Psychiatric advance directives (PADs) statutes presume competence to complete these documents, but the range and dimensions of decisional competence among people who actually complete PADs is unknown. This study examines clinical and neuropsychological correlates of performance on a measure to assess competence to complete PADs and investigates the effects of a facilitated PAD intervention on decisional capacity. N = 469 adults with psychotic disorders were interviewed at baseline and then randomly assigned to either a control group in which they received written materials about PADs or to an intervention group in which they were offered an opportunity to meet individually with a trained facilitator to create a PAD. At baseline, domains on the Decisional Competence Assessment Tool for PADs (DCAT-PAD) were most strongly associated with IQ, verbal memory, abstract thinking, and psychiatric symptoms. At one-month follow-up, participants in the intervention group showed more improvement on the DCAT-PAD than controls, particularly among participants with pre-morbid IQ estimates below the median of 100. The results suggest that PAD facilitation is an effective method to boost competence of
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Author ManuscriptLaw Hum Behav. Author manuscript; available in PMC 2013 November 04.
NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript cognitively-impaired clients to write PADs and make treatment decisions within PADs, thereby maximizing the chances their advance directives will be valid.
KeywordsPsychiatric advance directives; Treatment competence; Severe mental illness Mental health lawAt the heart of an evolving debate in mental health policy, law, and bioethics lies a tension between the principle of respect for patient autonomy in healthcare decisions and the responsibility to provide appropriate services to people with severe mental illness, many of whom experience intermittent impairment of decisional capacity and fluctuating attitudes towards accepting treatment. The acute controversy over involuntary outpatient commitment and other mandated treatment in the United States is a part of this larger debate, and perhaps no other issue has so polarized stakeholders in recent years (Monahan et al., 2001). Involuntary treatment may well be "effective" for improving treatment engagement and other clinical outcomes, but at the same time may override the personal liberty of people with mental illness (Swartz et al., 1999).Many believe psychiatric advance directives (PADs) may help resolve this dilemma by promoting both autonomy and beneficial treatment for people with mental illness (Appelbaum, 2004;Backlar, 2004;Saks, 2004;Srebnik, Russo, Sage, Peto, & Zick, 2003;Swanson, Tepper, Backlar, & Swartz, 2000;Varma & Goldman, 2005). In the past fifteen years, twenty-five states have passed psychiatric advance directives (PAD) laws allowing competent people to authorize proxy decision makers and document advance instructions or preferences regarding future mental health treatment in the ...