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Competence to Complete Psychiatric Advance Directives: Effects of Facilitated Decision Making

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Law and Human Behavior

Abstract

Psychiatric advance directives (PADs) statutes presume competence to complete these documents, but the range and dimensions of decisional competence among people who actually complete PADs is unknown. This study examines clinical and neuropsychological correlates of performance on a measure to assess competence to complete PADs and investigates the effects of a facilitated PAD intervention on decisional capacity. N=469 adults with psychotic disorders were interviewed at baseline and then randomly assigned to either a control group in which they received written materials about PADs or to an intervention group in which they were offered an opportunity to meet individually with a trained facilitator to create a PAD. At baseline, domains on the Decisional Competence Assessment Tool for PADs (DCAT-PAD) were most strongly associated with IQ, verbal memory, abstract thinking, and psychiatric symptoms. At one-month follow-up, participants in the intervention group showed more improvement on the DCAT-PAD than controls, particularly among participants with pre-morbid IQ estimates below the median of 100. The results suggest that PAD facilitation is an effective method to boost competence of cognitively-impaired clients to write PADs and make treatment decisions within PADs, thereby maximizing the chances their advance directives will be valid.

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Notes

  1. It is important to note that as soon as participants were randomized to the intervention group, an F-PAD facilitator immediately initiated contact with the participant to discuss the definitions and limits of PADs, evaluate whether the participant thought PADs would be useful, and ask if the participant wanted help writing a PAD. However, being assigned to the F-PAD intervention arm should not be confused with someone completing a PAD. Since PADs intend to promote patient choice and autonomy, there was no requirement that participants in the F-PAD intervention group complete a PAD; instead, assistance to do so was offered. At the one-month follow-up, more than half the participants in the F-PAD intervention group had completed a PAD (n=107) while the remainder were at different stages of completing PADs or deliberating whether they wanted to complete a PAD at all. Only four subjects in the control group completed a PAD by one-month. For more details about the content of these PADs, please see Swanson et al. (in press).

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Acknowledgements

This work was supported by the National Institute of Mental Health through a research grant (R01-MH063949) and Independent Research Scientist Career Award (K02-MH67864) to Jeffrey Swanson. The study was also supported by the John D. and Catherine T. MacArthur Foundation Research Network on Mandated Community Treatment.

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Authors and Affiliations

  1. Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Brightleaf Square Suite 23-A, 905 West Main Street, DUMC Box 3071, Durham, NC, 27710,, USA

    Eric B. Elbogen, Jeffrey W. Swanson, Marvin S. Swartz, Joelle Ferron, Richard A. Van Dorn & H. Ryan Wagner

  2. Department of Psychiatry, Columbia University, New York, New York, USA

    Paul S. Appelbaum

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  1. Eric B. Elbogen
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  2. Jeffrey W. Swanson
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  3. Paul S. Appelbaum
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  4. Marvin S. Swartz
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  5. Joelle Ferron
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  6. Richard A. Van Dorn
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  7. H. Ryan Wagner
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Correspondence to Eric B. Elbogen.

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Elbogen, E.B., Swanson, J.W., Appelbaum, P.S. et al. Competence to Complete Psychiatric Advance Directives: Effects of Facilitated Decision Making. Law Hum Behav 31, 275–289 (2007). https://doi.org/10.1007/s10979-006-9064-6

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  • DOI: https://doi.org/10.1007/s10979-006-9064-6

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