Psychiatric advanced directives, a form of medical document very similar to a living will that is usually applied only in end-of-life circumstances, have become legal in much of the United States over the past fifteen years, and they are currently being considered for broader application in order to allow those affected by potentially disabling mental illness to better advise medical authorities on their own preferred methods of care. The directives are pre-composed statements detailing the treatment of a given patient according to his or her own wishes in cases where those cannot be made clear due to the effects of the related condition. Created as an avenue of communication for patients incapacitated by major illness or injury, the advanced directives are both controversial and necessary.
The psychiatric advanced directive option is relatively new. It first took effect in Minnesota 1991, and the trend it began subsequently made its way across the U.S. Approximately one-half of the 50 states now offer it, and the issue of its implementation has emerged anew as the state of Virginia considers writing it into law. The orders have two general variations: "instruction" directives simply specify preferred treatments, where "proxy" directives give authority to third parties (usually family members or legal representatives) in the case of incapacitation. Most established directives use a combination of these two elements, specifying care but also leaving the direction of treatment in the hands of a trusted loved one or counsel. This sort of directive may be crucially relevant to those affected by conditions such as schizophrenia or severe bipolar disorder that can, in extreme cases, render them psychotic, incoherent or incapacitated, depriving them of the ability to direct their own care. Family members, though they are often painfully familiar with their loved ones' conditions, do not have the degree of intimate knowledge possessed by the patient him/herself, requiring written statements regarding the best mode of care in extreme, demanding situations.
Perhaps the most significant aspect of these legal directives is reinforcing a patient's right to refuse certain forms of treatment such as electro-convulsive therapy and certain medications with extreme side-effects. Faced with an unresponsive or potentially dangerous patient in the absence of any pre-existing personal guidelines, a doctor may well resort to such measures in the very legitimate interest of surrounding parties' well-being. And the issue of medical professionals rendered unable to contain a patient because of the stricture of these directives is a very real concern.
Descriptions of the directives may, however, be misleading. In many states they exist in name only as a physician can override the wishes of the patient at the time of treatment, effectively forcing him or her to take whichever medications the doctor sees fit. Most patients who suffer from chronic mental illness understand the nature of their particular cases better than those who treat them, especially when doctors do not have extensive knowledge of the individual cases. They have often been prescribed many different medications and are likely to know which particular meds best relieve their symptoms in the case of, for example, a momentarily crippling psychotic episode. On the other hand, the directives also allow patients to refuse psychiatric treatment altogether. The subsequent issues of gauging a patient's capacity and determining when their treatment wishes amount to a kind of euthenasia are complex and largely open to interpretation.
As acclaimed author and professor Elyn R. Saks stated in her recent TOL interview, psychiatric patients must be treated humanely in all circumstances, and forced restraint or medication should be considered only when absolutely necessary. If they make clear their wishes to be treated with alternate medications that offer fewer side effects or more satisfactory relief of symptoms, there is no reason to refuse them the treatment they want. Of course, the demands of a dramatic episode involving psychosis or incapacitation may render serious consideration impossible, which is precisely why we need psychiatric directives. The last word on treatment belongs to professionals, and a patient's preferences cannot allow for unnecessary suffering or compromise the safety of others, but as in cases of physical illness, the wishes of the patient should be followed whenever possible. Those suffering from mental illness are not intellectual or emotional invalids and should not be treated as such.
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