Psychiatric Advance Directives (PADs). A tool to promote therapeutic alliance, coordination of care, and the autonomy of the user.
(2013) 10th ENMESH Congress — Location: Verona (3.October.2013)
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- Background/Objectives: Psychiatric Advance Directives (PADs) are documents that allow users with severe and chronic mental illnesses to notify their treatment preferences for future crisis relapses and to appoint a surrogate decision-maker for a period of incompetence. PADs are supposed to reduce the resort to involuntary treatment, to reduce the length of hospitalisations, and to improve the compliance of users. However, their take-up rate has remained very low and their evaluation has given contradictory results. Our main objective was to develop a comprehensive PAD intervention process, which includes three stages (the design, the completion, and the honouring of a PAD document) to facilitate its effective use. Methods: Firstly, a realist systematic literature review was carried out on 47 references ranging from 1996 to 2010. Three theoretical frameworks underlying the intervention were identified and the available evidence supporting or contradicting these theoretical expectations was examined. Secondly, we carried out a stakeholder analysis on policy makers, health professionals, caregivers, and users, to determine their preferences and value criteria for using PADs. Results: The three theoretical frameworks identified were: enhancement of the autonomy of the user, improvement of the therapeutic alliance, and integration of care between health providers. Although designed in the first place with a view to sustaining the user’s autonomy, the intervention was more likely to be efficient within a therapeutic alliance framework. These three theoretical frameworks and feasibility were included in the stakeholders' survey, which showed that the criteria for choosing options varied according to the stage: alliance was more important at the design and completion stages, while coordination and feasibility gained importance at the honouring stage. Discussion/Conclusion: The support for the autonomy of the user and his/her involvement in treatment depends on the quality of the therapeutic alliance at the completion stage and of the coordination of care at the honouring stage. The clarification on expectations of PADs and value criteria in the course of the intervention may help to increase their take-up rates.
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Nicaise, P., Lorant, V., & Dubois, V. (2013). Psychiatric Advance Directives (PADs). A tool to promote therapeutic alliance, coordination of care, and the autonomy of the user. 10th ENMESH Congress, Verona. https://hdl.handle.net/2078.5/199578