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Advance directives empower users and need professionals for implementation

, 1 , 2 , 1

BMC Psychiatry

BioMed Central

WPA Thematic Conference. Coercive Treatment in Psychiatry: A Comprehensive Review

6-8 June 2007

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      Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness.

      Studies show a high potential demand for psychiatric advance directives but low completion rates. The authors conducted a randomized study of a structured, manualized intervention to facilitate completion of psychiatric advance directives. A total of 469 patients with severe mental illness were randomly assigned to a facilitated psychiatric advance directive session or a control group that received written information about psychiatric advance directives and referral to resources in the public mental health system. Completion of an advance directive, its structure and content, and its short-term effects on working alliance and treatment satisfaction were recorded. Sixty-one percent of participants in the facilitated session completed an advance directive or authorized a proxy decision maker, compared with only 3% of control group participants. Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the advance directive to refuse some medications and to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment. At 1-month follow-up, participants in the facilitated session had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the mental health services they believed they needed. The facilitation session is an effective method of helping patients complete psychiatric advance directives and ensuring that the documents contain useful information about patients' treatment preferences. Achieving the promise of psychiatric advance directives may require system-level policies to embed facilitation of these instruments in usual-care care settings.
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        Psychiatric advance directives: qualitative study of informed deliberations by mental health service users.

        Established legal mandates and high expectations for psychiatric advance directives are not matched by empirical evidence documenting their actual implementation. To explore the interests, concerns and planning activities of informed mental health service users contemplating such directives. Standard 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. Training 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. Advance 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.
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          Author and article information

          Affiliations
          [1 ]Department of Psychiatry, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
          [2 ]Ludwig Boltzmann Institute for Social Psychiatry, Spitalgasse 11, 1090 Vienna, Austria
          Conference
          BMC Psychiatry
          BMC Psychiatry
          BMC Psychiatry
          BioMed Central
          1471-244X
          2007
          19 December 2007
          : 7
          : Suppl 1
          : S110
          3332777
          1471-244X-7-S1-S110
          10.1186/1471-244X-7-S1-S110
          Copyright ©2007 Amering and Schaffer; licensee BioMed Central Ltd.
          WPA Thematic Conference. Coercive Treatment in Psychiatry: A Comprehensive Review
          Dresden, Germany
          6-8 June 2007
          Categories
          Oral Presentation

          Clinical Psychology & Psychiatry

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