What role do psychiatric advance directives have in today's emergency departments?

Emergency physician, Minneapolis

Psychiatric advance directives (PADs) allow persons to authorize proxy decision makers and document advance instructions or preferences about future mental health treatment in the event of a crisis. The intent of PAD legislation is to enhance treatment autonomy for persons with severe mental illnesses (such as schizophrenia, bipolar disorder, and major depression) who anticipate periods of decisional incapacity associated with illness relapse.

To date, 21 states have passed specific PAD statutes. Nevertheless, patients residing in states without PAD statutes can use medical advance directives to specify mental health treatment preferences or assign proxy decision makers for mental health decisions.

PADs provide a transportable document that conveys critical information about a patient's treatment history, including medical and mental disorders; emergency contact information; and known medication side effects. PADs also allow patients to designate health care agents to provide additional information to psychiatrists or other health care providers in the event of patients losing decisional capacity. Emergency department (ED) physicians typically know little about individual patients who present in psychiatric crises, yet they are required to make clinical decisions with arguably suboptimal patient data. With PADs, however, emergency physicians would gain access to critical medical information during the very moments that psychiatric patients are least able to communicate it.

Most PAD laws have been passed in the past decade. Findings from a recent national survey showed that although 70% of patients with mental illness indicate they would want a PAD, fewer than 10% have completed one.¹ Most psychiatric patients report logistical barriers as reasons for not obtaining a PAD, such as a lack of understanding how PADs work and having trouble notarizing the document while obtaining appropriate witnesses. Furthermore, surveys of mental health professionals reveal their concerns that some PADs may contain medically inappropriate instructions and that they may not realistically be able to access a patient's PAD during a crisis.² Subsequently, PADs are only rarely used in today's EDs.

As more patients learn about PADs and as psychiatrists and other physicians learn more about them, these directives will likely become more widely used. For example, state laws do not require physicians to follow medically inappropriate instructions; physicians who know this are more likely to endorse PADs.² In addition, PADs rarely contain medically inappropriate information and instead almost always contain clinically useful information³; this knowledge will lead to further acceptance of PADs as a viable tool for improving psychiatric decision making.

The establishment of the National Resource Center on Psychiatric Advance Directives should help disseminate state-by-state information on PADs and provide educational material to patients, family members, and physicians; their Web site (http://www.nrc-pad.org), currently under construction, will be launched in June. For these reasons, I expect PADs to play a greater role in EDs in the future, as they help to enhance not only patient autonomy but also clinical decision making.

Eric B. Elbogen, PhD

Assistant Professor

Department of Psychiatry and Behavioral Sciences

Duke University Medical Center

Durham, NC

References:

REFERENCES

1. Swanson JW, Swartz MS, Ferron J, et al. Psychiatric advance directives among public mental health consumers in five U.S. cities: prevalence, demand, and correlates.

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2006;34:43-57.2. Elbogen EB, Swartz MS, Van Dorn R, et al. Clinical decision making and views about psychiatric advance directives.

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2006;57:350-355. 3. Srebnik DS, Rutherford LT, Peto T, et al. The content and utility of psychiatric advance directives.

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2005;56:592-598.