Advance directives for mental health care: An analysis of state statutes.

State statutes enabling individuals to draft written durable advance directives for health care have approached future decisions about mental health care and treatment in several quite different ways. While some states incorporate mental health care into the generic advance directive law, others exclude some kinds of mental health care from the generic law, and a growing number of states have established distinct processes for mental health directives. The author surveys the state statutes and examines the extent to which the statutes may create barriers to the use of advance directives by people with mental illness. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Effect of long-term hyperosmolality on the Na+/H+ exchanger isoform NHE-3 in LLC-PK1 cells

Communication is an important cornerstone to the physician-patient relationship when considering advance directives. Discussing advance directives with patients is a process best initiated in routine, well-adult care that can be made more daunting when the patient is critically ill; yet, when patients are afflicted with cancer, communication on advance directives can be optimized when the primary care physician and oncologist together work with the patient. The need to counsel patients on advance directives regardless of the venue (whether inpatient or outpatient) highlights that an ongoing alliance between the oncologist and the primary care physician can help facilitate consent to, and allow periodic review of, advance directives by cancer patients. This process ensures that the patient's preferences are respected at life's end.     

Advocacy, recovery, and the challenges of consumerism for schizophrenia

Advocacy organizations such as the National Alliance for the Mentally Ill (NAMI) and patient consumer groups are playing an ever-increasing role in public health policy and patient care in schizophrenia. The recovery philosophy which recognizes the unique contributions of those who have experienced mental illness is now a part of treatment approaches in many states. Several states have extended these consumer initiatives to incorporate advance directives, an approach that has generated much debate. The NAMI destigmatization campaign, grounded in the neurobiology of major mental illness, is an unprecedented, concerted effort to change public opinion and to achieve parity at all levels for persons with severe and persistent mental illness. This article describes and chronicles these initiatives and explores their implications for the management of schizophrenia into the next millenium.     

Use of advance directives: facilitating health care decisions by adults with mental retardation and their families

As increasing numbers of adults with mental retardation survive into adulthood and old age, they may face decisions about their health care and end-of-life treatment. Advance directives may serve as a tool for communicating one's preferences about future medical treatment. Information about the types, extent of use, and ethical context of advanced directives is provided and four critical issues regarding use of advanced directives by adults with mental retardation and their families are examined: assessment of decision-making capacity, standards for surrogate decision-making, family involvement in advanced directives planning, and constraints on the use of advanced directives. Implications for professionals are discussed, including ways to facilitate advance care planning.     

Advance directives for psychiatric care: A theoretical and practical overview for legal professionals.

An advance directive for psychiatric care is a legally enforceable document that specifies the manner in which psychiatric treatment decisions are to be made in the event that a person later becomes incompetent to make informed health care decisions. Although the concept of psychiatric advance directives has gained considerable popularity in recent years, the groundswell of interest in these instruments largely precedes the development of a coherent body of governing law. Existing state statutes and case law provide significant legal authority for the use and enforcement of advance directives in psychiatric settings, but serious questions remain concerning the scope of their enforceability, particularly in the context of involuntary treatment. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Prisoners as patients. The experience of delivering mental health nursing care in an Australian prison

Correctional or prison mental health nursing is a highly specialized area of practice that has undergone substantive role development in recent years. However, little research has explored aspects of prison-based nursing practice or practice arrangements. The experience of delivering mental health nursing care in prison can be disempowering, resulting in feelings of frustration, isolation, and stigma. In developed nations, prison mental health nurses face the rewarding challenge of gaining greater recognition for the specialized nature of their practice and their key role in the correctional and criminal justice continuum.     

Strategies to promote the use of advance directives in a residency outpatient practice

OBJECTIVE: To evaluate patient education and resident education strategies to promote advance directives in the outpatient setting, and to assess barriers to implementation. DESIGN: Controlled clinical trial. SETTING: The internal medicine residents' practice of an urban, university medical center. PATIENTS/PARTICIPANTS: Medical residents and 250 patients seen at least twice in the 3 months prior to the study. INTERVENTIONS: We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, and videotaping of an actual discussion by each resident, followed by individual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discuss advance directives. MEASUREMENTS AND MAIN RESULTS: We interviewed 187 of these patients (response rate 75%) and surveyed 62 residents (response rate 70%). After 18 months, there were no significant differences in the number of advance directives in charts among the three groups. Documented advance directives discussions with patients in the resident education group increased from 3% to 17% (p < .001), more than those in the patient education (5%) or control group (10%, p = .04). Residents in the resident education group were more likely to report discussing advance directives than those in the patient education or control groups (p = .05). Lack of time (95%) and lack of continuity (76%) were the most frequently cited barriers. In multivariate logistic regression, nonwhite race and non-U.S. birth were negatively associated with patient interest in advance directives. Patient race and birthplace were not associated with actual discussions of advance directives. CONCLUSIONS: Even with intensive efforts to educate outpatients and residents about advance directives, important barriers remain, raising questions about how best to promote advance directives among outpatients.     

Foreword: Planning for the future through advance directive instruments.

The Foreword traces the development of advance directive instruments and discusses their legal enforceability and many benefits. Despite their advantages, advance directives remain underused and are frequently ignored by service providers. The contributors to this special issue discuss why this is so and offer and debate a variety of remedial proposals. They analyze the various legal, clinical, ethical, and practical issues presented by the use of advance directives for health and mental health care and examine new directions in their application. The Foreword describes the organization of this special issue, summarizes the articles it contains, and comments on their significance. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Client denial and resistance in the advance directive context: Reflections on how attorneys can identify and deal with a psycholegal soft spot.

An important reason why advance directive instruments are underused is that people faced with the need to think about the end of life, future mental health problems, or the need for nursing home admission experience psychological stress that produces denial and procrastination. This essay examines how lawyers who are counseling clients about advance directive instruments can deal with such client denial and resistance. It explains the psychological defense mechanism of denial and related forms of resistance and offers suggestions about techniques that lawyers can use for dealing with denial and resistance in counseling clients about advance directives. It suggests ways in which lawyers can develop their interpersonal skills, becoming more empathic and more sensitive to their clients' psychological needs. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Patients' attitudes toward advance directives and end-of-life treatment decisions

Much of the patient education about advance directives described in the literature involves explaining the purpose of advance directives to patients and guiding them through the process of issuing a directive. However, well over half of the subjects in this study claimed to know enough about the directives to issue one, and almost all subjects expressed a preference for issuing directives when healthy. Although health care agencies that wish to adhere to the PSDA must continue to ask all patients if they have issued an advance directive, aggressive patient education programs that press hospitalized patients to consider issuing an advance directive may be perceived by patients as coercive and uncaring. Patient education may be more likely to achieve the goals of the PSDA if it is provided before hospitalization and if patients are encouraged to discuss their care preferences with family members who would be in a position to speak for them at the end of life. Further study of the few patients who choose to issue an advance directive would be informative. When and why they chose to issue the directive should be explored. Patients who report issuing an advance directive but do not provide their physician or hospital with a copy of the directive upon admission should also be studied to determine if this represents a desire not to activate the directive during the current admission or simply confusion about the disposition of this document. Finally, most studies of advance directives have been cross-sectional. Longitudinal study of patients who issue advance directives are needed to determine the effectiveness of these documents in influencing the end-of-life treatment that patients receive.     

Ethical and professional conflicts in correctional psychology.

The role of the mental health professional in a prison setting has changed to reflect the prevailing ideology of the correctional administration that deemphasizes treatment and emphasizes security and custodial concerns. As a consequence, mental health professionals who work in corrections have experienced unique ethical and professional conflicts. Standards were developed to address the conflicts and provide guidelines for professional conduct, but dilemmas continue to exist. The authors indicate this can be attributed to (1) the standards being vague and (2) correctional personnel not understanding or supporting the standards or the psychologist's role as a mental health professional. This article examines these propositions in more detail, using vignettes and discussion, and offers other approaches to resolving the dilemmas and improving the delivery of mental health services to incarcerated individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Laryngeal cancer: quality-of-life and cost-effectiveness

The purpose of this paper is to review the current literature in relation to mental illness and criminal behaviour. The material presented for discussion was selected from forensic and general psychiatric literature. However, a number of important publications, policy documents and independent reports were used to explore the debate surrounding this subject. Contemporary studies of prison populations in the UK and abroad illustrated the difficulty in relating mental illness to crime. Papers presenting research in the UK revealed important implications for mental health policy and the way in which the penal system deals with mentally disordered offenders. The literature reviewed provided arguments for and against an association between mental illness and criminal behaviour. Methodological problems associated with criminological and psychiatric research were addressed in relation to the exploration of whether people suffering from a mental illness are more dangerous or violent than other people. Research papers focusing on public reaction to mentally ill people living in the community provided important considerations when addressing mental illness and criminal behaviour in the context of care in the community policy. This paper will be of interest to a broad range of mental health professionals, particularly those working with individuals who have a history of mental illness and violent behaviour, or mental health professionals working with mentally disordered offenders.     

Advance directives for psychiatric treatment: A view from the trenches.

Medical advance directives for end-of-life decisions at times that patients cannot express their preferences have become a major trend in recent state and federal legislation. The author argues that an extension of directives to cover future psychiatric treatment are fraught with both practical and ethical dilemmas. Although the potential for increasing patient autonomy is certainly positive, the potential for implementing covert ideological agendas has been present from the beginning, and the significant differences between medical end-of-life decisions and ongoing treatment of psychiatric patients must weigh against psychiatric advance directives unless major changes are made in existing procedures. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Barriers to completion of health care proxies: an examination of ethnic differences

BACKGROUND: Advance directives have not been uniformly used by different segments of the US population and studies have consistently shown a lower prevalence of advance directives among African Americans and Hispanics compared with non-Hispanic whites. OBJECTIVE: To examine barriers to completion of health care proxies for different ethnic groups. METHODS: One hundred ninety-seven subjects aged 65 years or older self-identified as African American (n = 65), Hispanic (n = 65), or non-Hispanic white (n = 67) attending a geriatrics and internal medicine outpatient clinic of a large New York City teaching hospital were administered a questionnaire. Questionnaires were developed to examine potential barriers to completion of health care proxies. Barriers were drawn from the literature and from focus groups. RESULTS: Significant predictors of proxy completion using logistic regression analysis included knowledge of health care proxies, availability of a health care agent, exposure to mechanical ventilation, age, and self-reported health status as fair to poor. Subjects who believed that a health care agent was irrelevant in the setting of involved family were significantly less likely to have completed a health care proxy. Although there were significant differences in the baseline completion rates of health care proxies for the 3 ethnic groups, ethnicity did not predict prior appointment of a health care agent in multivariate analysis. CONCLUSIONS: Differences in health care proxy completion rates across white, African American, and Hispanic elderly individuals in this New York City population seem to be related to potentially reversible barriers such as lack of knowledge and the perceived irrelevance of advance directives in the setting of involved family. Enhanced educational efforts of both health care personnel and patients could increase the rate of formal health care proxy appointment.     

Completing advance directives for health care decisions: Getting to yes.

The concept of advance directives for health care decision making has been judicially condoned, legislatively promoted, and systematically implemented by health care institutions, yet the execution rate of advance directives remains low. Physicians should discuss with their patients advance care planning generally and end-of-life issues specifically, preferably when patients are in good health and not when they face an acute medical crisis. The physician–hospital relationship poses particular challenges for the optimal implementation of advance directives that must be addressed. Hospital administrators must improve education of patients and physicians on the value of such documents as well as internal mechanisms to ensure better implementation of directives. Health insurance plans may be better able to ensure optimal gathering and implementation of directives. Patients must become more familiar and more comfortable with advance care planning and the reality of death and dying issues. Full acceptance of the value of directives ultimately rests on achieving full participation of all involved—providers, patients, families, and payors—in this most profound process. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The continuing ethical dilemma of the do-not-resuscitate order

The continued use of the do-not-resuscitate (DNR) order remains very confusing to health care workers, especially when surgical intervention is undertaken either by choice or necessity. Although ethics committees can aid in clarification, and the use of advance directives can further define patient wishes, patient and family member education is necessary to ascertain what a surgical patient really desires. As technology advances, perioperative nurses will continue to be bombarded with ethical issues surrounding the DNR order. This article addresses how nurses can be proactive in obtaining answers to these difficult questions and learn how to deal with this dilemma.     

Application of applied behavior analysis to mental health issues.

The theoretical and conceptual basis for behavior analysis emerged from the fields of experimental psychology, physiology, and philosophy, effectively melding theory with scientific rigor. Behavior analysis has since expanded from controlled laboratories into applied settings, including hospitals, clinics, schools, family homes, and communities. Much of the early research in applied behavior analysis (ABA) included participants with mental health disorders and developmental disabilities. ABA research for persons with developmental disabilities is vibrant and expansive; however, there is a paucity of recent research in behavior analytic assessment and treatment for persons with mental health diagnoses. This article describes how ABA technology can advance mental health services for children and adults utilizing a multidisciplinary approach to link professionals from psychology, psychiatry, and other associated disciplines to optimize patient outcomes. Discussion focuses on historic applications of behavior analysis, opportunities, and barriers in the mental health field, and ways in which ABA can contribute to a multidisciplinary treatment approach. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Failure of erythropoietin treatment in a case with primary autonomic failure

All prisons provide healthcare services which aim to meet the needs of prisoners. The goal of the service is to give prisoners access to the same quality and range of health care as the NHS gives the general public. However, within the prison environment priorities centre around order, control and discipline and therefore an ethos of health care needs to be developed. Custody reduces the prisoner's opportunity for self-care and independent action as inmates have to consult nursing or medical staff for even the most simple remedies. Nursing staff in the prison service can play a significant part in primary health care, mental disorder and health promotion. Nurses have the knowledge, skills and attitudes needed to deal with this diverse and vulnerable prison population and to promote a positive interface between custody and care.     

The significance for psychology of O'Connor v. Donaldson..

Recently, the US Supreme Court handed down a potentially landmark decision in the area of the right of mental patients to treatment. It is argued that there are 2 inherent flaws in the Court's holding that may significantly diminish its impact: the absence of definition of the concepts dangerous and treatment. This article (a) contends that these flaws reflect the absence of meaningful assistance from the mental health professions and (b) calls for empirical research to assist the judiciary in implementing the long-overdue humane treatment of the mentally ill. Psychiatry is seen as having failed to meet this challenge; it is observed that psychology, with its unique orientation toward scholarship and research, should meet the challenge. (PsycINFO Database Record (c) 2010 APA, all rights reserved)