Astrid Gieselmann & Professor Jochen Vollmann, Ruhr Universität Bochum
How should advance directives be implemented in psychiatry? Clinicians’ attitudes toward different types of advance directives in psychiatric treatment in Germany.
Advance directives are designed to specify a person’s preferences for treatment in case one becomes
incompetent to make treatment decisions in the future. In most western countries, they are seen as a
useful tool to promote patient autonomy with regard to end-of-life medical decisions and dementia.
Advance directives, however, may also be useful for individuals with mental disorders such as bipolar
disorder, schizophrenia, or depression: Writing such an advance directive allows someone with a
mental disorder to express his treatment preferences, while in a competent state of mind, regarding
decisions that must be made when his capacity for decision-making is impaired, which enables
patients to stay in control in a crisis. Furthermore, other additional advantages related to psychiatric
treatment have been discussed, such as enhanced therapeutic relationships, improved compliance with
treatment, reduction of coercive treatment in psychiatry, and decreased perceived coercion.
Although the benefits of the use of advance directives in psychiatry are widely acknowledged, and
German law authorizes their use, the application of advance directives in German psychiatric practice
remains low. This surprising fact raises several questions. First, which barriers prevent the further
implementation of advance directives in psychiatric treatment? Second, because endorsement by
psychiatrists is an important precondition for their successful implementation, what do clinicians think
about the use of advance directives?
This presentation will address these questions by reporting the preliminary findings of a survey of 396
German psychiatrists on their experiences and attitudes toward different types of advance directives,
including psychiatric advance directives, which are written by patients without any specific assistance,
and joint crisis plans (“Behandlungsvereinbarungen”), where involvement of the clinical team is
required. The presentation will describe perceptions of potential barriers to the implementation of
advance directives and the finding that clinicians’ attitudes differ largely according to the type of
advance directive. Ethical and practical questions regarding these different types of advance directives
will also be discussed, along with the relevance of these questions for increasing the use of advance
directives in psychiatry.