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ADVANCE DIRECTIVES

An 'Advance Directive' is a document that enables someone with a diagnosis of mental illness to keep control of their lives when turmoil sets in for whatever reason.

An Advance Directive can be either a legal document (as in Scotland, for example), or an informal document. At the present time there is no state or territory in Australia that has legally binding Advance Directive legislation. Despite this, some people still choose to make informal Advance Directives. Sometimes they say that both the process of putting together such a document and sharing it with treating professionals is as important as the end result.

In the new Victorian Mental Health Act, due to enter into law in 2013, clinicians in public services working with people being held under the Act will be required to take into account the 'Advance Statements' of patients. This is a step forward, though there are flaws in the drafting of this legislation from a consumer perspective. 'Advance Statements' are weaker than 'Advance Directives'. Consumers are lobbying for the introduction of Equal Opportunities legislation which will make Advance Directives legally binding for all people with mental illness.

Some clinicians see Advance Directives as 'Ulysses Agreements'. This is derived from the myth of Ulysses who, so scared of being attracted to the evil sirens on the banks of the river, got his men to tie him to the mast of his ship to stop him doing something foolish and perhaps deadly. Clinicians who use this analogy are usually thinking of people agreeing to forced treatment in advance (conceptualised as 'when they are well') to ensure they don't do anything to harm themselves or their reputation when they are 'sick'.

Other clinicians, and some people diagnosed with mental illness, conceive of Advance Directives as a therapeutic tool. Neither Ulysses Agreements nor 'Advance Directives as Therapy' are used regularly in Australia.

Advance Directives are NOT treatment plans, though they can be about treatment, outlining in advance what works for us and what does not - what we are allergic to, which treatments do more harm than good, what is likely to make us dissociate, who we do and do not want to visit us, etc.

Advance Directives are written, owned and controlled by the person diagnosed with the mental illness. Clinicians, spouses, lovers, family, friends and possibly co-workers may be asked to read and sign off on the document.

Treatment plans, on the other hand, are, in practice, conceived and written by clinicians and signed off by the person with the diagnosis of mental illness - often to keep the peace.


Hints for writing an Advance Directive

For instructional advance directives (i.e. those related to treatment) to be useful they have to be:

  1. Practical: something that clinicians will read and can do something about;
  2. Specific: i.e. they should name the medication, state the exact problem and your response to it (show you have clearly thought through this document);
  3. Contextually sensible: don't hand a huge document to emergency department staff because they won't read it - perhaps an authoritative letter from your psychiatrist might work better in this situation;
  4. Not too angry and demanding: it will be resented and no one will refer to it other than to perhaps give you another diagnosis;
  5. Instructive: if you can think of the easiest ways your needs can be met, suggest these and make it clear that you're trying to help not hinder;
  6. Clear and concise: Look at it through the eyes of the reading clinician where possible. What do they want to know?
  7. Kept up to date: An out-of-date Advance Directive not only can bring you trouble, it also increases the cynicism amongst treating staff about the worth of these documents. Work out where up-to-date copies are to be kept, who can distribute them and to whom.
  8. Signed off by as many people as possible with whom you want to be involved;
  9. Signed off by a psychiatrist to say you are of 'sound mind' when you put it together (this is helpful but not always possible);
  10. Distributed to everyone who is included in the document: psychiatrist, GP, pharmacist, primary carer, special friends, family, counsellor, clinical psychologist, boss (if it's a Workplace Advance Directive), work colleagues.

Narrative or legal

Different people will prefer different approaches to documentation. As there is no enforcement in legislation yet there is no right or wrong way to present an advance directive, but it is sensible to think about the consequences of each approach.

A narrative style may be best suited where you, in partnership with your clinician, wish to use the document as a therapeutic tool as well as an instructive one.

However, they can put people off because they can require a lot of reading. This style may also lead you to divulge more personal information than you intended, putting your privacy at risk.

Many people prefer something that looks as authoritative as possible and will therefore opt for a legal style advance directive. Organisations such as the community legal centres and friends or relatives who are trained in the law can help advise you how to write something in this manner.

However, there are things to be considered here too. Firstly, it is easy to forget that these documents are only quasi-legal documents. They have NO legal authority. It's important not to have expectations that can't be realised.

Secondly, there can be animosity between some lawyers and some psychiatrists over these documents, both because these professions are naturally competitive (dare we suggest), but more importantly because they sometimes have very different charters in relation to mental health issues. It is possible that some psychiatrists might see lawyers as manipulating your ideas if your document looks like it has been drafted by a lawyer.


Content

We sometimes talk of a 'four-in-one Advance Directive'. This just means there are, in effect, four Advance Directives which can (but certainly don't have to) be used together or separately:

  1. The first might include our own early warning signs of trouble ahead, and what we want ourselves to remember to do. Hint: this is the personal part of the advance directive and you may choose not to show it to anyone. Also, experience has taught some of us not to put it first because clinicians are more comfortable telling us what we should do rather reading what we would like them to do. Conceptually it is first; for practical reasons, you may want to put it last.
  2. Instructions for psychiatrists and clinical psychologists about want you would like them to do if things go pear-shaped. This section should also include information for clinicians in services, as well as emergency clinicians.
  3. Instructions for what you need from your friends and family.
  4. Instructions for your work, detailing what they need to do (and not do) if things get out of hand or you need help.

These can be mixed and matched. We do not have to give all four Advance Directives to anyone and we should try and resist attempts by anyone to turn these documents into tools for therapy alone. If this is done they will lose their integrity as an instructional tool.