Implementation of self-binding directives: Recommendations based on expert consensus and input by stakeholders in three European countries.
Self-binding directives (SBDs) are psychiatric advance directives including a clause in which mental health service users give advance consent to involuntary hospital admission and treatment, and grant mental health professionals permission to overrule anticipated treatment refusals during future mental health crises1, 2. They are also known as “Ulysses contracts” or “Ulysses arrangements”. SBDs can enable people with mental disorders which involve fluctuating mental capacity and regular treatment refusals during crises (e.g., psychotic and bipolar disorders) to stay in control of their life and treatment1. During episodes, these people may make decisions that are incompatible with their deeply-held values, convictions and preferences. Such decisions regularly involve refusal of hospital admission or treatment and can have far-reaching consequences. By enabling service users to authorize professionals to overrule such refusals, SBDs are essential to advance care planning in people with psychotic or bipolar disorders. While potential ethical benefits and risks of SBDs have been discussed extensively in the ethics and legal literature, little was known about stakeholders’ views on the opportunities and challenges of SBDs until recently. Recent studies conducted in Germany, The Netherlands and the UK reveal that stakeholders perceive promotion of autonomy, avoidance of harm, possibility of early intervention, improvement of the therapeutic relationship, and involvement of trusted persons as opportunities of SBDs3-9. Perceived challenges include lack of awareness and knowledge of SBDs, lack of formal support for SBD completion, undue influence during the drafting process, inaccessibility of SBDs during crisis, lack of cross-agency coordination, problems of interpretation of SBD content, difficulties in mental capacity assessment, restricted therapeutic flexibility due to narrow SBD instructions, infeasibility of SBDs due to scarce resources, disappointment due to non-compliance with SBD instructions, and outdated SBD content3-9. Stakeholders who participated in these studies tended to see the implementation of SBDs as ethically desirable, provided that the above-mentioned challenges are addressed through the implementation of appropriate safeguards. Based on suggestions made by stakeholders and a structured expert consensus process among authors, we have derived the following recommendations for the legal and clinical implementation of SBDs.