Dr. Marvin Swartz Tells SARDAA About Psychiatric Advance Directives

Marvin SwartzOn October 26th, 2013 at SARDAA’s second annual conference, Dr. Marvin Swartz gave us valuable information about Psychiatric Advance Directives (PAD’s) and how they help people with mental illness. Although most people associate advance directives with giving control of their care away to someone else, they actually allow a person to remain in control of their treatment even when they are very sick. A psychiatric advance directive allows a person to decide, when they are in a healthy state of mind, how they want to be treated when they are too sick to make decisions for themselves. This is much better than waiting until one is very ill and then having a court appoint a guardian or conservator to make decisions about psychiatric care. A PAD allows a person to say “I consent to X,” “I prohibit Y,” “send me to this hospital.” It appoints a healthcare power of attorney to stand in for them when they are too sick to make decisions. It takes effect when a doctor diagnoses a patient and says they are “incapacitated.” It is not decided by a judge, in contrast to guardianship.

Unfortunately, only 25 states have stand-alone psychiatric advance directives. They can be written into a general advance directive, though. For more information on psychiatric advance directives, click here.

“The movement toward patient-centered care has fueled considerable interest in PAD’s, analogous to medical advance directives and health care proxies, as a possible remedy for loss of patient autonomy in mental healthcare decisions, patient alienation from the treatment process, and associated poor clinical outcomes. Based on the hope for these benefits, 25 U.S. legislatures have adopted PAD statutes and are encouraging the appointment of healthcare proxies, through durable power of attorney, for persons with mental illness. PAD’s may include three types of anticipatory decision-making: 1) informed consent to future treatment; 2) a forecast of personal values; 3) and the entrusting of someone to act as a proxy decision maker. The role of a healthcare agent (HCA), or proxy decision maker, is to help ensure that the patient’s previously expressed wishes are fulfilled; to further interpret what treatment the patient would wish to receive (or not receive); or to act in the patient’s best interest and protect the patient’s welfare. A recently conducted study in 5 U.S. communities found that people with mental illness should write down the type of treatment they would like to receive if they become very ill at some point in the future; 70-83% across sites wished a PAD, but only 4-13% had any form of PAD.”

Marvin S. Swartz, M.D. is Professor and Head of the Division of Social and Community Psychiatry, Director of the Duke AHEC Program and Director of the National Resource Center on Psychiatric Advance Directives. Dr. Swartz has been extensively involved in research and policy issues related to the organization and care of mentally ill individuals at the state and national level. He was a Network Member in the MacArthur Foundation Research Network on Mandated Community Treatment examining use of legal tools to promote recovery mental health treatment. He co-led a North Carolina study examining the effectiveness of Psychiatric Advance Directives and the NIMH funded Clinical Antipsychotics Trials of Intervention Effectiveness study. He is currently a co-investigator of a study of the cost of criminal justice involvement of mentally ill individuals and the effectiveness of gun laws in reducing gun related deaths. Dr. Swartz was the recipient of the 2011 Public Health Association’s Carl Taube Award and the 2012 American Psychiatric Association’s Senior Scholar, Health Services Research Award for career contributions to mental health services research.

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