Consistency of psychiatric crisis care with advance directive instructions

Objectives: Psychiatric advance directives document clients' treatment preferences in advance of periods of diminished capacity for decision making. This article presents the first empirical data regarding rates and predictors of whether crisis care is consistent with psychiatric advance directives. Methods: Participants were 106 community mental health outpatients who had completed a directive. Participants' mental health services were examined over a two-year period with interviews and chart reviews to determine whether clinical interventions were consistent with directive instructions. Results: Across 90 crisis events in which an advance directive was accessed, the average rate of care consistent with directive instructions was 67%. Instructions regarding medications, preemergency interventions, nonhospital alternatives, and most nontreatment personal care issues were consistent with care in nearly all cases. Somewhat less consistent with care were instructions to contact a surrogate decision maker and preferences among hospitals; between hospitals and hospital alternatives; and among seclusion, restraint, and sedating medication. Clients with fewer prior outpatient commitment orders and who had a surrogate decision maker who accessed the directive were more likely to have care consistent with directive instructions. The most commonly reported reason for overriding directive instructions was clinical need. Conclusions: Overall, crisis care was largely consistent with directive instructions. To increase the likelihood of consistency, clients would be well advised to appoint a surrogate decision maker, particularly one who could be actively involved during crises. Encouraging creation and use of directives could be viewed as a positive step in the process of recovery and as an additional method of communicating client preferences during psychiatric crises.