COMMENTARY

In this study, advance directives had little effect on compulsory admissions. Although the authors discuss possible reasons for this finding, they do not comment on what may be the fundamental reason for the lack of difference between groups: the advance directives were not really advance directives. According to Webster’s Collegiate Dictionary, a directive is “something that serves to direct, guide, and usually impel toward an action or goal.” What the authors provided in this study was a “preference statement” which was “not intended to address compulsory admission directly.” Further, professionals were not legally bound to comply with patients’ preferences for care. The document produced by the intervention group was hardly different from what the control group might express to a professional in a good doctor-patient relationship. It may well be that there were no differences in outcome because there was no real difference in process between the two groups.

Advance directives can be healthcare proxies which empower others to act on behalf of the patient when he or she becomes incompetent to act on his or her own behalf. Alternatively, an advance directive may specify which interventions are authorised when psychosis re-emerges and the individual is no longer competent. Such advance directives might prove effective, especially in jurisdictions that do not permit individuals to modify or terminate advance directives when they are incompetent to do so.¹

Papageorgiou et al conclude that the impact of advance directives on other aspects of treatment and care requires further study. I concur. The impact of advance directives on compulsory treatment also requires further study. First, however, we need to obtain greater consensus on what an “advance directive” actually is for psychiatric treatment and care.