potential legal liability in such cases, may be reluctant
to support PADs or to encourage patients to complete
them. Although understandable, this reaction would
beg the question of whether any substantial number of
patients actually use PADs to document advance
refusals of all medication; new research suggests that
this may be a moot concern.
The presumption of competence to execute PADs is
another controversial legal feature of these statutes. On
the one hand, some mental health professionals would
argue that a clinical assessment of competence should
be required for patients who want to complete PADs,
in view of the fluctuating decisional capacity that often
characterizes severe mental illness. On the other hand,
some scholars have noted that mandatory screening
for competence—placing the burden on people with
mental illness to prove that they are competent before
completing a legal document—would amount to dis-
crimination against adults with disabilities.
Currently, only two jurisdictions, Indiana and
Louisiana, require that persons with mental illness be
deemed competent before they write a valid PAD.
However, in states where this is not required, there
could still be practical reasons for patients to voluntar-
ily request a clinical assessment of their competence
prior to completing a PAD. Even people who do not
have mental illnesses may elect to have a competence
assessment at the time they prepare a legal document
such as a will—precisely to avoid the problem of later
challenges to testamentary capacity and thus ensure
that their wishes are followed. With respect to imple-
menting PADs, the practical question is, How can
people with severe mental illness best ensure that
future clinicians will abide by their preferences as
documented in advance, without unduly questioning
their competence to make those advance decisions
and thus calling into doubt the PAD’s legal validity?Current Research and Trends
While a number of legal and ethical questions about
PADs remain unanswered, a body of empirical
research on PADs has begun to emerge. Studies indi-
cate that although approximately 70% of patients
with mental illness would want a PAD if offered
assistance in completing one, less than 10% have
actually completed a PAD. Why is there a gap
between interest in and completion of PADs? First,
people with mental illness report difficulty in under-
standing advance directives, skepticism about theirbenefit, and lack of contact with a trusted individual
who could serve as proxy decision maker. The sheer
complexity of filling out these legal forms, obtaining
witnesses, having the documents notarized, and filing
the documents in a medical record or registry may
pose a formidable barrier.
Recent surveys of mental health professionals’ atti-
tudes about PADs suggest that they are generally sup-
portive of these legal instruments but have significant
concerns about some features of PADs and the feasi-
bility of implementing them in usual care settings.
Clinicians are concerned, for example, about follow-
ing PADs that may contain treatment refusals or med-
ically inappropriate instructions. They also worry
about lack of access to PAD documents in a crisis,
lack of staff training on PADs, lack of communication
between staff across different components of mental
health systems, and lack of time to review the advance
directive documents.
For these reasons, among others, PADs have yet to
gain widespread use in systems of care for people
with severe mental illness. The research indicates,
however, that as more people learn about these laws,
PADs will be used more frequently. For instance,
whereas most of the psychiatrists, social workers, and
psychologists surveyed believed that PADs would
help people with severe mental illnesses, clinicians
with more legal knowledge about PADs were more
likely to endorse PADs as a beneficial part of patients’
treatment planning. Additionally, research indicates
that PADs typically contain clinically useful informa-
tion and almost never include medically inappropriate
information. Swanson and colleagues analyzed the
content of more than 100 PAD documents and found
that psychiatrists rated the advance directives to be
highly consistent with standards of community prac-
tice. Most participants used the advance directive to
refuse some medications but provided clear reasons
for their choices; none used an advance directive to
refuse all treatment. Instead, most people who com-
pleted PADs used these documents to request that
inpatient staff treat them with respect and talk with
them about their treatment. More than one third listed
specific medical conditions and/or medication side
effects that would directly lead to more informed clin-
ical decision making by doctors in emergency depart-
ments and inpatient settings.
Finally, new evidence is emerging from a large-
scale randomized clinical trial of N=469 individuals
with mental illness, suggesting that a manualized636 ———Psychiatric Advance DirectivesP-Cutler (Encyc)-45463.qxd 11/18/2007 12:43 PM Page 636