Objective: To provide a Canadian perspective on psychiatric advance directives (PADs) and assess whether these documents can be implemented as an adjunct to mental health services to empower people with mental illness.
Method: We reviewed Canadian jurisprudence over the past 15 years related to people with mental illness and the right to refuse medical treatment. Provincial mental health legislation is explained to discern PADs' possible effect in Canada.
Results: Evidence is accumulating that legal and mental health professionals see PADs as useful documents to promote patient autonomy. Canadian jurisprudence, mental health legislation, and psychological research suggest that PADs could be implemented by legal and mental health professionals. Mental health legislation has the power to prohibit or facilitate choices regarding the right to refuse medical treatment.
Conclusions: This review suggests the need for greater empirical research to be conducted in Canada to determine stakeholders' perceptions of whether PADs could successfully be implemented and their interaction with legislation.
(Can J Psychiatry 2007;52:397-402)
Information on funding and support and author affiliations appears at the end of the article.
* PADs may be effective legal documents that provide greater patient autonomy and lead to better clinical outcomes.
* Mental and legal professionals may be influenced to respect a patient's refusal of treatment if it is based on provincial legislation.
* Canadian courts are increasingly willing to uphold patients' rights to refuse certain forms of medical treatment.
* Conclusions are drawn from jurisprudence and legislation; further empirical research is needed.
* Canadian jurisprudence and legislation are not generalizable to judicial systems in other jurisdictions.
Key Words: psychiatric advance directives, law, ethics, treatment refusal, autonomy, legislation, coercion, mental illness
Abbreviations used in this article
PAD psychiatric advance directive
CCB Consent and Capacity Board
HCCA Health Care Consent Act
CCQ Civil Code of Quebec
Psychiatric advance directives are legal documents that allow competent individuals to declare their treatment preferences in advance of a mental health crisis. Recent Canadian jurisprudence, mental health legislation, and psychological research indicate that PADs could be accommodated within the Canadian legal framework to provide a greater role for patients to make autonomous treatment choices. Irrespective of how irrational or misguided the right to refuse medical treatment may appear, unwanted interference to one's body is a paramount right, and any legal exceptions are always carved from this fundamental rule.1 Although such rights must be balanced with safety to oneself and others, PADs are rooted in a theory of liberal individualism that democratic societies should honour the rights of individuals to have their voices heard2 while respecting the human needs of the mentally ill.3
Literature Search and Review
Search strategies to identify journal articles on PADs and the right to refuse medical treatment originated from medical and legal sources. The key term psychiatric advance directive was entered into Ovid's MEDLINE (30 hits) and overlapped with PsycINFO (9 hits) to identify articles (primarily from 1998 to the present, when PADs began appearing in the literature). After reviewing the abstracts and methodological quality of these studies, we included journal articles on the basis of their legal, medical, and ethical applicability to Canada. Twenty-nine articles were included in the final review. Of the 39 hits found in PsycINFO, MEDLINE, and legal databases, 9 articles were included. This is because PADs are also referred to as advance directives (for psychiatric care, mental care, and so on; these were included where appropriate). …