Ever Arrested (% Yes)

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Psychiatric Advance Directives Perspectives
and Research Highlights
Jeff Swanson Marvin Swartz (with help from
Richard Bonnie)
Department of Psychiatry Behavioral
Sciences Duke University School of Medicine
Acknowledgment Support from the National
Institute of Mental Health, the John D. and
Catherine T. MacArthur Foundation, the Greenwall
Foundation, and the National Resource Center on
Psychiatric Advance Directives (NRC-PAD)
www.nrc-pad.org
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(No Transcript)
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Increasing interest in Psychiatric Advance
Directives (PADs) in the US new laws in 25
states since 1991
PENNSYLVANIA MONTANA NEW JERSEY NORTH
CAROLINA OREGON OHIO OKLAHOMA SOUTH
DAKOTA TEXAS UTAH WASHINGTON WYOMING
NEW MEXICO
ALASKA ARIZONA HAWAII IDAHO INDIANA
ILLINOIS KENTUCKY LOUISIANA MAINE
MARYLAND MICHIGAN MINNESOTA
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PAD prevalence
and latent demand
Would you want to complete a PAD if someone
showed you how and helped you do it?
100
65.50 77.45 said yes.
75
2004 MacArthur Network Survey of 1,011
psychiatric outpatients Have you completed a
mental health advance instruction or appointed a
health care agent?
50
3.90 12.87 said yes.
25
0
Durham (n204)
San Francisco (n200)
Tampa (n202)
Worcester (n200)
Chicago (n205)
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High latent demand for PADs but low completion
rates

• Problem Why dont people complete PADs? (What
  are the barriers?)
• Dont know enough about PADs
• No one to help with the mechanics of completing
  the document
• Dont trust anyone to appoint as proxy
  decisionmaker
• Proposed solution Facilitated Psychiatric
  Advance Directive Intervention
• 60-90 minute structured, manualized session with
  trained facilitator.
• Educate and assist consumer in completing legal
  Advance Instruction and/or Health Care Power of
  Attorney

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Research questions

• Does PAD facilitation work for people with
  serious mental illness? (Will they complete
  PADs?)
• Assuming consumers do complete PADs, what do the
  documents contain? (Are PAD instructions
  feasible and consistent with clinical practice
  standards?)
• Do PADs work as intended? (And might they have
  other, indirect benefits?)
• How do PADs interact with other leverages?

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Design of core study Effectively Implementing
PADs (R01 MH63949 and MacArthur Network funded)

• Enrolled sample of 469 patients with serious
  mental illness from 2 county outpatient mental
  health centers and 1 regional state psychiatric
  hospital in North Carolina
• Random assignment
• 1. Experimental group Facilitated Psychiatric
  Advance Directive (F-PAD) (n239)
• 2. Control group receive written information
  about PADs and referral to existing resources
  (n230)
• Structured interview assessments at baseline, 1
  month, 6 months, 12 months, 24 months record
  reviews

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F-PAD study outcomes

• Short-term outcomes
• PAD completion rate
• PAD document structure content
• Intermediate outcomes
• Outpatient treatment engagement
• Working alliance with clinicians
• Long-range outcomes
• Reduce MH crises
• Reduce coercive crisis interventions and
  involuntary treatment

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Key findings PAD completion and document content

• Completion Intervention group participants
  significantly more likely to complete PADs
• (61 vs. 3.)
• PAD structure 71 of PADs combined the
  instructional directive with health care power of
  attorney.

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Key findings PAD completion and document content
(cont.)

• Prescriptive vs. proscriptive function Almost
  all PADs included treatment requests as well as
  refusals, but no participant used a PAD to refuse
  all medications and/or treatment.
• Concordance with standard care PAD instructions
  were systematically rated by psychiatrists, and
  mostly found to be feasible and consistent with
  clinical practice standards.

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Key findings outpatient treatment engagement

• At 1 month follow-up, F-PAD participants
• Significantly greater positive change in working
  alliance with case managers and clinicians
  (adjusted OR1.67)
• Significantly more likely to report receiving
  mental health services they felt they needed
  (adjusted OR1.57)

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Key findings outpatient treatment engagement
(cont.)

• At 6 months follow-up, PAD completers had
• Significantly greater improvement on treatment
  satisfaction scale (Mental Health Support
  ProgramMHSPscale)
• Adjusted OR1.71 for top quartile
• As the result of services I received, I deal
  more effectively with daily problemsI am better
  able to control my lifeI am getting along better
  with my familyI do better in school and/or
  work.

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Key findings outpatient treatment engagement
(cont.)

• At 6 months follow-up, PAD completers had
• higher utilization of outpatient services
• medication management visits (probability 41 vs.
  33 per month)
• outpatient crisis prevention visits (probability
  19 vs. 10 per month)
• At 12 months, PAD completers had significantly
  increased concordance between requested and
  prescribed meds.

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Key findings prevention of crises and coercion

• By 6 months follow-up, PAD completers had fewer
  crisis episodes (adjusted OR0.46)
• At 24 months, PAD completers had reduced
  likelihood of coercive crisis interventions
  (adjusted OR0.50)
• Controlled (weighted) for propensity to complete
  PAD.

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Adjusted predicted probability1 of any coercive
crisis interventions at follow-up for psychiatric
advance directive (PAD) completers and
noncompleters, by any episode of decisional
incapacity within period
Incapacity, no PAD Incapacity, with PAD No
incapacity, no PAD No incapacity, with PAD
Predicted Probability
12 months
24 months
6 months
Follow-up wave
1 Estimates produced from GEE regression Model 2
(see Table II).
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Adjusted predicted probability1 of any coercive
crisis interventions at follow-up for psychiatric
advance directive (PAD) completers and
noncompleters, by any episode of decisional
incapacity within period
Incapacity, no PAD Incapacity, with PAD No
incapacity, no PAD No incapacity, with PAD
Completing a Facilitated PAD reduced by about 50
the chance of any coercive crisis intervention
over 24 months Adjusted Odds Ratio 0.50
(plt0.05)
Predicted Probability
12 months
24 months
6 months
Follow-up wave
1 Estimates produced from GEE regression Model 2
(see Table II).
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History of coercion in PAD study participants
Lifetime prevalence of coercive crisis
interventions
Type of intervention Percent
Police transport to treatment 67.78
Placed in handcuffs 41.84
Involuntary commitment 61.09
Seclusion on locked unit 49.79
Physical restraints used 37.66
Forced medications 33.89
Any coercive crisis intervention 82.43
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Summary of key findings

• Large latent demand but low completion of
  psychiatric advance directives among public
  mental health consumers in the USA
• Structured facilitation (F-PAD) can overcome most
  of these barriers Most consumers offered
  facilitation complete legal PADs.
• Completed facilitated PADs tend to contain useful
  information and are consistent with clinical
  practice standards

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Summary of key findings (cont.)

• Even though PADs are designed legally to
  determine treatment during incapacitating crises,
  they can have an indirect benefit of improving
  engagement in outpatient treatment process.
• PADs can help prevent crises as well as reduce
  the use of coercion when crises occur.
• PADs may have their greatest impact for people
  under other forms of leveraged treatment.

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How an instructional PAD can work

• I didn't ever want to receive ECT again. I had
  received it back in 2001 and it really messed me
  up This time, with a PAD I did not receive any
  treatments that I did not want. They were very
  respectful.I really felt like the hospital took
  better care of me because I had my PAD. In fact,
  I think it's the best care that I've ever
  received.

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How an instructional PAD can work

• The doctor didn't treat me like a nut case
  because some hospitals do. He said You've got
  rights and it's great that you know you have
  them. He said to me, Now you know your rights
  and we'll try to respect those completelyAnd he
  did a lot for my health too.