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PSYCHIATRIC ADVANCE DIRECTIVES FOR IMPROVED HEALTHCARE
Project Number PCC 02-054 funded
by HSR&D.
July 1, 2003 -
June 30, 2007
Psychiatric advance directives (PADs) are legal documents that allow competent persons to declare their treatment preferences in advance of a mental health crisis, when they may lose capacity to make reliable health care decisions. Twenty states have now adopted PAD legislation. Our pilot research suggests that most patients with severe mental illness (SMI) approve of PADs, that many believe PADs would be personally useful, and that most are readily able to complete PADs if given assistance. Our research findings, federal mandates, and the actions of 20 state legislatures suggest that PADs are supported both in policy and theory. Despite this, the VA does not have a specific policy for PADs or mechanism to notify veterans of their right to prepare PADs. The downstream effects of PADs on patient care, service use, and clinical outcomes are unknown.
To describe veteran preferences for PAD content and completion. To determine the effects of PADs on patients’ willingness to engage in treatment. To examine the effectiveness of PADs in guiding treatment during a mental health crisis. To evaluate the effects of PADS on mental health service use and clinical outcomes.
We are conducting a randomized trial of a PAD intervention with a targeted enrollment of 340 veterans with SMI to examine the implementation of PADs over 1 year. Patients are randomly assigned to the PAD intervention or a “usual care” control group. All participants and their clinicians are given information about PADs. In addition, PAD patients are given individual assistance in completing a PAD. Patients undergo a structured interview at baseline, 1 month, 6 months, and 12 months to examine PAD content, structure, and completion, as well as to examine PAD effects on treatment engagement, mental health crisis management, VA service use, and clinical outcomes. The primary outcome variable of involuntary commitment rate will be examined by logistic regression adjusting with a limited number of predictors. The primary variables of perceived coercion and treatment adherence will be examined using generalized estimating equation methods. Because this is an efficacy trial, we will use an intent-to-treat approach to the analyses.
In the first phase of the study, which began July 1, 2003, we hired and trained personnel. In February and March of 2004, we completed a pilot of 9 patients with severe mental illness (SMI). On the basis of the results of this pilot, the competency measure was revised and survey instruments were modified and shortened to improve comprehension and reduce respondent burden. Formal enrollment began March 25, 2004, and ended on December 31, 2005. As of December 2005, we have approached 323 patients with SMI: 240 were consented and randomized. There were a total of 51 refusals, 30 approached but excluded, and 2 patients consented but not enrolled. Of the patients enrolled in the study, 82 patients have had at least one psychiatric rehospitalization at the Durham VA since enrolling in the study. Thus, on the basis of current data, we have observed a 34% readmission rate to the Durham VAMC.
We have conducted preliminary analyses of baseline data. In a multiple linear regression controlling for demographic and clinical variables, patients who were involuntarily committed or had low subjective social support had higher perceived coercion scores. In a separate analysis, those who were involuntarily committed or who reported perceived coercion during the admission process had lower perceptions of care (satisfaction) scores. Another analysis examined medication nonadherence. Nonadherence was associated with current drug use disorder and poor insight into illness. Anecdotal data from the study suggests that many patients perceive a benefit to having a psychiatric advance directive. Although data collection is ongoing, it is hypothesized that effective use of psychiatric advance directives may improve clinician/client communication and reduce psychiatric hospitalization and involuntary commitment rates downstream.
Participant enrollment has ended but the study is ongoing. Data collection will be completed in December 2006.
The practical impact of this research will be improved management of mental health crisis by streamlining care through advanced treatment planning. Another impact will be improved working alliance between patients and clinicians, enhanced treatment engagement, and a potential shift in patterns of service use from inpatient to outpatient services. This research will also yield two transportable products: a tested manual for facilitating PADs and a progress note template for PAD documentation in CPRS. This study will inform various stakeholders (e.g.,veterans, clinicians, and policy makers) about emerging questions concerning PADs. This patient-centered research contributes directly to improving quality of mental health services to veterans.
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