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Advance Directives for Persons With Serious Mental Illness

First, advance directive statutes typically create a legal presumption that persons completing the forms were competent to do so, requiring affirmative evidence of incompetence to invalidate their directives. This comports with the usual legal maxim that all adults are presumed competent unless proven otherwise.

Second, although the cognitive impairments associated with serious mental illnesses may impair patients' decisional capacities, subtle deficits are insufficient to render someone incompetent. Because in a democratic society we desire to maximize the number of people who can make decisions for themselves, the threshold for declaring someone incompetent is a high one; even many patients hospitalized with acute psychoses or depression remain competent to make decisions about their treatment (1).

Finally, the published data on patients' capacities to write psychiatric advance directives, although limited at this point, suggests that even patients with serious mental disorders are generally quite capable of performing this task (2). Anecdotal reports from other researchers appear to confirm these data. Although there may be a role for formal instruments to assess competence in a small number of cases, concerns about patients' capacities ought not to be a major barrier to more widespread use of advance directives for psychiatric treatment and end-of-life care.

Editor's Note: Dr. Appelbaum's Taking Issue piece in the May issue discussed the role of stigma in the promotion of advance directives among persons with serious mental illness (3).

Paul S. Appelbaum, M.D.

References

1. Grisso T, Appelbaum PS: The MacArthur Treatment Competence Study: III. abilities of patients to consent to psychiatric and medical treatments. Law and Human Behavior 19:149–174,1995[CrossRef][Medline]
2. Srebnik D, Appelbaum PS, Russo J: Assessing competence to complete psychiatric advance directives with the Competency Assessment Tool for Psychiatric Advance Directives. Comprehensive Psychiatry 45:239–245,2004[CrossRef][Medline]
3. Appelbaum PA: Advance directives: stigma strikes again. Psychiatric Services 56:515,2005[Free Full Text]

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Appelbaum, P. S. Search for Related Content Articles by Appelbaum, P. S. Chronically Mentally Ill Patients Treatment Compliance Confidentiality Informed Consent Other Ethics Issues Crisis and Emergency Treatment Health Policy and Legislation Quality of Care, Practice Guidelines Violence in Treatment Settings Antisocial Personality Disorders Other Violence/Aggression

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