Appropriateness of psychiatric advance directives facilitated by peer support specialists and clinicians on Assertive Community Treatment teams

Abstract

Background

Psychiatric advance directives (PADs) are used to document a person’s treatment preferences for a future mental health crisis. Peer support specialists have been proposed to facilitate PADs, but little is known about the quality of peer versus clinician facilitated PADs.

Aims

This study examined whether PAD documents facilitated by peer specialists and non-peer clinicians differed in the mix of treatment requests and refusals and expert ratings of feasibility and consistency.

Methods

Analyses were conducted of content and expert ratings of 72 PAD documents from a randomized trial of PAD facilitation by peers and clinicians on Assertive Community Treatment (ACT) teams. A count of treatment refusals and requests was used to classify documents as predominantly prescriptive, proscriptive, or balanced. Regression was used to estimate relationships between PAD facilitator type and content.

Results

Peer-facilitated PADs were significantly more likely to be predominantly prescriptive than were PADs facilitated by non-peer clinicians. Prescriptive PADs were more likely to receive expert ratings of high feasibility and consistency.

Conclusions

Results should alleviate some clinicians’ apprehensions regarding the appropriateness of peer-facilitated PADs, such as the concern that people with lived experience with mental illness might encourage other consumers to use their PAD primarily for treatment refusals.

Keywords:

• Psychiatric advance directives
• serious mental illness
• peer support specialists
• treatment decision making
• assertive community treatment
• psychiatric disability
• mental incapacity
• patient self determination
• mental illness recovery

Acknowledgements

The success of this project depended on the efforts of consumers and staff of assertive community treatment teams at four agencies—Carolina Outreach, University of North Carolina, Easter Seals, and Fellowship Health Resources, Inc.—and the authors are deeply grateful for their participation and collaboration.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The research reported in this article was supported by grant # 90IF0027 from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). NIDILRR is a center within the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS). Writing of this article was also supported by the Wilson Center for Science and Justice at Duke Law School.