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QUESTION: Do advance directives about a patient’s preferences for mental health treatment reduce compulsory readmission to hospital?
Randomised controlled trial with allocation concealed block design. Research assistants were not blind to treatment allocation.
2 acute psychiatric services in inner London, United Kingdom; October 1997–October 1998.
156 adult inpatients discharged from compulsory psychiatric hospital treatment within the study period who were able to read in English. People treated under special sections of the Mental Health Act, about to be transferred to other hospitals, or with organic brain disease were excluded.
All participants received standard community psychiatric care. In addition, one group received the advance directive initiative. Advance directives are descriptions of a person’s preferences for treatment, should they lose capacity to make decisions about treatment in future. In this study, guidelines about creating an advance directive were supplied in the booklet Preferences for Care. The booklet contained statements on future preferences for treatment. Participants were encouraged to complete these and sign the directive or to dictate their preferences to a researcher. Participants were asked to keep the booklet in a safe place. Copies were given to their key workers and general practitioners. Copies were also filed with the hospital and in general practice records.
Main outcome measures
The primary outcome was rate of compulsory readmission to psychiatric hospital.
19% of the advance directive group and 21% of controls were compulsorily readmitted to psychiatric care within one year of discharge (P > 0.05). There was no significant difference between groups in the number of compulsory or voluntary readmissions, days spent in hospital or satisfaction with psychiatric services.
Advance directives about treatment preferences did not reduce compulsory or voluntary readmissions for people with serious mental illness at 12 months.
In this study, advance directives had little effect on compulsory admissions. Although the authors discuss possible reasons for this finding, they do not comment on what may be the fundamental reason for the lack of difference between groups: the advance directives were not really advance directives. According to Webster’s Collegiate Dictionary, a directive is “something that serves to direct, guide, and usually impel toward an action or goal.” What the authors provided in this study was a “preference statement” which was “not intended to address compulsory admission directly.” Further, professionals were not legally bound to comply with patients’ preferences for care. The document produced by the intervention group was hardly different from what the control group might express to a professional in a good doctor-patient relationship. It may well be that there were no differences in outcome because there was no real difference in process between the two groups.
Advance directives can be healthcare proxies which empower others to act on behalf of the patient when he or she becomes incompetent to act on his or her own behalf. Alternatively, an advance directive may specify which interventions are authorised when psychosis re-emerges and the individual is no longer competent. Such advance directives might prove effective, especially in jurisdictions that do not permit individuals to modify or terminate advance directives when they are incompetent to do so.1
Papageorgiou et al conclude that the impact of advance directives on other aspects of treatment and care requires further study. I concur. The impact of advance directives on compulsory treatment also requires further study. First, however, we need to obtain greater consensus on what an “advance directive” actually is for psychiatric treatment and care.
Source of funding: National Health Service Executive, London Research and Development Programme.
For correspondence: M King, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London, UK.
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