Evaluation of advance statements in psychiatric care.

Abstract

Background: An advance statement in psychiatric care is a statement of a person's preferences for treatment, should he or she lose capacity to make treatment decisions in the future. The underlying principle for implementing these instruments is the promotion of patients' self-determination and autonomy.;Objective: To evaluate whether use of advance statements by patients with severe mental illness leads to lower rates of compulsory readmission to hospital.;Design: Randomised controlled trial. Setting Two inner city psychiatric hospitals in North London.;Participants: One hundred and fifty six in-patients about to be discharged from compulsory treatment under the Mental Health Act were recruited. To be included, participants had to be 18 years old and over, with mental capacity, able to read and write English and on section 2, 3 or 4 of the Mental Health Act.;Intervention: The preference for care group and the control group both received standard psychiatric care plus a number of standardised questionnaires at baseline and a year after discharge from section. In addition to that the preference for care group received the psychiatric advance statement at baseline.;Outcome measures: The main outcome measure was the rate of compulsory re-admission. Other outcome measures involved: the patients' self-efficacy and satisfaction with psychiatric services, their mental health status assessment, their views about the usefulness of the advance statements, assessment of the content of the statement and the views of mental health professionals in relation to the usefulness of the statement.;Results: Fifteen patients (19%) in the intervention group and 16 (21%) in the control group were readmitted compulsorily within 1 year of discharge. There was no difference in the numbers of compulsory readmissions, numbers of patients readmitted voluntarily, self-efficacy or satisfaction with psychiatric services. Patients with severe and enduring mental health problems were capable of drawing up advance statements with their views in relation to signs of lapses and relapses, and their preferences and refusals on certain aspects of their treatment and needs whilst hospitalised. Patients did not use the advance statements as an opportunity to refuse all subsequent treatment. Although 40% of patients did not find the advance statements useful, this may have occurred because the professionals involved in their care did not refer to or take account of them. Most mental health professionals who returned questionnaires did not find the advance statements useful in the management of the patients.;Conclusion: Users' advance statements for psychiatric care had little observable impact on the outcome of care at twelve months. Even if rates of compulsory treatment were not affected, one cannot rule out possible beneficial effects such as improvement of therapeutic alliance and communication with mental health professionals. Thus, the impact of advance statements on other aspects of care requires further study