Giving Patients a Voice in Their Mental Health Care Before They’re Too Ill to Have a Say

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Increasingly, patients, advocates and doctors believe psychiatric advance directives (called PADs), a legal document declaring what treatment a patient does and doesn’t want, could help transform the mental health system by allowing patients to shape their care even when they lose touch with reality. Hospitals must put them in patients’ medical records and doctors are expected to follow them unless they document that specific preferences aren’t in the patients’ best medical interest.

As the pendulum has swung from institutionalization to outpatient care, psychiatric directives also offer a middle path by allowing patients to designate family members to speak for them when they’re too sick to do so themselves.

But some doctors and hospitals are wary that the documents could tie their hands and discourage treatment they consider warranted. Some worry the directives won’t be updated to reflect medical advances. Others question whether people with serious psychiatric conditions are ever capable of lucidly completing such directives.

“A decision based on erroneous information on a PAD, that can happen,” said Dr. Katayoun Tabrizi, a forensic psychiatrist at Duke. “This is not a cookbook.”

Still, early research and experience suggest that PADs, authorized by law in 27 states and possible in others as part of conventional medical advance directives, could help some of the millions of people with serious mental illness cope better and guide doctors treating them.

As people with serious mental illness cycle in and out of hospitals, many landing on the streets or in prison, better approaches are urgently needed.

Effective PADs “would enhance people receiving appropriate treatment,” said Dr. Mark Rapaport, chairman of psychiatry and behavioral sciences at Emory University. “But this is going to be really hard to do.”

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