Academic journal article Social Work

Psychiatric Advance Directives and Social Workers: An Integrative Review

Academic journal article Social Work

Psychiatric Advance Directives and Social Workers: An Integrative Review

Article excerpt

Individuals with severe mental illness (SMI) often experience episodic crises alternating with times of stability. During crises, social workers and other providers often implement mandated interventions, such as involuntary hospitalization. On the one hand, many providers see these interventions as necessary to prevent harm and protect those with SMI (Swanson, McCrary, Swartz, Van Dorn, & Elbogen, 2007); on the other hand, many people with SMI describe such interventions as frightening, disempowering, traumatic, and a barrier to treatment (Swartz, Swanson, &Hannon, 2003; Van Dorn, Elbogen, et al., 2006). Social workers thus face difficult ethical decisions when engaging in crisis intervention. They may be required to choose between supporting individual autonomy and self-determination and preventing possible harm to the client or others.

Psychiatric advance directives (PADs) offer one strategy to reduce mandated interventions (Swanson et al., 2008). PADs are legal documents that allow individuals to express preferences for future treatment (Joshi, 2003) and are designed to be created while the individual is competent and go into effect during periods of decisional incapacity (Swanson, Swartz, Ferron, Elbogen, &Van Dorn, 2006). (PADs are one type of "advance statement" for mental health treatment. Others include wellness recovery action plans, joint crisis plans, and crisis cards. Goals for documenting preferences are somewhat similar [compare, Henderson, Swanson, Szmukler, Thornicroft, & Zinkler, 2008]; however, PADs are the only method that is legally binding on the clinician, but clinicians are not legally obligated to provide care that conflicts with community practice standards. We discuss this in the Overriding PADs and Community Standards of Care section.) PADs support individuals' autonomy and self-determination when they are in crisis and cannot voice their preferences and needs because of their illness (Swanson, Tepper, Backlar, & Swartz, 2000). PADs may also affect clinical outcomes that indirectly reduce crises and coercion. For example, PADs have the potential to improve treatment engagement, adherence, and service utilization, which may then affect crisis management, including deescalation of crises as an alternative to hospitalization, timely notification of clinicians and family members regarding decomposition, or (if hospitalization is required) improved inpatient management strategies.

PADs can include an advance instruction (AI) or a healthcare power of attorney (HCPA). In an AI, individuals can accept or refuse certain medications or other treatments (for example, electroconvulsive therapy) and identify hospital preferences. AIs may also be used to provide information on ways to deescalate crises, make requests for actions if hospitalized (for example, contact a family member), and agree to future hospitalizations. An HCPA (variously called a "healthcare agent," "healthcare proxy," or "durable power of attorney for health care") lets individuals appoint a representative to make treatment decisions on their behalf (that is, using substitute judgment for the client's known preferences) when they are unable to do so (Appelbaum, 2004). In most states, PADs are valid until revoked, which can occur at any time as long as the client is not declared incompetent or incapable; in some states, PADs expire within a certain time period (for example, two years in Pennsylvania, three years in Oregon, five years in Louisiana).

Given their ability to support autonomy and self-determination and the potential to decrease mandated interventions, PADs should be of great interest to social workers. However, little exists in the social work literature regarding PADs, and social workers' knowledge of PADs appears limited. In a survey of 193 social workers, only 5 percent reported being "very familiar" with AIs, and only 15 percent reported being "very familiar" with HCPAs for mental health (Scheyett et al. …

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