Advance Directives in Psychiatry: Resolving Issues of Autonomy and Competence
Introduction
Advance directives have been championed and debated in the literature, espoused by patient advocates, and incorporated or proposed in the majority of Canadian provinces and nearly every U.S. state. Advance directives allow individuals to make decisions for future medical treatment while they are competent to do so in anticipation of future incompetence. While intuitively it would seem that advance directives are unquestionably beneficial to patients and their caregivers, and to the management of increasingly scarce health care resources, the issues raised by advance directives are complex. How these issues are understood will have practical implications for how advance directives are implemented.
Advance directives originated from the Karen Ann Quinlan and Nancy Cruzan cases, which raised the issue of decision making regarding life-sustaining treatment when a patient has lost competence. In both cases, the focus was on making such decisions in a way that reflected the known wishes of the incapacitated patient rather than relying on doctors to make the decisions when the patient was no longer able to do so. In the literature, this has frequently been characterized as marking a trend toward patient autonomy as opposed to long-held Hippocratic paternalism whereby the doctor did what he presumed to be best for the patient. As in the Quinlan and Cruzan cases, loss of competence for the medically ill patient is typically a chronic, irreversible condition arising from dementia, the end stages of severe illness, or a persisting vegetative state.
However, there has been a growing interest in the special case of psychiatric patients, for whom loss of competence is more likely to be episodic. When patients begin to decompensate as a result of a major psychiatric disorder—that is, become manic, psychotic, or significantly depressed—loss of competence may occur early on as insight and judgment become impaired. This can be an important obstacle to timely treatment because decisions made under these circumstances may not be what the person might have chosen at his baseline state. This includes decisions regarding hospitalization, medication, or even whether to show up for appointments. Although loss of competence can become a chronic state in psychiatric illness, more often it fluctuates with the periods of decompensation and remission that tend to characterize psychiatric illness. Advance directives therefore have the potential to be a particularly relevant and useful tool in psychiatry by allowing patients, when competent, to opt for treatment that they might refuse when their competence becomes impaired. They would be particularly useful for those patients who arrive at a point where they require treatment because their functioning has become severely impaired by their illness, who have lost the capacity to recognize this themselves, yet who have not decompensated to the point that they require civil commitment. By facilitating earlier intervention and treatment, these patients could potentially shorten the length of time they are decompensated and thereby lessen the hardship, both emotional and financial, for themselves and their families.
This specialized role for advance directives in psychiatry is captured in the name they have been given: Ulysses directives. This is the Latin name given to the hero of Homer’s Iliad, who undertook a perilous 10-year voyage home with his men following the Trojan War. Their journey involved an encounter with the Sirens, notorious for their enchanted singing that had lured many an unwary sailor close, only to be shipwrecked upon the rocks on which they sang. Ulysses, longing to hear their song, sagely instructed his crew to stop up their ears with wax and to tie him firmly to the mast of his ship. Thus deafened, the crew would succumb neither to the enchantments of the Sirens nor to Ulysses’s entreaties to sail toward them as he fell under their charms. Similarly, Ulysses directives, in the fullest sense, would allow the physician to heed the patient’s prior competent instructions when these are at odds with the wishes expressed in a subsequent incompetent state.
The parallel with Ulysses’s voyage is instructive in illustrating the intent of such directives: to circumvent refusal of treatment requested by a previously competent patient when this refusal is motivated by illness-induced incompetence. It also provides a metaphor for the hazards attendant on any attempt to incorporate advance directives into practice. As part of his voyage, Ulysses had to navigate his ship through a narrow strait flanked by two sea monsters, Scylla and Charybdis, who devoured whatever came within their reach. The Scylla and Charybdis of Ulysses directives are, paradoxically, the two concepts on which these directives are based: the principles of autonomy and competence. Most of the literature on advance directives, and all of the controversy the topic has stirred, has focused on one or both of these cardinal aspects.
Section snippets
Autonomy
The ideal of patient autonomy has been a driving force in the move toward advance directives. The essence of this notion is that the individual is an independent being with the right to control his own fate by freely making choices that pertain to his interests. The case of A. P. exemplifies this. A. P. was a 23-year-old woman who had diagnosed herself as bipolar using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition—Revised. She had never consulted a psychiatrist
Competence
Whereas autonomy has provided a philosophical context for advance directives, their practical implementation depends on notions of competence. Advance directives will be triggered when the patient is deemed incompetent. However, precisely when the line is crossed from competence to incompetence is unclear.
Conclusion and Recommendations
Advance directives have the potential to alter the traditional patient–physician relationship in significant and positive ways by allowing patients to exercise greater autonomy over their treatment decisions. The effect of advance directives in psychiatry may be significant financial and nonfinancial savings at an individual, family, and societal level if patients are able to opt for earlier treatment and choose to do so. The goal of advance directives is twofold: to ensure that patients are
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Self-binding directives in psychiatric practice: a systematic review of reasons
2023, The Lancet PsychiatryAdvance directives based on cognitive therapy: A way to overcome coercion related problems
2009, Patient Education and CounselingAdvance directives in bipolar disorder, a cognitive behavioural conceptualization
2008, International Journal of Law and PsychiatryCitation Excerpt :MHADs are particularly relevant to bipolar patients who are likely to have mostly episodic losses of competence (Ritchie et al., 1998).