Opportunities and challenges of self-binding directives: an interview study with mental health service users and professionals in the Netherlands

Using coercion in mental disorders or risking the patient's death? An analysis of the protocols of a clinical ethics committee and a derived decision algorithm

While principle-based ethics is well known and widely accepted in psychiatry, much less is known about how decisions are made in clinical practice, which case scenarios exist, and which challenges exist for decision-making. Protocols of the central ethics committee responsible for four psychiatric hospitals over 7 years (N=17) were analysed. While four cases concerned suicide risk in the case of intended hospital discharge, the vast majority (N=13) concerned questions of whether the responsible physician should or should not initiate the use of coercion in patients lacking mental capacity. The committee's recommendations were non-uniform. Forced feeding and electroconvulsive therapy were endorsed in each one case. In two cases of intermittent loss of capacity due to heavy drinking or intermittent severe suicidal ideation, a self-binding contract was recommended and the use of coercion was considered as justified for a very limited period. In all other cases, most of which involved involuntary treatment, the use of coercion was not endorsed. Without exception, the recommendations were accepted with relief by the physicians and their treatment teams, who feared liability in the event of harm to the patient. Eventually, a model of a decision algorithm was derived from the ethical arguments in the protocols.

Self-binding directives in psychiatric practice: a systematic review of reasons

Self-binding directives (SBDs) are an ethically controversial type of advance decision making involving advance requests for involuntary treatment. This study systematically reviewed the academic literature on psychiatric SBDs to elucidate reasons for and against their use in psychiatric practice. Full-text articles were thematically analysed within the international, interdisciplinary authorship team to produce a hierarchy of reasons. We found 50 eligible articles. Reasons for SBD use were promoting service user autonomy, promoting wellbeing and reducing harm, improving relationships, justifying coercion, stakeholder support, and reducing coercion. Reasons against SBD use were diminishing service user autonomy, unmanageable implementation problems, difficulties with assessing mental capacity, challenging personal identity, legislative issues, and causing harm. A secondary finding was a clarified concept of capacity-sensitive SBDs. Future pilot implementation projects that operationalise the clarified definition of capacity-sensitive SBDs with safeguards around informed consent, capacity assessment, support for drafting, and independent review are required.

Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries

BACKGROUND

Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs.

AIMS

This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom.

METHOD

Comparisons between the empirical findings were drawn using a structured expert consensus process.

RESULTS

Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns.

CONCLUSIONS

Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.