title: Overriding psychiatric advance directives: factors associated with psychiatrists' decisions to preempt patients' advance refusal of hospitalization and medication.
abstract: Psychiatric advance directives (PADs) are intended to support patients' treatment decisions during a crisis. However, PAD statutes give clinicians broad discretion over whether to carry out patients' advance instructions. This study uses data from a survey of psychiatrists (N=164) to examine reasons for overriding PADs. In response to a hypothetical vignette, 47% of psychiatrists indicated that they would override a valid, competently-executed PAD that refused hospitalization and medication. PAD override was more likely among psychiatrists who worked in hospital emergency departments; those who were concerned about patients' violence risk and lack of insight; and those who were legally defensive. PAD override was less likely among participants who believed that involuntary treatment is largely unnecessary in a high-quality mental health system.
authors.affiliation: Services Effectiveness Research Program, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3071, Durham, North Carolina 27710, USA. jeffrey.swanson@duke.edu
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Swanson
authors.forename: S
authors.initials: S
authors.lastname: Van McCrary
authors.forename: Marvin S
authors.initials: MS
authors.lastname: Swartz
authors.forename: Richard A
authors.initials: RA
authors.lastname: Van Dorn
authors.forename: Eric B
authors.initials: EB
authors.lastname: Elbogen
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000331:legislation & jurisprudence*; D000368:Aged; D000369:Aged, 80 and over; D003419:Crisis Intervention / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D003657:Decision Making; D004358:Drug Therapy / Q000706:statistics & numerical data; D005260:Female; D019538:Health Care Surveys; D006760:Hospitalization; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000188:drug therapy / Q000453:epidemiology / Q000534:rehabilitation; D008605:Mental Health Services / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D008875:Middle Aged; D010817:Physician-Patient Relations; D017009:Professional Autonomy; D011570:Psychiatry / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D016312:Treatment Refusal; D014481:United States