy, or ECT, and tips for medical personnel on how to minimize the use of restraints or seclusion. A model form in Texas lays out details on a patient’s consent, or lack of it, for specific medications. A Michigan form guides a patient in legally designating a personal advocate in case of crisis.
But how are PADs actually used? And what happens if, in the breach, a doctor’s judgment clashes with the stated wishes of the patient? The Health Blog asked medical sociologist Jeff Swanson (pictured) from Duke University, who’s been active in research on mental health policy and treatment options for people with serious mental illness.
First, Swanson laid out a key difference between the advance directives for psychiatry and those typical for medical care. A living will focuses primarily on “forgoing unwanted treatment,” Swanson said. “The goal of the psychiatric advanced directive is to [help you] recover. You’re trying, in a way, to protect yourself from decisions you might make when you’re ill.” . . . .
Though PADs are legal documents, most state laws on the subject contain override clauses, Swanson said. In a crisis, a doctor can invoke his or her clinical judgment to act in the best interest of the patient, essentially ignoring the PAD. Empirical data are hard to come by. But “clinical experience and anecdotal reports suggest that overrides occur with some frequency,” according to a commentary Swanson published last year in the Journal of the American Academy of Psychiatry and Law.