Workstream III — Improving the advance care planning process
Mental health service users can state treatment preferences in psychiatric advance directives (PADs) for future mental health crises in which their decision-making capacity is impaired. Their primary goal is to preserve and strengthen patient autonomy; initial practical experience and scientific studies have also identified the improvement of the quality of subjective treatment and the therapeutic relationship as advantages. Furthermore, PADs can contribute to the reduction of coercive measures, compulsory treatment and involuntary commitment. The PADs have been legally binding in Germany since 2009. They also contribute to achieving the goals set out in the UN Convention on the Rights of Persons with Disabilities by promoting self-determination and equal treatment. In their PADs, service users typically document medication and hospitalization preferences, preferred types of treatment, relevant somatic comorbidities, contact people and instructions regarding the care of finances, dependants and pets.
One service user talked about PADs in an interview study (Kim et al. 2007) as follows:
It’s probably one of the best things that’s come into mental health in a long time because it gives you rights, while you’re sound and while you know what’s best for you – and you’re the only person that knows what’s best for you deep down.
Despite a high level of interest in PADs among service users, the actual completion rates in Germany are low. This suggests that there are several barriers to PAD completion. One possible barrier could be the concern of some psychiatrists that the preferences documented might not be compatible with current practice standards or that patients could use them to reject any treatment, causing an increased risk of harm to self or others. Research has shown that these concerns are usually unfounded, particularly in the case of PADs created in collaboration with mental health professionals.
The goal of this workstream is to contribute to the reduction of barriers to the widespread implementation of effective PADs. This includes, in particular, improving the quality of documents, proposing solutions to ethical dilemmas arising in the context of PADs, and promoting the transfer of perspectives and knowledge between researchers, practitioners and service users. The methods used include conceptual analyses, empirical research and systematic reviews.