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Lasalvia A, Patuzzo S, Braun E, Henderson C. Advance statements in mental healthcare: time to close the evidence to practice gap. Epidemiol Psychiatr Sci 2023; 32:e68. [PMID: 38053411 PMCID: PMC10803188 DOI: 10.1017/s2045796023000835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/11/2023] [Indexed: 12/07/2023] Open
Abstract
This article discusses advance statements in mental health care, which allow individuals with mental disorders to express their preferences for treatment during mental health crises. Despite the evidence supporting their effectiveness, their implementation in clinical practice remains limited. This article explores variations among advance statements, such as psychiatric advance directives (PADs), joint crisis plans (JCPs) and self-binding directives (SBDs), highlighting their content, development process and legal status. We outline the benefits of advance statements, including empowerment, early intervention, improved therapeutic relationships and reduced compulsory admissions. We then draw attention to the challenges that may contribute to their lack of implementation, including legal complexities, communication issues, cultural factors, potential inequities, healthcare provider knowledge, changing preferences, resource constraints, crisis responses, data privacy, family involvement, and long-term evaluation. In conclusion, advance statements offer significant benefits but require addressing these critical aspects to ensure ethical and effective use. Bridging the evidence-to-practice gap is essential, with a focus on implementation science. Integrating these tools into routine clinical practice can significantly benefit individuals with severe mental disorders and mental health systems.
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Affiliation(s)
- Antonio Lasalvia
- Section of Psychiatry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Patuzzo
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Esther Braun
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Philosophy, University of Oxford, Oxford, UK
| | - Claire Henderson
- Health Service and Population Research Department P029, David Goldberg Centre, King’s College London Institute of Psychiatry, London, UK
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Stephenson L, Gieselmann A, Gergel T, Owen G, Gather J, Scholten M. Self-binding directives in psychiatric practice: a systematic review of reasons. Lancet Psychiatry 2023; 10:887-895. [PMID: 37714174 DOI: 10.1016/s2215-0366(23)00221-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/02/2023] [Accepted: 06/13/2023] [Indexed: 09/17/2023]
Abstract
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.
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Affiliation(s)
- Lucy Stephenson
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Astrid Gieselmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany; Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Tania Gergel
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Gareth Owen
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany; Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
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Scholten M, Efkemann SA, Faissner M, Finke M, Gather J, Gergel T, Gieselmann A, van der Ham L, Juckel G, van Melle L, Owen G, Potthoff S, Stephenson LA, Szmukler G, Vellinga A, Vollmann J, Voskes Y, Werning A, Widdershoven G. Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries. Eur Psychiatry 2023; 66:e48. [PMID: 37293987 PMCID: PMC10305757 DOI: 10.1192/j.eurpsy.2023.2421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/29/2023] [Indexed: 06/10/2023] Open
Abstract
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.
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Affiliation(s)
- Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Simone A. Efkemann
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Mirjam Faissner
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Marleen Finke
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Tania Gergel
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Astrid Gieselmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry and Psychotherapy, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Lia van der Ham
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Laura van Melle
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- GGZ inGeest, Amsterdam, The Netherlands
| | - Gareth Owen
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Lucy A. Stephenson
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - George Szmukler
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | | | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Yolande Voskes
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anna Werning
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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van Melle L, van der Ham L, Voskes Y, Widdershoven G, Scholten M. Opportunities and challenges of self-binding directives: an interview study with mental health service users and professionals in the Netherlands. BMC Med Ethics 2023; 24:38. [PMID: 37270612 DOI: 10.1186/s12910-023-00915-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/17/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Self-binding directives (SBDs) are psychiatric advance directives that include the possibility for service users to consent in advance to compulsory care in future mental health crises. Legal provisions for SBDs exist in the Netherlands since 2008 and were updated in 2020. While ethicists and legal scholars have identified several benefits and risks of SBDs, few data on stakeholder perspectives on SBDs are available. AIMS The aim of the study was to identify opportunities and challenges of SBDs perceived by stakeholders who have personal or professional experience with legally enforceable SBDs. METHODS Data collection was carried out in the Netherlands from February 2020 to October 2021 by means of semi-structured interviews. Participants were selected through purposive sampling and snowball methods. Interviews were conducted with mental health service users (n = 7), professionals (n = 13), and an expert on SBD policy (n = 1), resulting in a total number of 21 interviews. The data were analyzed thematically. RESULTS Perceived benefits of SBDs included increased autonomy, improvement of the therapeutic relationship, possibility of early intervention and prevention of harm, prevention of compulsory care, reduction of the duration of compulsory care and recovery, mitigation of negative experiences around compulsory care, and guidance for professionals in providing compulsory care. Perceived risks included infeasibility of SBD instructions, difficulty in decision-making around SBD activation, limited accessibility of SBDs, disappointment of service users due to non-compliance with SBDs, and limited evaluation and updating of SBD content. Barriers to SBD completion included lack of knowledge of SBDs among professionals, lack of motivation or insight among service users, and lack of professional support for SBD completion. Facilitators of SBD completion and activation included support for SBD completion, involvement of relatives and peer experts, specification of SBD content, and evaluation of compulsory care and SBD content. The new legal framework was regarded as having both positive and negative effects on SBD implementation. CONCLUSIONS Stakeholders who have personal or professional experience with legally enforceable SBDs perceive SBDs as having important benefits and tend not to articulate the fundamental ethical concerns about SBDs which can be found in the ethics and legal literature. Instead, they perceive ethical and practical challenges that can be addressed through the implementation of suitable safeguards.
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Affiliation(s)
- Laura van Melle
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lia van der Ham
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yolande Voskes
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstr. 258a, 44799, Bochum, Germany.
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