Clinical decision making and views about psychiatric advance directives

Objectives: Psychiatric advance directives allow competent persons to document advance instructions or designate a health care agent to communicate their preferences for future mental health treatment in the event of an incapacitating crisis. Although laws authorizing psychiatric advance directives have proliferated, little is known about clinicians' understanding and perceptions of these legal tools. Methods: A total of 597 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey about their attitudes toward psychiatric advance directives and decision making about following such directives. Results: Approximately half the sample (47 percent) agreed that advance instructions would be helpful to consumers with severe mental illnesses, and a majority (57 percent) endorsed health care agents as beneficial. Regardless of profession, clinicians had more positive attitudes about psychiatric advance directives when they correctly recognized that they were not required by state law to follow directives that note the patient's refusal of appropriate medical treatment. In multivariate analyses, the decision to abide by a patient's advance refusal of treatment in a hypothetical scenario was predicted by knowing the laws associated with these directives, valuing family opinions about treatment, and respecting patient autonomy. Conclusions: Clinicians correctly apprised of the state law were more likely to endorse psychiatric advance directives. Thus clinicians may be more willing to use directives if they are educated about the legal parameters of their implementation. The clinicians' profession had only an indirect influence on whether clinicians would follow an advance instruction that noted the patient's refusal of appropriate treatment; rather, clinicians' values and legal knowledge had the greatest effect, highlighting the potentially complex ethical dilemmas faced by mental health professionals who encounter these directives.