Facilitation of Psychiatric Advance Directives by Peers and Clinicians on Assertive Community Treatment Teams

Abstract

Objective: Psychiatric advance directives (PADs) provide a legal mechanism for competent adults with serious mental health conditions to document their future crisis-care preferences and authorize a trusted surrogate to make treatment decisions for them during anticipated periods of decisional incapacity. An evidence-based intervention, the Facilitated Psychiatric Advance Directive (FPAD) can overcome most barriers to PAD completion in a controlled research setting. The present study implemented the FPAD intervention in usual-care settings as delivered by two kinds of staff on Assertive Community Treatment (ACT) teams: certified peer support specialists and non-peer clinicians.

Methods: ACT consumers were randomly assigned, within teams, to FPAD from either a peer or clinician. The rate of PAD completion and quality was measured and compared to the previous research standard and across facilitator type. Logistic regression was used to model the likelihood of PAD completion.

Results: This study of implementation shows that PADs can be facilitated in a community-based mental health setting, by peers and clinicians working on ACT teams. The quality of PADs was similar to that achieved under controlled study conditions. The PAD completion rate achieved in the intent-to-treat sample (n=145) was somewhat inferior to the prior study’s standard, but the rate for the retained sample (n=116) was not. Rates achieved by peers and clinicians were not statistically different from each other in either sample.

Conclusions: Peers and clinicians could play a crucial role in increasing the supply of PADs, an important step toward improving their implementation in mental health care.

Keywords: Advance directives/proxies, Assertive Community Treatment, Community mental health services, recovery, staff roles, peer support specialists