Psychiatric advance directive?

Nursing, Jul 2000 by Salladay, Susan A

MENTAL HEALTH

I'm a psychiatric nurse practitioner working with a 19-year-old college freshman. Mark has Fabry's disease, a rare congenital condition caused by an enzyme deficiency. Ultimately, glycolipid accumulation impairs the kidneys and other organs, causing death.

Mark had been hospitalized with chronic bronchitis, dyspnea, and other complications. He was depressed because his symptoms worsened after he started college. His physician asked him to voluntarily admit himself to our hospital's mental health unit, and he agreed.

Upon admission, he gave his physician and nurses a copy of his psychiatric advance directive (PAD) for mental health decision making. He said he'd read about PADS on the Internet and wanted to use one to make his treatment preferences known. He believes that we should honor his PAD because he's competent to make his own treatment choices.

Although I've heard about PADS, this is my first experience with one. Are my patient's expectations justified?-H.G., WASH.

In theory, a PAD allows a competent patient to express his wishes about mental health treatment to be followed if he were to become incompetent or unable to express his preferences. For example, it allows him to indicate his preferences about electroconvulsive therapy, seclusion, restraints, and psychotropic medications.

A PAD also allows him to designate a health care agent for mental health decision making and to state a preference for a court-appointed guardian. Other issues it may cover include his preferences about participating in hospital-based research experiments, who should be prohibited from visiting him in the hospital, and who should care for or have temporary custody of minor children.

But a PAD isn't the same as an advance directive for health care (ADHC)-a durable power of attorney for health care or living will. Unlike PADS, which have questionable legal status, ADHCs are legal documents governed by state laws that clarify the extent and limits of a patient's right to refuse treatment. Each state defines a health care provider's obligation to honor a patient's ADHC.

Remember, the ADHC lets a patient refuse medical treatment that provides no benefit but serves only to prolong the dying process. That's a far cry from mental health treatments that can provide benefits and may improve quality of life, or at least limit debilitating symptoms. For this reason, the PAD's refusal of treatment section is quite different from the ADHC's-and much more problematic ethically.

Although a patient may have been competent when he signed his PAD, a court could order psychiatric treatment against his wishes if he were to become incompetent. Bottom line: Although caregivers have an ethical obligation to consider the patient's wishes, his wishes as expressed in a PAD aren't legally binding.

If your patient hasn't done so already, encourage him to complete an ADHC. Tell him that it offers a better way for him to ensure that his health care wishes will be honored.

Finally, pay careful attention to your patient's discharge planning because he may have left important support systems back in his hometown when he started college. To ensure continuity of care in his new location, get his permission to coordinate care and services with his college health clinic.