Dresser

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Atkinson, J. M.

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Ulysses' crew or Circe? - the implications of advance directives in mental health for psychiatrists

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Ulysses' crew or Circe? – the implications of advance directives in mental health for psychiatrists

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Atkinson, J.M.

      Atkinson, J.M. (2004) Ulysses’ crew or Circe? – the implications of advance directives in mental health for psychiatrists. Psychiatric Bulletin 38(3-4).        http://eprints.gla.ac.uk/4183/  Deposited on: 14 May 2008   Glasgow ePrints Service http://eprints.gla.ac.uk opinion & debateJ ACQUEL I N E M . AT K I N S ONUlysses’ crew or Circe? - the implications of advancedirectives in mental health for psychiatristsAdvance directives in mental health care are currentlyattracting interest, although there is some anxiety thatthey can restrict clinical freedom. The so-called ‘Ulyssescontract’ is a form of opt-in to services that has beensuggested in the USA. Psychiatrists might thus considerthemselves to be the equivalent of Ulysses’ crew in beingbound by the contract. This paper suggests, in somecases, that they might function more as Circe, whosuggested the directions to Ulysses, and considers this inthe light of contemporary relationships betweenpsychiatrists and patients.‘‘Youmustbindmevery tight, standingmeupagainst the stepofthe mast and lashed to themast itself so that I cannot stir fromthe spot. And if I begandcommand youto releaseme, youmusttighten and add tomy bonds.’’ (Homer, 2003:161)With these words, Ulysses (or Odysseus) instructed hiscrew as to their actions towards him as they cross thepath of the Sirens and their wondrous songs, and createdan early form of advance directive. Echoing his directions,the name ‘Ulysses contract’ was given to a form ofadvance directive in mental health in the USA (Dresser,1982, 1984; Winston et al, 1982), also termed an ‘opt-in’advance directive, whereby patients agree in advance totreatment they may refuse later when ill. Although inBritain the emphasis probably has been on advancedirectives that opt out or refuse treatment, both ideasare current.However else they are interpreted, an advancedirective has at least two participants: the person whodraws it up and the person(s) who must implement it.Advance directives, whether seen as enhancing patientautonomy or promoting partnerships and collaborationdemand a mutual understanding of the directive and anappropriate response, whether this be Ulysses’ crew or apatient’s psychiatrist. Psychiatrists have expressedconcern about the implementation of advance directives,seeing them as a limitation to clinical judgement (ScottishParliament, 2002a). Ulysses’ advance directive wassuccessful in that he and the crew navigated the hazard(i.e. the Sirens). Does an analysis of Ulysses’ story help usto understand contemporary relationships and point tosuccessful outcomes?Ulysses’ advance directive was noteworthy in anumber of respects:1. The idea for the plan and its instructions did notoriginate with him, but with Circe, a known expert{on the Sirens.2. He wanted to experience something known to bedangerous, indeed almost certainly lethal, but tohave a safety net.3. He required something to be done to him - namelyrestraint.4. He required something not to be done to him - hisears not to be plugged with wax.5. He made provision for a change of mind - he was tobe ignored and restrained further.6. Conditionswere put on the crew - their ears were tobe plugged with beeswax.7. He and the crew were in agreement about thegoal - to come safely past the Sirens.8. The plan did not require resources beyond those thatthe crew already had.If asked to rank these, it is likely that point 7 would beimportant for staff: agreement about the desirability ofoutcome. Staff are likely to be happier to implement anadvance directive if they believe that both the patient andthey will have a good outcome. In the case of Ulysses, ifpoints 3 and 5 were followed no harm would come tohim. In many cases, staff fear that a refusal of treatment(point 4) will lead to harm for the patient and possiblynegative consequences for themselves, whether this is inthe difficult management of an ill patient or the extra callon limited resources by a longer period of illness (Halpern& Szmuckler, 1997). A recent study found advance direc-tives to be of limited value based on staff-selected groupoutcomes, but individual patients may have found themempowering (Papaggergiou et al, 2002). It is, however,the potential for additional resources that concerns manyin allowing patients to run the course of their illnessepisode; discussion of resource allocation is outsidethe scope of this article, but it will have an impact onattitudes.The crew may have had faith in the plan because ofits provenance - the goddess Circe. Advance directivesbased on experience and expertise may thus find more{ Although undeni-ably an expert on theSirens, Circe has amore dubious repu-tation as someonewho, under the guiseof hospitality,drugged unwarymen and turnedthem into swine(www.messagenet.com/myths/bios/circe).For Evaluation Only.Copyright (c) by Foxit Software Company, 2004 - 2007Edited by Foxit PDF Editorfavour with staff, whether presented independently ordrawn up with staff, than advance directives based onthings that a patient believes but has not experienced.There is, arguably, a difference between someone whohas experienced severe illness and electroconvulsivetherapy and found it so distressing that they do not wantit again, and someone who has experienced neither andis basing their decision on media reporting.Although Ulysses’ directive is usually seen as opt-in,in that he required action to be taken, it can also be seenas an opt-out of what is arguably the more conservativeoption, namely plugging his ears with wax along with hiscrew and thus avoiding being bewitched by the songs.Ulysses thus wishes to experience something that,although dangerous, is potentially enriching and put inplace a safety net to keep him from harm. Patients whochoose to experience an episode of illness (whether theybelieve it to be an enriching experience or whether it issimply less bad than the alternative treatment) may needto be aware of what safety nets, including restraints, theyare prepared to put in place to manage the illnessepisode. Staff may be more comfortable with advancedirectives that acknowledge the consequences of thisand make provision for them.We are not told of thecrew’s response to having to restrain their captain, butthe negative consequences to staff in using restraint havebeen noted (Scottish Parliament, 2002b).It seems clear from Ulysses’ account that he did notwant to die. The limits of advance directives need to bestated. Advance directives made for end-of-life scenariosare clear about the outcome. Those in mental health maybe less so, and no illness or episode is completelypredictable. Directives should at least cover whether aperson is prepared to die, or how long they are preparedto remain acutely ill before starting treatment.Ulysses’ advance directive worked because it was, ineffect, a limited forward plan that had the agreement ofthose who had to implement it. It dealt with a veryspecific set of circumstances, with known outcomes andagreed goals. It is likely that the more an advance direc-tive conforms to these parameters, the more acceptableit will be to staff. It also had one overriding advantagethat current advance directives do not. Ulysses’ was incharge, the crew was his and he had already broughtthem safely through many dangers. Advance directivesnecessarily challenge the authority from which staffusually operate. Psychiatrists may feel limited if they putthemselves in the position of Ulysses’ crew and mayprefer the role of Circe who proposes the plan. A proac-tive approach to future planning may promote patientchoice and reassure psychiatrists that the plan isworkable.Advance directives require changes on the part ofboth staff and patients. Staff would have to accept notonly patients’ choices, but the experience that leads tothese choices. Patients would need to accept theresponsibility that comes with having their choiceshonoured, even if these choices do not always have theexpected outcomes. After all, Ulysses knew that passingthe Sirens would only lead to the twin dangers of Scyllaand Charybdis. And, in this respect, both patients andstaff can find themselves between a rock and a hardplace when balancing patient choice, uncertain outcomesand limited resources.Declaration of interestDr Atkinson is in receipt of a research grant from theNuffield Foundation to research advance directives inmental health.ReferencesDRESSER, R. (1982) Ulysses and thepsychiatrists: a legal and policy analysisof the voluntary commitment contract.Harvard Civil Rights - Civil LibertiesLaw Review,16, 833-835. (1984) Bound to treatment: theUlysses contract. Hastings CentreReport,14,13-16.HALPERN, A. & SZMUCKLER, G. (1997)Psychiatric advance directives:reconciling autonomy and non-consensual treatment. PsychiatricBulletin, 21, 323-327.HOMER (2003) The Odyssey (translatedbyV. Rieu). London: Penguin.PAPAGEORGIOU, A., KING, M.,JANMOHAMED, A., et al (2002)Advance directives for patients withserious mental illness: a randomisedcontrolled trial. British Journal ofPsychiatry,181, 513-519.SCOTTISH PARLIAMENT (2002a)Health and Community CareCommittee Official Report Wednesday30th October 2002. Edinbugh:Scottish Parliament. (2002b) Health and CommunityCare Committee Official ReportWednesday 9th October 2002.Edinburgh: Scottish Parliament.WINSTON, M.,WINSTON, S.,APPELBAUM, P., et al (1982) Can asubject consent to a Ulysses contract?Hastings Centre Report,12, 26-28.*Jacqueline M. Atkinson Public Health and Health Policy (PhD), Faculty ofMedicine, University of Glasgow,1Lilybank Gardens, Glasgow G12 8RZFor Evaluation Only.Copyright (c) by Foxit Software Company, 2004 - 2007Edited by Foxit PDF Editor

Boundto treatment: the Ulysses contract. Hastings Centre Report,14,13-16.

Can a subject consent toa Ulyssescontract? Hastings Centre Report,12,26-28. *Jacqueline M. Atkinson Public Healthand Health Policy (PhD), Facultyof Medicine, University of Glasgow,1Lilybank Gardens, Glasgow G128RZ For Evaluation Only.

Copyright (c) by Foxit Software Company,

etal(2002) Advance directives for patients with seriousmentalillness:arandomised controlled trial.

Healthand Community Care Committee

Psychiatric advance directives: reconcilingautonomyandnonconsensualtreatment. Psychiatric Bulletin, 21,323-327. HOMER(2003)TheOdyssey(translated byV.

Ulysses and the psychiatrists:alegalandpolicyanalysis of the voluntarycommitment contract. Harvard CivilRights- CivilLiberties Law Review,16,833-835.

Ulysses’ crew or Circe? – the implications of advance directives in mental health for psychiatrists

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Ulysses’ crew or Circe? – the implications of advance directives in mental health for psychiatrists

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