Clinicians’ Attitudes Regarding Barriers to the Implementation of Psychiatric Advance Directives

  • Richard A. Van DornEmail author
  • Marvin S. Swartz
  • Eric B. Elbogen
  • Jeffrey W. Swanson
  • Mimi Kim
  • Joelle Ferron
  • Laura A. McDaniel
  • Anna M. Scheyett


Psychiatric advance directives (PADs) may include documenting advance instructions (AIs) and/or designating health care agents (HCAs). Laws authorizing PADs have proliferated in the past decade, but there has been little research regarding perceptions of barriers to the implementation of PADs among groups of mental health professionals.


A total of N=591 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey regarding their perceptions of potential barriers to the effective implementation of PADs.


Across the three professional groups barriers related to operational features of the work environment (e.g., lack of communication between staff, lack of access to the document) were reported at a higher rate than clinical barriers (e.g., inappropriate treatment requests, consumers’ desire to change their mind about treatment during crises). However, psychiatrists were more likely to report clinical barriers to implementation than both psychologists and social workers. In multivariable analyses, legal defensiveness, employment in public sector mental health services, and a belief that treatment refusals will outweigh the benefits of PADs were associated with more perceived barriers, whereas age and endorsing positive perceptions of PADs were associated with fewer perceived barriers.


Psychiatrists, psychologists and social workers tend to perceive significant potential barriers to PADs, related to operational aspects of these professionals’ work environment as well as certain clinical features of PADs for persons with severe mental illness. Additionally, legal defensiveness and general endorsement of PADs appear to shape perceptions of barriers to the effective implementation of PADs.


barriers mental health clinicians psychiatric advance directives 



This work was supported by the Greenwall and MacArthur Foundations, a National Research Service Award Postdoctoral Traineeship from the NIMH to Drs. Van Dorn and Kim and NIMH K02 to Dr. Swanson.


  1. Allen M. (2004). Hargrave v. Vermont and the quality of care. Psychiatric Services 55: 1067CrossRefPubMedGoogle Scholar
  2. Amering M., Denk E., Griengl H., Sibitz I., Stastny P. (1999). Psychiatric wills of mental health professionals: a survey of opinions regarding advance directives in psychiatry. Social Psychiatry and Psychiatric Epidemiology 34: 30–34CrossRefPubMedGoogle Scholar
  3. Amering M., Stastny P., Hopper K. (2005). Psychiatric advance directives: Qualitative study of informed deliberations by mental health service users. British Journal of Psychiatry 186: 247–252CrossRefPubMedGoogle Scholar
  4. Appelbaum P.S. (2004a). In reply: Hargrave v. Vermont and the quality of care. Psychiatric Services 55: 1067–1068CrossRefGoogle Scholar
  5. Appelbaum P.S. (2004b). Psychiatric advance directives and the treatment of committed patients. Psychiatric Services 55: 751–752,763CrossRefGoogle Scholar
  6. Atkinson J.M., Garner H.C., Gilmour W. (2004). Models of advance directives in mental health care: Stakeholder views. Social Psychiatry & Psychiatric Epidemiology 39: 667–672CrossRefGoogle Scholar
  7. Backlar P., McFarland B.H., Swanson J.W., Mahler J. (2001). Consumer, provider, and informal caregiver opinions on psychiatric advance directives. Administration & Policy in Mental Health 28(6): 427–441CrossRefGoogle Scholar
  8. Elbogen, E. B., Swartz, M. S., Van Dorn, R. A., Swanson, J. W., Ferron, J., Kim, M., et al. (in press). Clinician decision-making and attitudes on implementing psychiatric advance directives. Psychiatric Services.Google Scholar
  9. Grol R. (1997). Personal paper: Beliefs and evidence in changing clinical practice. British Medical Journal 315: 418–421PubMedGoogle Scholar
  10. Grol R., Wensing M. (2004). What drives change?: Barriers to and incentives for achieving evidence-based practice. Medical Journal of Australia 180: s57–s60PubMedGoogle Scholar
  11. Hargrave v. Vermont 340 F. 3d 27 (2nd Circuit 2003).Google Scholar
  12. Henderson C., Flood C., Leese M., Thornicroft G., Sutherby, K., Szmukler G. (2004). Effect of joint crisis plans on use of compulsory treatment in psychiatry: Single blind randomised controlled trial. British Medical Journal 329(July 17): 136–140PubMedCrossRefGoogle Scholar
  13. Joshi K.G. (2003). Psychiatric advance directives. Journal of Psychiatric Practice 9(4): 303–306CrossRefPubMedGoogle Scholar
  14. Keefe B., Pinals D.A. (2004). Durable power of attorney for psychiatric care. Journal of the American Academy of Psychiatry & the Law 32: 202–204Google Scholar
  15. McCrary, S. V., Swanson, J. W., Coulehan, J., Faber-Langendoen, K., Olick, R. S., & Belling, C. (in press). Physicians’ legal defensiveness in end-of-life treatment decisions: Comparing attitudes and knowledge in states with different laws. Journal of Clinical Ethics.Google Scholar
  16. Miller R.D. (1998). Advance directives for psychiatric treatment: A view from the trenches. Psychology, Public Policy, & Law 4(3): 728–745CrossRefGoogle Scholar
  17. Moulding N.T., Silagy C.A., Weller D.P. (1999). A framework for effective management of change in clinical practice: Dissemination and implementation of clinical practice guidelines. Quality in Health Care 8: 177–183PubMedCrossRefGoogle Scholar
  18. Noble L.M., Douglas B.C. (2004). What users and relatives want from mental health services. Current Opinion in Psychiatry 17: 289–296CrossRefGoogle Scholar
  19. Papageorgiou A., King M., Janmohamed A., Davidson O., Dawson J. (2002). Advance directives for patients compulsorily admitted to hospital with serious mental illness. British Journal of Psychiatry 181: 513–519CrossRefPubMedGoogle Scholar
  20. Peto T., Srebnik D., Zick E., Russo J. (2004). Support needed to create psychiatric advance directives. Administration and Policy in Mental Health 31: 409–418CrossRefPubMedGoogle Scholar
  21. Srebnik D., Brodoff L. (2003). Implementing psychiatric advance directives: Service provider issues and answers. Journal of Behavioral Health Services and Research 30(3): 253–268PubMedCrossRefGoogle Scholar
  22. Srebnik D., La Fond J. (1999). Advance directives for mental health treatment. Psychiatric Services 50(7): 919–925PubMedGoogle Scholar
  23. Srebnik D., Russo J., Sage J., Peto T., Zick E. (2003). Interest in psychiatric advance directives among high users of crisis services and hospitalization. Psychiatric Services 54(7): 981–986CrossRefPubMedGoogle Scholar
  24. Srebnik D.S., Rutherford L.T., Peto T., Russo J., Zick E., Jaffe C., et al. (2005). The content and clinical utility of psychiatric advance directives. Psychiatric Services 56: 592–598CrossRefPubMedGoogle Scholar
  25. StataCorp. (2003). Stata Statistical Software: Release 8.0. College Station, TX, StataCorp LPGoogle Scholar
  26. Swanson J.W., McCrary S.V. (1996). Medical futility decisions and physicians’ legal defensiveness: The impact of anticipated conflict on thresholds for end-of-life treatment. Social Science & Medicine 42: 125–132CrossRefGoogle Scholar
  27. Swanson, J. W., Swartz, M. S., Ferron, J., Elbogen, E. B., & Van Dorn, R. A. (In-press). Psychiatric advance directives among public mental health consumers in five U.S. cities: Prevalence, demand, and correlates. Journal of the American Academy of Psychiatry and Law.Google Scholar
  28. Swanson J.W., Swartz M.S., Hannon M.J., Elbogen E.B., Wagner H., McCauley B.J., Butterfield M.I. (2003). Psychiatric advance directives: A survey of persons with schizophrenia, family members, and treatments providers. International Journal of Forensic Mental Health 2(1): 73–86Google Scholar
  29. Swanson J.W., Tepper M.C., Backlar P.B., Swartz M.S. (2000). Psychiatric advance directives: An alternative to coercive treatment?. Psychiatry 63(2): 160–172PubMedGoogle Scholar
  30. Varekamp I. (2005). Ulysses directives in the Netherlands: Opinions of psychiatrists and clients. Health Policy 70: 291–301CrossRefGoogle Scholar
  31. Vuckovich P.K. (2003). Psychiatric advance directives. Journal of the American Psychiatric Nurses Association 9: 55–59CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2005

Authors and Affiliations

  • Richard A. Van Dorn
    • 1
    • 3
    Email author
  • Marvin S. Swartz
    • 1
  • Eric B. Elbogen
    • 1
  • Jeffrey W. Swanson
    • 1
  • Mimi Kim
    • 1
  • Joelle Ferron
    • 1
  • Laura A. McDaniel
    • 2
  • Anna M. Scheyett
    • 2
  1. 1.Services Effectiveness Research Program in the Department of Psychiatry & Behavioral SciencesDuke University Medical CenterDurhamUSA
  2. 2.School of Social WorkUniversity of North Carolina-Chapel HillChapel HillUSA
  3. 3.Services Effectiveness Research Program in the Department of Psychiatry & Behavioral SciencesDuke University School of MedicineDurhamUSA

Personalised recommendations