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Psychiatric Advance Directives in India: What will the future hold?
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Psychiatric Advance Directives in India: What will the future hold? Ashutosh Ratnam a,*, Abhijit Rudra b, K. Chatterjee a, R.C. Das a a b
Department of Psychiatry, Armed Forces Medical College, Pune 411040, Maharashtra, India Department of Forensic Medicine and Toxicology, Armed Forces Medical College, Pune 411040, Maharashtra, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 April 2015 Received in revised form 14 June 2015 Accepted 20 June 2015 Available online xxx
Psychiatric Advance Directives (PADs) have been incorporated into India’s Mental Health Care Bill, 2013. This is the first time any form of Advance Directive stands to receive legal sanction in India. PADs have numerous theoretical and empirically tenable therapeutic and financial advantages. Western experiences have shown high acceptance for the concept among psychiatric patients, and illustrated that most stable patients with severe mental illness retain the capacity to frame PADs consistent with community practice standards. However active psychopathology does impair this capacity, and therein, current subjective assessments of competence performed by Physicians without objective instruments are often inaccurate. Though PADs champion patient autonomy, when applied and studied, they have shown little significant advantage—there is currently not enough data to support evidence-based universal recommendations for PADs. PADs as incorporated into the Mental Health Care Bill model on existing Western statutes, and though many of the strengths of earlier systems have been subsumed, so have several of the shortcomings. The risks, benefits and applicability of PADs in India are complicated by the social re-calibration of patient autonomy, mental-healthcare delivery system weaknesses, and the relatively peripheral role the Psychiatrist is mandated to play in the entire advance directive process. Treating patients within the framework of their pre-stated wishes will be a much more intricate and arduous task than most of modern Psychiatric practice in India, but the difficulties, obstacles and inevitable failures encountered will provide evidence of the delivery system’s weaknesses and thereby contribute to its strength. ß 2015 Elsevier B.V. All rights reserved.
Keywords: Mental Health Care Bill Psychiatric Advance Directives
1. Introduction Advance Directives have been incorporated into the Mental Health Bill 2013 (MHB2013) introduced into the Indian Parliament on 19 Aug 2013 (New Mental Health Bill Decriminalises Suicide, 2013). This is the first time in India’s history that any form of advance directive verges on receiving legal sanction. Psychiatry has both been accorded the prerogative and entrusted the responsibility of ushering the concept of advance directives into the Indian medical landscape. The results delivered are certain to change the nature of medical care in the country. Advance directives derive from the bio-ethical principle of autonomy—that every person has the right to decide what is to be done to his body or mind during the course of medical treatment. Though numerous definitions have been put forward, the advance directive is, in spirit, a decision whose autonomy transcends time,
* Corresponding author at: Department of Psychiatry Armed Forces Medical College (AFMC), Sholapur Road, Pune 411040, Maharashtra, India. Tel.: +91 8412846332. E-mail address: [email protected] (A. Ratnam).
circumstance and (supposed) better judgement. In Psychiatry, it becomes a legal instrument an individual deemed to be of sound mind (and therefore legally competent to decide), can use to specify his preferences and instructions regarding future mental health treatment. It is invoked anticipating that in the future he/ she may either lose. (a) the capacity to give/withhold informed consent for the necessary best standard treatment, or, (b) the ability to decide in his/her own best interests (Appelbaum, 2004). PADs may be grouped into (Winick, 1996): (a) Instructional directives containing a patient’s instructions specifying what to do in a mental health crisis should he/she lose competence and be left unable to communicate his/her wishes. (b) Proxy directives in which a patient designates a legally empowered proxy who will make mental healthcare decisions on his/her behalf should he/she lose competence.
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(c) Hybrid directives which use features of both of the above i.e. an instructional advance directive is put in place, and a proxy is then conferred decision making authority on the timing and circumstances of its enforcement when the patient loses competence. This is the form of PADs incorporated into the MHB2013. 2. History The need for PADs was contemplated in the backdrop of poor opinion of legally mandated psychiatric treatment in the West. Ironically, the man with perhaps the poorest opinion of all, Thomas Szaz was one of the first to conceive and advocate the concept. He proposed the mechanism of a ‘psychiatric will’, both ‘‘prohibiting (a person’s) confinement in a mental hospital or his/her involuntary treatment for mental illness’’ and condoning ‘‘the use of involuntary psychiatric interventions’’ by those who felt such a need (Szasz, 1982). The defining legislation for the PAD was the Patient SelfDetermination Act of 1990 in USA—a new set of federal requirements were introduced at all American healthcare facilities according patients the right to accept/refuse treatment and to formulate legally-binding advance directives regarding treatment (Hoge, 1994; Swisher, 1991). The law could ‘‘be used to establish an advance directive for mental health care, to be used in the event the person becomes incapacitated, and/or to appoint an agent for mental health care’’. Consequently, in 1991 for the first time in US history, a New York court recognized the non-statutory version of a psychiatric will—a lady named Rosa M who had been involuntarily hospitalized since 1990 recently withdrew consent for ECT in an advance directive. Days later, her supervising psychiatrists approached the judiciary for permission to overrule her refusal, stating the seriousness of her mental illness merited the procedure. In rejecting their opinion, despite noting that Rosa did at the time not have the capacity to make a reasoned treatment decision, the court held that ‘‘that the right to determine what will be done to one’s own body extended equally to the mentally ill’’. It further added that because nothing suggested that ‘‘at the time she withdrew consent, (she) did not have the capacity to knowingly discontinue ECT’’ that her ‘‘informed refusal. . .must be honoured, even if the patient becomes incompetent’’ (Matter of Rosa M., 155 Misc. 2d 103 NY Sup Ct, 1991). Twenty-six American states have since adopted laws specifically defining and authorising PADs. In all others, patients may use general statutes regarding medical advance directives to address their mental healthcare wishes (American Psychiatric Association, 2009). Almost unnoticed, several other countries have also put the concept into practice—Norway, for example has enforced a Law of Psychiatric Health Protection since the 1970s. One of its clauses allows persons (if they wish) to commit themselves to an irreversible admission to a psychiatric hospital, from which they are not allowed to leave for up to 03 weeks, nullifying later declarations for discharge (Atkinson, 2007). 3. Theoretical advantages The state of Psychiatric practice has been described as a choice between coercion and neglect—tragically this seems at least in part to hold true, considering how non-compliance fuelled by poor patient insight is perhaps the highest and most commonly encountered clinical hurdle. Conceptually, PADs should remedy this situation in several ways 3.1. Reducing the element of coercion The damage the sense of humiliation coercive treatment causes cannot be overstated. The numerous anti-therapeutic feelings like
apathy, distrust, submissiveness, dehumanisation and frustration that coercion induces affect the patient’s willingness to continue with a therapeutic alliance in particular and the therapeutic process in general (impacting treatment continuity and overall outcome, respectively) (Gallagher, 1998). Psychiatric patients usually have little opposition to the treatment process itself—it is the depersonalising and disempowering involuntary detentions that most are averse to (Topp and Leslie, 2009). Advance directives provide patients with a sense of informed consent and participation, giving them a ‘voice’ and offering treatment options of a noncoercive nature (Hoge et al., 1998). The treatment process then shows itself to offer more than the sad choice between either repeated institutionalisation or fragmented, subpar treatment. 3.2. Direct therapeutic gains When applied and studied, PADs show strong associations with increased compliance, preventive care facilitation and improved clinician interactions (Winick, 1996). Empowering patients to take treatment decisions enhances self-esteem, which has direct implications on their willingness to adhere to long-term treatment plans. Such patients are likelier to achieve eventual successful outcomes (Winick, 1996). Well thought-out therapeutic directives also facilitate the prior earmarking of resources for better crisis management, and efficient mobilisation when invoked. 3.3. Financial benefits Mental healthcare is plagued by the ‘revolving door syndrome’—a pattern of repeated involuntary hospitalisation, subsequent postdischarge noncompliance and an ensuing decompensation experienced by large numbers of patients (Gallagher, 1998). The same patients are likely to be forcibly hospitalised over and over again with little therapeutic gain, explaining the burgeoning costs of psychiatric care (Keogh et al., 1999). Indian studies describe psychiatric patient re-admission rates of 21–27% (Fernandez et al., 1987; Singh et al., 2014). Coercive sentiments lead to poor response and adherence to treatment, and prolonged inpatient occupancy deprives other patients of the opportunity for care in an overwhelmed mental healthcare system. Instead, when patients are actively involved in their care, an economic valuation of such joint crisis plans found a 78% probability of cost-effectiveness in preventing re-admissions compared to current service information initiatives (Flood et al., 2006). 4. PADs in the mental health bill, 2013 The intent to protect patient autonomy using advance directives, evident in the letter of the MHB2013, is obvious. The text reads that every person shall have the right to make an advance directive in writing, specifying ‘‘the way the person wishes to be cared for and treated’’ or ‘‘not to be cared for and treated’’ for a mental illness. The person can also specify ‘‘the individual or individuals in order of preference he wants to appoint as his nominated representative’’ regarding treatment decisions. A patient is conferred this right to make an advance directive ‘‘irrespective of his past mental illness or treatment’’, and the advance directive is to be invoked ‘‘only when a person ceases to have the capacity to make mental healthcare or treatment decisions and shall remain effective until such a person regains capacity to make mental healthcare or treatment decisions’’. An advance directive is to be attested by two witnesses and should either be registered with the Board in the district, or be ‘‘signed by a medical practitioner certifying that the person has the capacity to make mental health care and treatment decisions at the time of making the advance directive’’. Furthermore, the advance
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directive may be ‘‘revoked, amended or cancelled by the person who made it at any time’’. A treating medical officer or psychiatrist is duty bound to ‘‘propose or give treatment to a person with mental illness, in accordance with his valid advance directive’’. The bill also states that a mental health professional, a relative or a care-giver of the patient who desires not to follow the advance directive during treatment ‘‘may make an application to the concerned Board to review, alter, modify or cancel the advance directive’’. Finally, the bill also demarcates competence, stated that a person ‘‘is deemed to have capacity to make decisions regarding his mental health-care or treatment’’ if such a person can (a) understand the information relevant to the mental healthcare or treatment decision; (b) retain that information; (c) use or weight that information as part of the process of making the mental healthcare or treatment decision; and (d) communicate this decision by any means’’ (Govt of India, 2013). 5. General past experiences No Indian precedent of an advance directive exists, so inferences have to be drawn based upon experiences gained elsewhere. We can then only make educated guesses about likely outcomes, considering variables the Indian setting introduces. 5.1. Patient acceptance Robust evidence shows that one-half to two-thirds of people with severe mental illness would complete a Psychiatric Advance Directive if offered the choice and provided necessary assistance (Srebnik et al., 2003; Swanson et al., 2003). However very little of this genuine desire results in the actual execution of advance directives—only 4–13% of OPD patients receiving public sector psychiatric treatment in 05 American states surveyed had executed a PAD (Swanson et al., 2006a,b). 5.2. Implementation problems Analysis of this wide gap between the desire to and actual execution of a PAD (<13%) shows that certain unique obstacles hinder PAD completion. Serious mental illness leaves patients unable to maintain social contact with trusted individuals who could serve as proxies. Filling legal forms, arranging witnesses, and getting documents notarized and filed in medical records or registries become tasks of intimidating and overwhelming cognitive complexity (Swanson et al., 2003). When elderly patients preparing advance directives were provided semi-structured manual interviews and guided discussions about anticipatory health planning, combined with provisions for legal aid, they achieved a 100% increase in completion rates compared to when no such assistance was provided (High, 1993). It is reasonable to hypothesise that identical assistance would optimise PAD execution rates among the mentally ill. A group provided such facilitated guidance, education and aid was compared with a control group provided only educative literature on PADs—advance directive completion rates of the two groups were 61% and 3%, respectively. Furthermore, all PADs completed by intervention group participants matched community practice standards and included feasible action plans for crisis hospitalisation (Swanson et al., 2006a,b). 5.3. Patient competence/capacity to frame a PAD Evaluating existing PAD statutes shows that prevailing assessment criteria are universally marred by poor objectivity—e.g. various American states currently use standards like being ‘‘competent’’, ‘‘of sound mind’’, having ‘‘capacity’’ or being ‘‘not incapacitated,’’ capacity then defined as the ability to ‘‘provide
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informed consent’’ (Srebnik and Kim, 2006). One of the closest objective dissections of decision-making capacity described an amalgamation of the functional abilities to: (a) express a choice, (b) understand the facts of the decision-making situation, (c) appreciate and apply the significance of the information for one’s own situation, (d) reason and engage in a logical process of weighing options (Appelbaum and Grisso, 1995).
Compromised decision-making is a core deficit in florid mental illness. Using the above criteria, 50% of patients admitted with symptomatic Schizophrenia or bipolar disorder had impairment in at least one element of competence, as did 20–25% of those with severe depression (Appelbaum, 2007). The central question becomes whether seriously ill psychiatric patients are ever left with enough competence to frame a PAD of acceptable technical validity. Field data indicates an emphatic affirmative. 80 patients with severe mental illness left significantly impaired in major areas of functioning (average GAF score 30 9.1) showed median scores approaching maximum possible measures on understanding, appreciation, and reasoning scales, demonstrating adequate decision-making capacity (Srebnik et al., 2004). 82% patients with serious mental illness correctly understood the key concepts of PADs (Backlar et al., 2001). Schizophrenia patients in assisted-living setups showed diminished understanding compared to controls, but normal appreciation and reasoning (Palmer et al., 2004). Objective competence evaluations negate how subjectivity can err on either side. On the one hand, the mere assignment of diagnostic categories like dementia or psychosis may be confused with a determination of incapacity (Marson et al., 1997), and on the other hand, the practical rule of thumb ensures that in absence of reasons to question a patient’s decision-making, presumed competence will prematurely prevail (Srebnik and Kim, 2006). 5.4. Competence assessment by physicians There is proven merit in providing physicians with objective tools to gauge capacity (Etchells et al., 1999; Marson et al., 1997). These need not be Likart-Scales with cut-offs. Merely providing standards to guide judgement with (such as in the provided Table 1) remarkably improve accuracy. Five physicians were made to review videotapes of patients, assess capacity and rate patient competence—their agreement rates were no better than chance (K = 0.14). When provided a similar table of standards to apply, their inter-rater agreement showed a four-fold increment (K = 0.46) (Marson et al., 1997). Physicians are frequently unaware of patients’ decision-making incapacity, and when incapacity is suspected, the standard to apply is often unclear. Such certifications of competence may disastrously have omitted use of relevant criteria (McKinnon et al., 1989). Though the letter of the MHB2013 does not contain any such objective assessment tool, its planned guidance document for capacity assessment is hopefully that instrument. 5.5. Evidence-based recommendations The Cochrane Library published an exhaustive review of PADs but the ambiguity of results achieved was unfortunate. When considered as a broad group across qualifying studies, patients formulating PADs showed no statistically significant advantages regarding overall admissions, involuntary readmissions, durations of involuntary admissions, OPD attendance, treatment compliance, self-harm or incarceration frequency. Cochrane’s recommendation
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Table 1 Legally relevant criteria for decision-making capacity and approaches to assessment of the patient. Criterion
Patient’s task
Physician’s assessment approach
Questions for clinical assessment
Comments
Communicate a choice
Clearly indicate a preferred treatment option
Ask patient to indicate a treatment choice
Frequent reversals of choice because of psychiatric or neurological conditions may indicate lack of capacity
Understand the Relevant Information
Grasp the fundamental meaning of information communicated by physician
Encourage patient to paraphrase disclosed information regarding medical condition and treatment
Appreciate the Situation and its consequences
Acknowledge medical condition and likely consequences of treatment options
Ask patient to describe views of medical condition, proposed treatment, and likely outcomes
Reason about treatment options
Engage in a rational process of manipulating the information
Ask patient to compare treatment options and consequences and to offer reasons for selection of option
Have you decided whether to follow your doctor’s [or my] recommendation for treatment? Can you tell me what that decision is? [If no decision] What is making it hard for you to decide? Please tell me in your own words what your doctor [or I] told you about: The problem with your health now The recommended treatment The possible benefits and risks (or discomforts) of the treatment Any alternative treatments and their risks and benefits The risks and benefits of no treatment What do you believe is wrong with your health now? Do you believe that you need some kind of treatment? What is treatment likely to do for you? What will make you believe it will have that effect? What do you believe will happen if you are not treated? Why do you think your doctor has [or I have] recommended this treatment? How did you decide to accept or reject the recommended treatment? What makes [chosen option] better than [alternative option]?
Information to be understood includes nature of patient’s condition, nature and purpose of proposed treatment, possible benefits and risks of that treatment, and alternative approaches (including no treatment) and their benefits and risks Courts have recognised that patients who do not acknowledge their illnesses (often referred to as ‘‘lack of insight’’) cannot make valid decisions about treatment Delusions or pathological levels of distortion or denial are the most common causes of impairment
This criterion focuses on the process by which a decision is reached, not the outcome of the patient’s choice, since patients have the right to make ‘‘unreasonable choices’’
Taken from Appelbaum (2007) (Appelbaum, P.S., 2007. Assessment of patients’ competence to consent to treatment. N. Engl. J. Med., 357(18), 1834–1840. doi:http:// doi.org/10.1056/NEJMcp074045.
for patients was that it was at the time, ‘‘not possible to recommend advance treatment directives for people with severe mental illness due to the lack of supporting data’’. The review however made grounds for some optimism. Foremost, one of the RCTs taken for review had less admissions in the PAD arm (24 vs 35, p > 0.05), numerically alone considered ‘‘encouraging of the need of further trials’’. Secondly, the confidence with which recommendations could be offered was tempered by the paucity of data available (from potentially 485 relevant papers, only 02 met review criteria, forming a study group of only 321 patients). The recommendation for clinicians hinted of guarded optimism— results ‘‘suggest that more intensive interventions, such as joint crisis planning, may be of benefit in terms of reduction of involuntary readmissions or assessments under the Mental Health Act’’ (Campbell and Kisely, 2009).
6. Nuances in application to the Indian scenario The PAD is a legal attempt to put the final say regarding treatment in the hands of the patient concerned, regardless of the opinions of those around him/her. The dangers, benefits and the degree of success with which PADs will be allowed to achieve this declared goal change in the Indian context (Avasthi, 2010). Risking generalisation, the proxy decision-making authority caretakers exercise in the Indian social setup does deprive persons with disabilities/handicaps of autonomy. But this same setup curiously provides these disempowered persons protection they desperately require, considering the depravity they may otherwise fall prey to (Chandra et al., 2003). By according precedence to and then enforcing the authority of an advance directive which goes against
the better judgement of family/support group members, the patient’s long-term support system stands jeopardised. The PAD’s success requires a streamlined, integrated and dynamic mental-healthcare delivery system which sadly does not exist (Khandelwal et al., 2004)—e.g. the process of overruling an advance directive requires an appeal to be submitted to a board, the board to then review the appeal and then convey a decision. All the while, the patient stays in the state which was serious enough to merit a psychiatrist’s refusal to comply with instructions for/ against treatment. Psychiatrists are not mandated to play any role in the conceptualisation and thereby in the assessment of feasibility of a PAD. Any medical officer regardless of psychiatric experience can certify competence to frame the document, also overlooking how the presence of the psychiatrist during PAD formulation reduces anxiety during future crises (Srebnik et al., 2003). The first place a psychiatrist’s decision-making is invoked is during revocation of a PAD. The next psychiatrist is involved in the review process, as part of the review board, likely assessing whether the patient’s competence was suspect to begin with. Thus a situation is created where the opinions of two psychiatrists regarding a patient’s competence (itself a nebulous entity) are pitted against each other, and by virtue of being on the review board, one begins with considerable leverage. 7. Conclusion Even in countries where PADs are already in force, clinicians consistently report uneasiness about ensuing legal liability, resource/logistics shortfalls and interference with clinical aspects of care (Shields et al., 2014)—treating psychiatric patients within the framework of their pre-stated wishes is clearly a much more
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intricate and arduous task than doing so in India’s prevailing ‘doctor-patient hierarchy’ zeitgeist (Kala, 2013; Pathare et al., 2015). Accepting this challenge is an opportunity for Psychiatry to counter allegations of autocracy and impunity its most vocal critics level. Apprehension regarding PADs in India stems largely from a sense of unpreparedness. Template evaluations testing the merit in this diffidence have already begun—75 patients in Tamil Nadu undertook a (facilitated) filling-up of model PADs. The results provide grounds for optimism—none refused any form of treatment outright, and 93% wanted to be taken to a hospital in case of a relapse/decisional incapacity. The majority (n = 37) did not even demand any particular choice of medication and expressed confidence in their doctor’s advice. Predictably, ECT use remained a contentious area–a slender majority of patients (39 v/s 30) were unwilling to consider it at all (Pathare et al., 2015). A second study evaluated 92 completed model PADs of patients at SCARF, Chennai (Kumar et al., 2013). Yet again, all patients wanted to continue treatment. Furthermore, none demanded exorbitant/ esoteric treatment, in fact 53% declared the clinic where they were already receiving treatment as their centre of choice for future crises. Most wanted to be treated as outpatients and with oral medication (39%), but a sizable number agreed they might need inpatient treatment and injectibles if deemed necessary by their doctor (31.5%). Difficulties, obstacles and failures will inevitably be encountered on introducing PADs into a setting with underpowered infrastructure and safeguards, but the concept’s cardinal, indubitable merit remains that it espouses the autonomy of patients ravaged by both their diseases and their disenfranchisement. References American Psychiatric Association, 2009. Resource Document on Psychiatric Advance Directives Retrieved from hhttp://www.psychiatry.org/file%20library/ learn/archives/rd2009_advancedirectives.pdfi Appelbaum, P.S., 2004. Law & psychiatry: psychiatric advance directives and the treatment of committed patients. Psychiatr. Serv. 55 (7), 751–763, DOI http:// doi.org/10.1176/appi.ps.55.7.751. Appelbaum, P.S., 2007. Assessment of patients’ competence to consent to treatment. N. Engl. J. Med. 357 (18), 1834–1840, DOI http://doi.org/10.1056/ NEJMcp074045. Appelbaum, P.S., Grisso, T., 1995. The MacArthur treatment competence study I: mental illness and competence to consent to treatment. Law Hum. Behav. 19 (2), 105–126. Atkinson, J.M., 2007. Advance directives in mental health: theory. In: Practice and EthicsJessica Kingsley Publishers, London. Avasthi, A., 2010. Preserve and strengthen family to promote mental health. Indian J. Psychiatry 52 (2), 113–126, DOI http://doi.org/10.4103/0019-5545.64582. Backlar, P., McFarland, B.H., Swanson, J.W., Mahler, J., 2001. Consumer, provider, and informal caregiver opinions on psychiatric advance directives. Admin. Policy Ment. Health 28 (6), 427–441. Campbell, L.A., Kisely, S.R., 2009. Advance treatment directives for people with severe mental illness. In: The Cochrane Collaboration (Eds.), Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd, Chichester, UK, Retrieved from hhttp://doi.wiley.com/10.1002/14651858.CD005963.pub2i Chandra, P.S., Carey, M.P., Carey, K.B., Shalinianant, A., Thomas, T., 2003. Sexual coercion and abuse among women with a severe mental illness in India: an exploratory investigation. Compr. Psychiatry 44 (3), 205–212, DOI http:// doi.org/10.1016/S0010-440X(03)00004-X. Etchells, E., Darzins, P., Silberfeld, M., Singer, P.A., McKenny, J., Naglie, G., Strang, D., 1999. Assessment of patient capacity to consent to treatment. J. Gen. Intern. Med. 14 (1), 27–34, DOI http://doi.org/10.1046/j.1525-1497.1999.00277.x. Fernandez, A., Chaturvedi, S.K., Beig, A., Gopinath, P.S., 1987. Readmission of psychiatric patients in a psychiatric hospital. Indian J. Psychiatry 29 (1), 85–88. Flood, C., Byford, S., Henderson, C., Leese, M., Thornicroft, G., Sutherby, K., Szmukler, G., 2006. Joint crisis plans for people with psychosis: economic evaluation of a randomised controlled trial. BMJ (Clin. Res. Ed.) 333 (7571), 729, DOI http:// doi.org/10.1136/bmj.38929.653704.55. Gallagher, E.M., 1998. Advance directives for psychiatric care: a theoretical and practical overview for legal professionals. Psychol. Public Policy Law 4 (3),
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Interest in psychiatric advance directives among high users of crisis services and hospitalization. Psychiatr. Serv. (Washington, D.C.) 54 (7), 981–986. Swanson, J., Swartz, M., Ferron, J., Elbogen, E., Van Dorn, R., 2006a. Psychiatric advance directives among public mental health consumers in five U.S. cities: prevalence, demand, and correlates. J. Am. Acad. Psychiatry Law 34 (1), 43–57. Swanson, J.W., Swartz, M.S., Elbogen, E.B., Van Dorn, R.A., Ferron, J., Wagner, H.R., et al., 2006b. Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. Am. J. Psychiatry 163 (11), 1943–1951, DOI http://doi.org/ 10.1176/appi.ajp.163.11.1943. Swanson, J.W., Swartz, M.S., Hannon, M.J., Elbogen, E.B., Wagner, H.R., McCauley, B.J., Butterfield, M.I., 2003. Psychiatric advance directives: a survey of persons with schizophrenia, family members, and treatment providers. Int. J. Forensic Ment. Health 2 (1), 73–86, DOI http://doi.org/10.1080/14999013.2003. 10471180. Swisher, K.N., 1991. Implementing the PSDA for psychiatric patients: a commonsense approach. J. Clin. Ethics 2 (3), 199–205. Szasz, T.S., 1982. The psychiatric will: a new mechanism for protecting persons against ‘‘psychosis’’ and psychiatry. Am. Psychol. 37 (7), 762–770, DOI http:// doi.org/10.1037/0003-066X.37.7.762. Topp, V., Leslie, C., 2009. Defending the right to autonomy and self determination: advance directives for mental health. Health Issues 101, 26–28, Available from hhttp://www.communitylaw.org.au/mhlc/cb_pages/files/HIJ%2 02009%20Advance%20directives_Topp%20%26%20Leslie(1).pdfi Winick, B.J., 1996. Advance directive instruments for those with mental illness. Univ. Miami Law Rev. 51 (1), 57–95.
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Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Psychiatric Advance Directives in India: What will the future hold? Ashutosh Ratnam a,*, Abhijit Rudra b, K. Chatterjee a, R.C. Das a a b
Department of Psychiatry, Armed Forces Medical College, Pune 411040, Maharashtra, India Department of Forensic Medicine and Toxicology, Armed Forces Medical College, Pune 411040, Maharashtra, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 April 2015 Received in revised form 14 June 2015 Accepted 20 June 2015 Available online xxx
Psychiatric Advance Directives (PADs) have been incorporated into India’s Mental Health Care Bill, 2013. This is the first time any form of Advance Directive stands to receive legal sanction in India. PADs have numerous theoretical and empirically tenable therapeutic and financial advantages. Western experiences have shown high acceptance for the concept among psychiatric patients, and illustrated that most stable patients with severe mental illness retain the capacity to frame PADs consistent with community practice standards. However active psychopathology does impair this capacity, and therein, current subjective assessments of competence performed by Physicians without objective instruments are often inaccurate. Though PADs champion patient autonomy, when applied and studied, they have shown little significant advantage—there is currently not enough data to support evidence-based universal recommendations for PADs. PADs as incorporated into the Mental Health Care Bill model on existing Western statutes, and though many of the strengths of earlier systems have been subsumed, so have several of the shortcomings. The risks, benefits and applicability of PADs in India are complicated by the social re-calibration of patient autonomy, mental-healthcare delivery system weaknesses, and the relatively peripheral role the Psychiatrist is mandated to play in the entire advance directive process. Treating patients within the framework of their pre-stated wishes will be a much more intricate and arduous task than most of modern Psychiatric practice in India, but the difficulties, obstacles and inevitable failures encountered will provide evidence of the delivery system’s weaknesses and thereby contribute to its strength. ß 2015 Elsevier B.V. All rights reserved.
Keywords: Mental Health Care Bill Psychiatric Advance Directives
1. Introduction Advance Directives have been incorporated into the Mental Health Bill 2013 (MHB2013) introduced into the Indian Parliament on 19 Aug 2013 (New Mental Health Bill Decriminalises Suicide, 2013). This is the first time in India’s history that any form of advance directive verges on receiving legal sanction. Psychiatry has both been accorded the prerogative and entrusted the responsibility of ushering the concept of advance directives into the Indian medical landscape. The results delivered are certain to change the nature of medical care in the country. Advance directives derive from the bio-ethical principle of autonomy—that every person has the right to decide what is to be done to his body or mind during the course of medical treatment. Though numerous definitions have been put forward, the advance directive is, in spirit, a decision whose autonomy transcends time,
* Corresponding author at: Department of Psychiatry Armed Forces Medical College (AFMC), Sholapur Road, Pune 411040, Maharashtra, India. Tel.: +91 8412846332. E-mail address: [email protected] (A. Ratnam).
circumstance and (supposed) better judgement. In Psychiatry, it becomes a legal instrument an individual deemed to be of sound mind (and therefore legally competent to decide), can use to specify his preferences and instructions regarding future mental health treatment. It is invoked anticipating that in the future he/ she may either lose. (a) the capacity to give/withhold informed consent for the necessary best standard treatment, or, (b) the ability to decide in his/her own best interests (Appelbaum, 2004). PADs may be grouped into (Winick, 1996): (a) Instructional directives containing a patient’s instructions specifying what to do in a mental health crisis should he/she lose competence and be left unable to communicate his/her wishes. (b) Proxy directives in which a patient designates a legally empowered proxy who will make mental healthcare decisions on his/her behalf should he/she lose competence.
http://dx.doi.org/10.1016/j.ajp.2015.06.004 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
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(c) Hybrid directives which use features of both of the above i.e. an instructional advance directive is put in place, and a proxy is then conferred decision making authority on the timing and circumstances of its enforcement when the patient loses competence. This is the form of PADs incorporated into the MHB2013. 2. History The need for PADs was contemplated in the backdrop of poor opinion of legally mandated psychiatric treatment in the West. Ironically, the man with perhaps the poorest opinion of all, Thomas Szaz was one of the first to conceive and advocate the concept. He proposed the mechanism of a ‘psychiatric will’, both ‘‘prohibiting (a person’s) confinement in a mental hospital or his/her involuntary treatment for mental illness’’ and condoning ‘‘the use of involuntary psychiatric interventions’’ by those who felt such a need (Szasz, 1982). The defining legislation for the PAD was the Patient SelfDetermination Act of 1990 in USA—a new set of federal requirements were introduced at all American healthcare facilities according patients the right to accept/refuse treatment and to formulate legally-binding advance directives regarding treatment (Hoge, 1994; Swisher, 1991). The law could ‘‘be used to establish an advance directive for mental health care, to be used in the event the person becomes incapacitated, and/or to appoint an agent for mental health care’’. Consequently, in 1991 for the first time in US history, a New York court recognized the non-statutory version of a psychiatric will—a lady named Rosa M who had been involuntarily hospitalized since 1990 recently withdrew consent for ECT in an advance directive. Days later, her supervising psychiatrists approached the judiciary for permission to overrule her refusal, stating the seriousness of her mental illness merited the procedure. In rejecting their opinion, despite noting that Rosa did at the time not have the capacity to make a reasoned treatment decision, the court held that ‘‘that the right to determine what will be done to one’s own body extended equally to the mentally ill’’. It further added that because nothing suggested that ‘‘at the time she withdrew consent, (she) did not have the capacity to knowingly discontinue ECT’’ that her ‘‘informed refusal. . .must be honoured, even if the patient becomes incompetent’’ (Matter of Rosa M., 155 Misc. 2d 103 NY Sup Ct, 1991). Twenty-six American states have since adopted laws specifically defining and authorising PADs. In all others, patients may use general statutes regarding medical advance directives to address their mental healthcare wishes (American Psychiatric Association, 2009). Almost unnoticed, several other countries have also put the concept into practice—Norway, for example has enforced a Law of Psychiatric Health Protection since the 1970s. One of its clauses allows persons (if they wish) to commit themselves to an irreversible admission to a psychiatric hospital, from which they are not allowed to leave for up to 03 weeks, nullifying later declarations for discharge (Atkinson, 2007). 3. Theoretical advantages The state of Psychiatric practice has been described as a choice between coercion and neglect—tragically this seems at least in part to hold true, considering how non-compliance fuelled by poor patient insight is perhaps the highest and most commonly encountered clinical hurdle. Conceptually, PADs should remedy this situation in several ways 3.1. Reducing the element of coercion The damage the sense of humiliation coercive treatment causes cannot be overstated. The numerous anti-therapeutic feelings like
apathy, distrust, submissiveness, dehumanisation and frustration that coercion induces affect the patient’s willingness to continue with a therapeutic alliance in particular and the therapeutic process in general (impacting treatment continuity and overall outcome, respectively) (Gallagher, 1998). Psychiatric patients usually have little opposition to the treatment process itself—it is the depersonalising and disempowering involuntary detentions that most are averse to (Topp and Leslie, 2009). Advance directives provide patients with a sense of informed consent and participation, giving them a ‘voice’ and offering treatment options of a noncoercive nature (Hoge et al., 1998). The treatment process then shows itself to offer more than the sad choice between either repeated institutionalisation or fragmented, subpar treatment. 3.2. Direct therapeutic gains When applied and studied, PADs show strong associations with increased compliance, preventive care facilitation and improved clinician interactions (Winick, 1996). Empowering patients to take treatment decisions enhances self-esteem, which has direct implications on their willingness to adhere to long-term treatment plans. Such patients are likelier to achieve eventual successful outcomes (Winick, 1996). Well thought-out therapeutic directives also facilitate the prior earmarking of resources for better crisis management, and efficient mobilisation when invoked. 3.3. Financial benefits Mental healthcare is plagued by the ‘revolving door syndrome’—a pattern of repeated involuntary hospitalisation, subsequent postdischarge noncompliance and an ensuing decompensation experienced by large numbers of patients (Gallagher, 1998). The same patients are likely to be forcibly hospitalised over and over again with little therapeutic gain, explaining the burgeoning costs of psychiatric care (Keogh et al., 1999). Indian studies describe psychiatric patient re-admission rates of 21–27% (Fernandez et al., 1987; Singh et al., 2014). Coercive sentiments lead to poor response and adherence to treatment, and prolonged inpatient occupancy deprives other patients of the opportunity for care in an overwhelmed mental healthcare system. Instead, when patients are actively involved in their care, an economic valuation of such joint crisis plans found a 78% probability of cost-effectiveness in preventing re-admissions compared to current service information initiatives (Flood et al., 2006). 4. PADs in the mental health bill, 2013 The intent to protect patient autonomy using advance directives, evident in the letter of the MHB2013, is obvious. The text reads that every person shall have the right to make an advance directive in writing, specifying ‘‘the way the person wishes to be cared for and treated’’ or ‘‘not to be cared for and treated’’ for a mental illness. The person can also specify ‘‘the individual or individuals in order of preference he wants to appoint as his nominated representative’’ regarding treatment decisions. A patient is conferred this right to make an advance directive ‘‘irrespective of his past mental illness or treatment’’, and the advance directive is to be invoked ‘‘only when a person ceases to have the capacity to make mental healthcare or treatment decisions and shall remain effective until such a person regains capacity to make mental healthcare or treatment decisions’’. An advance directive is to be attested by two witnesses and should either be registered with the Board in the district, or be ‘‘signed by a medical practitioner certifying that the person has the capacity to make mental health care and treatment decisions at the time of making the advance directive’’. Furthermore, the advance
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directive may be ‘‘revoked, amended or cancelled by the person who made it at any time’’. A treating medical officer or psychiatrist is duty bound to ‘‘propose or give treatment to a person with mental illness, in accordance with his valid advance directive’’. The bill also states that a mental health professional, a relative or a care-giver of the patient who desires not to follow the advance directive during treatment ‘‘may make an application to the concerned Board to review, alter, modify or cancel the advance directive’’. Finally, the bill also demarcates competence, stated that a person ‘‘is deemed to have capacity to make decisions regarding his mental health-care or treatment’’ if such a person can (a) understand the information relevant to the mental healthcare or treatment decision; (b) retain that information; (c) use or weight that information as part of the process of making the mental healthcare or treatment decision; and (d) communicate this decision by any means’’ (Govt of India, 2013). 5. General past experiences No Indian precedent of an advance directive exists, so inferences have to be drawn based upon experiences gained elsewhere. We can then only make educated guesses about likely outcomes, considering variables the Indian setting introduces. 5.1. Patient acceptance Robust evidence shows that one-half to two-thirds of people with severe mental illness would complete a Psychiatric Advance Directive if offered the choice and provided necessary assistance (Srebnik et al., 2003; Swanson et al., 2003). However very little of this genuine desire results in the actual execution of advance directives—only 4–13% of OPD patients receiving public sector psychiatric treatment in 05 American states surveyed had executed a PAD (Swanson et al., 2006a,b). 5.2. Implementation problems Analysis of this wide gap between the desire to and actual execution of a PAD (<13%) shows that certain unique obstacles hinder PAD completion. Serious mental illness leaves patients unable to maintain social contact with trusted individuals who could serve as proxies. Filling legal forms, arranging witnesses, and getting documents notarized and filed in medical records or registries become tasks of intimidating and overwhelming cognitive complexity (Swanson et al., 2003). When elderly patients preparing advance directives were provided semi-structured manual interviews and guided discussions about anticipatory health planning, combined with provisions for legal aid, they achieved a 100% increase in completion rates compared to when no such assistance was provided (High, 1993). It is reasonable to hypothesise that identical assistance would optimise PAD execution rates among the mentally ill. A group provided such facilitated guidance, education and aid was compared with a control group provided only educative literature on PADs—advance directive completion rates of the two groups were 61% and 3%, respectively. Furthermore, all PADs completed by intervention group participants matched community practice standards and included feasible action plans for crisis hospitalisation (Swanson et al., 2006a,b). 5.3. Patient competence/capacity to frame a PAD Evaluating existing PAD statutes shows that prevailing assessment criteria are universally marred by poor objectivity—e.g. various American states currently use standards like being ‘‘competent’’, ‘‘of sound mind’’, having ‘‘capacity’’ or being ‘‘not incapacitated,’’ capacity then defined as the ability to ‘‘provide
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informed consent’’ (Srebnik and Kim, 2006). One of the closest objective dissections of decision-making capacity described an amalgamation of the functional abilities to: (a) express a choice, (b) understand the facts of the decision-making situation, (c) appreciate and apply the significance of the information for one’s own situation, (d) reason and engage in a logical process of weighing options (Appelbaum and Grisso, 1995).
Compromised decision-making is a core deficit in florid mental illness. Using the above criteria, 50% of patients admitted with symptomatic Schizophrenia or bipolar disorder had impairment in at least one element of competence, as did 20–25% of those with severe depression (Appelbaum, 2007). The central question becomes whether seriously ill psychiatric patients are ever left with enough competence to frame a PAD of acceptable technical validity. Field data indicates an emphatic affirmative. 80 patients with severe mental illness left significantly impaired in major areas of functioning (average GAF score 30 9.1) showed median scores approaching maximum possible measures on understanding, appreciation, and reasoning scales, demonstrating adequate decision-making capacity (Srebnik et al., 2004). 82% patients with serious mental illness correctly understood the key concepts of PADs (Backlar et al., 2001). Schizophrenia patients in assisted-living setups showed diminished understanding compared to controls, but normal appreciation and reasoning (Palmer et al., 2004). Objective competence evaluations negate how subjectivity can err on either side. On the one hand, the mere assignment of diagnostic categories like dementia or psychosis may be confused with a determination of incapacity (Marson et al., 1997), and on the other hand, the practical rule of thumb ensures that in absence of reasons to question a patient’s decision-making, presumed competence will prematurely prevail (Srebnik and Kim, 2006). 5.4. Competence assessment by physicians There is proven merit in providing physicians with objective tools to gauge capacity (Etchells et al., 1999; Marson et al., 1997). These need not be Likart-Scales with cut-offs. Merely providing standards to guide judgement with (such as in the provided Table 1) remarkably improve accuracy. Five physicians were made to review videotapes of patients, assess capacity and rate patient competence—their agreement rates were no better than chance (K = 0.14). When provided a similar table of standards to apply, their inter-rater agreement showed a four-fold increment (K = 0.46) (Marson et al., 1997). Physicians are frequently unaware of patients’ decision-making incapacity, and when incapacity is suspected, the standard to apply is often unclear. Such certifications of competence may disastrously have omitted use of relevant criteria (McKinnon et al., 1989). Though the letter of the MHB2013 does not contain any such objective assessment tool, its planned guidance document for capacity assessment is hopefully that instrument. 5.5. Evidence-based recommendations The Cochrane Library published an exhaustive review of PADs but the ambiguity of results achieved was unfortunate. When considered as a broad group across qualifying studies, patients formulating PADs showed no statistically significant advantages regarding overall admissions, involuntary readmissions, durations of involuntary admissions, OPD attendance, treatment compliance, self-harm or incarceration frequency. Cochrane’s recommendation
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Table 1 Legally relevant criteria for decision-making capacity and approaches to assessment of the patient. Criterion
Patient’s task
Physician’s assessment approach
Questions for clinical assessment
Comments
Communicate a choice
Clearly indicate a preferred treatment option
Ask patient to indicate a treatment choice
Frequent reversals of choice because of psychiatric or neurological conditions may indicate lack of capacity
Understand the Relevant Information
Grasp the fundamental meaning of information communicated by physician
Encourage patient to paraphrase disclosed information regarding medical condition and treatment
Appreciate the Situation and its consequences
Acknowledge medical condition and likely consequences of treatment options
Ask patient to describe views of medical condition, proposed treatment, and likely outcomes
Reason about treatment options
Engage in a rational process of manipulating the information
Ask patient to compare treatment options and consequences and to offer reasons for selection of option
Have you decided whether to follow your doctor’s [or my] recommendation for treatment? Can you tell me what that decision is? [If no decision] What is making it hard for you to decide? Please tell me in your own words what your doctor [or I] told you about: The problem with your health now The recommended treatment The possible benefits and risks (or discomforts) of the treatment Any alternative treatments and their risks and benefits The risks and benefits of no treatment What do you believe is wrong with your health now? Do you believe that you need some kind of treatment? What is treatment likely to do for you? What will make you believe it will have that effect? What do you believe will happen if you are not treated? Why do you think your doctor has [or I have] recommended this treatment? How did you decide to accept or reject the recommended treatment? What makes [chosen option] better than [alternative option]?
Information to be understood includes nature of patient’s condition, nature and purpose of proposed treatment, possible benefits and risks of that treatment, and alternative approaches (including no treatment) and their benefits and risks Courts have recognised that patients who do not acknowledge their illnesses (often referred to as ‘‘lack of insight’’) cannot make valid decisions about treatment Delusions or pathological levels of distortion or denial are the most common causes of impairment
This criterion focuses on the process by which a decision is reached, not the outcome of the patient’s choice, since patients have the right to make ‘‘unreasonable choices’’
Taken from Appelbaum (2007) (Appelbaum, P.S., 2007. Assessment of patients’ competence to consent to treatment. N. Engl. J. Med., 357(18), 1834–1840. doi:http:// doi.org/10.1056/NEJMcp074045.
for patients was that it was at the time, ‘‘not possible to recommend advance treatment directives for people with severe mental illness due to the lack of supporting data’’. The review however made grounds for some optimism. Foremost, one of the RCTs taken for review had less admissions in the PAD arm (24 vs 35, p > 0.05), numerically alone considered ‘‘encouraging of the need of further trials’’. Secondly, the confidence with which recommendations could be offered was tempered by the paucity of data available (from potentially 485 relevant papers, only 02 met review criteria, forming a study group of only 321 patients). The recommendation for clinicians hinted of guarded optimism— results ‘‘suggest that more intensive interventions, such as joint crisis planning, may be of benefit in terms of reduction of involuntary readmissions or assessments under the Mental Health Act’’ (Campbell and Kisely, 2009).
6. Nuances in application to the Indian scenario The PAD is a legal attempt to put the final say regarding treatment in the hands of the patient concerned, regardless of the opinions of those around him/her. The dangers, benefits and the degree of success with which PADs will be allowed to achieve this declared goal change in the Indian context (Avasthi, 2010). Risking generalisation, the proxy decision-making authority caretakers exercise in the Indian social setup does deprive persons with disabilities/handicaps of autonomy. But this same setup curiously provides these disempowered persons protection they desperately require, considering the depravity they may otherwise fall prey to (Chandra et al., 2003). By according precedence to and then enforcing the authority of an advance directive which goes against
the better judgement of family/support group members, the patient’s long-term support system stands jeopardised. The PAD’s success requires a streamlined, integrated and dynamic mental-healthcare delivery system which sadly does not exist (Khandelwal et al., 2004)—e.g. the process of overruling an advance directive requires an appeal to be submitted to a board, the board to then review the appeal and then convey a decision. All the while, the patient stays in the state which was serious enough to merit a psychiatrist’s refusal to comply with instructions for/ against treatment. Psychiatrists are not mandated to play any role in the conceptualisation and thereby in the assessment of feasibility of a PAD. Any medical officer regardless of psychiatric experience can certify competence to frame the document, also overlooking how the presence of the psychiatrist during PAD formulation reduces anxiety during future crises (Srebnik et al., 2003). The first place a psychiatrist’s decision-making is invoked is during revocation of a PAD. The next psychiatrist is involved in the review process, as part of the review board, likely assessing whether the patient’s competence was suspect to begin with. Thus a situation is created where the opinions of two psychiatrists regarding a patient’s competence (itself a nebulous entity) are pitted against each other, and by virtue of being on the review board, one begins with considerable leverage. 7. Conclusion Even in countries where PADs are already in force, clinicians consistently report uneasiness about ensuing legal liability, resource/logistics shortfalls and interference with clinical aspects of care (Shields et al., 2014)—treating psychiatric patients within the framework of their pre-stated wishes is clearly a much more
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intricate and arduous task than doing so in India’s prevailing ‘doctor-patient hierarchy’ zeitgeist (Kala, 2013; Pathare et al., 2015). Accepting this challenge is an opportunity for Psychiatry to counter allegations of autocracy and impunity its most vocal critics level. Apprehension regarding PADs in India stems largely from a sense of unpreparedness. Template evaluations testing the merit in this diffidence have already begun—75 patients in Tamil Nadu undertook a (facilitated) filling-up of model PADs. The results provide grounds for optimism—none refused any form of treatment outright, and 93% wanted to be taken to a hospital in case of a relapse/decisional incapacity. The majority (n = 37) did not even demand any particular choice of medication and expressed confidence in their doctor’s advice. Predictably, ECT use remained a contentious area–a slender majority of patients (39 v/s 30) were unwilling to consider it at all (Pathare et al., 2015). A second study evaluated 92 completed model PADs of patients at SCARF, Chennai (Kumar et al., 2013). Yet again, all patients wanted to continue treatment. Furthermore, none demanded exorbitant/ esoteric treatment, in fact 53% declared the clinic where they were already receiving treatment as their centre of choice for future crises. Most wanted to be treated as outpatients and with oral medication (39%), but a sizable number agreed they might need inpatient treatment and injectibles if deemed necessary by their doctor (31.5%). Difficulties, obstacles and failures will inevitably be encountered on introducing PADs into a setting with underpowered infrastructure and safeguards, but the concept’s cardinal, indubitable merit remains that it espouses the autonomy of patients ravaged by both their diseases and their disenfranchisement. References American Psychiatric Association, 2009. Resource Document on Psychiatric Advance Directives Retrieved from hhttp://www.psychiatry.org/file%20library/ learn/archives/rd2009_advancedirectives.pdfi Appelbaum, P.S., 2004. Law & psychiatry: psychiatric advance directives and the treatment of committed patients. Psychiatr. Serv. 55 (7), 751–763, DOI http:// doi.org/10.1176/appi.ps.55.7.751. Appelbaum, P.S., 2007. Assessment of patients’ competence to consent to treatment. N. Engl. J. Med. 357 (18), 1834–1840, DOI http://doi.org/10.1056/ NEJMcp074045. Appelbaum, P.S., Grisso, T., 1995. The MacArthur treatment competence study I: mental illness and competence to consent to treatment. Law Hum. Behav. 19 (2), 105–126. Atkinson, J.M., 2007. Advance directives in mental health: theory. In: Practice and EthicsJessica Kingsley Publishers, London. Avasthi, A., 2010. Preserve and strengthen family to promote mental health. Indian J. Psychiatry 52 (2), 113–126, DOI http://doi.org/10.4103/0019-5545.64582. Backlar, P., McFarland, B.H., Swanson, J.W., Mahler, J., 2001. Consumer, provider, and informal caregiver opinions on psychiatric advance directives. Admin. Policy Ment. Health 28 (6), 427–441. Campbell, L.A., Kisely, S.R., 2009. Advance treatment directives for people with severe mental illness. In: The Cochrane Collaboration (Eds.), Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd, Chichester, UK, Retrieved from hhttp://doi.wiley.com/10.1002/14651858.CD005963.pub2i Chandra, P.S., Carey, M.P., Carey, K.B., Shalinianant, A., Thomas, T., 2003. Sexual coercion and abuse among women with a severe mental illness in India: an exploratory investigation. Compr. Psychiatry 44 (3), 205–212, DOI http:// doi.org/10.1016/S0010-440X(03)00004-X. Etchells, E., Darzins, P., Silberfeld, M., Singer, P.A., McKenny, J., Naglie, G., Strang, D., 1999. Assessment of patient capacity to consent to treatment. J. Gen. Intern. Med. 14 (1), 27–34, DOI http://doi.org/10.1046/j.1525-1497.1999.00277.x. Fernandez, A., Chaturvedi, S.K., Beig, A., Gopinath, P.S., 1987. Readmission of psychiatric patients in a psychiatric hospital. Indian J. Psychiatry 29 (1), 85–88. Flood, C., Byford, S., Henderson, C., Leese, M., Thornicroft, G., Sutherby, K., Szmukler, G., 2006. Joint crisis plans for people with psychosis: economic evaluation of a randomised controlled trial. BMJ (Clin. Res. Ed.) 333 (7571), 729, DOI http:// doi.org/10.1136/bmj.38929.653704.55. Gallagher, E.M., 1998. Advance directives for psychiatric care: a theoretical and practical overview for legal professionals. Psychol. Public Policy Law 4 (3),
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Please cite this article in press as: Ratnam, A., et al., Psychiatric Advance Directives in India: What will the future hold? Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.06.004