Va. Studies Directives Giving the Mentally Ill A Say in Their Care

Anders, who has bipolar disorder and schizophrenia, was taken to the psychiatric wing of a hospital. There, doctors punched her name into a database and were given instant information on how she wanted to be treated. She was not to be given Haldol, the antipsychotic drug. But the doctor could give her Zyprexa, a drug that she has had a good experience with. And the doctor could see what family member to call.

"It's something that has made life much, much more manageable, where I don't have to be so afraid anymore," said Anders, who said she first had bipolar disorder diagnosed 30 years ago. "It helps me trust that I'm going to get the right care when I need it."

Some mental health experts, however, question the power and practicality of the documents, as well as their necessity.

In several states, clauses allow people with such illnesses to revoke their directives, even in the midst of a psychotic episode. Officials in those states often give the power of revocability to patients because they say ignoring the protestations -- even in situations where refusal of some medications is frequent -- could amount to coercive treatment.

"An irrevocability clause really equates to forced medication unless the person is sitting passively and accepts the medication," said Robert Fleischner, a staff attorney at the Center for Public Representation, a disability law firm in Northampton, Mass., that has done work on the documents.

In some cases, advance directives do not deliver the autonomy they appear to promise. Some states allow doctors to override instructions if every reasonable effort to follow the document has been exhausted. Moreover, state laws that allow for involuntary commitment when a person is a danger to themselves or others trump the instructions in the directives.

"They are a nice idea, but in many cases they're ineffective," said Steven Daviss, chairman of the psychiatric department at Baltimore Washington Medical Center in Glen Burnie.

Even though the first psychiatric advance directive statutes were developed years ago, they are still seldom used -- a problem also found with general advance directives. A 2006 survey by several researchers at Duke University School of Medicine found that although 66 percent of more than 1,000 people with mental illness would consider filling out an advance directive, less than 10 percent actually did. In many cases, the study found very little understanding of how the documents worked and general distrust that patients' wishes would be observed. And in many states, including Maryland, there is no central directory to help track those who have the directives.

In Virginia the discussion has centered on whether the state should develop a separate psychiatric advance directive statute or just broaden existing laws to accommodate such directives in non-end-of-life situations. Officials in Virginia said they found that having a directive for psychiatric care and a directive for general health care could be confusing for doctors in an emergency. In addition, they said that by separating those with psychiatric advance directives from those with general health-care directives, they might be promoting stigmatization of the mentally ill.

"I think the concern is that a separate statute would further separate people who have mental illness from the rest of the population," said Terry Grimes, president of Empowerment for Healthy Minds, an advocacy group in Blacksburg, Va., and a member of the state Supreme Court's commission studying the mental health system. "Many of us are coming from the perspective that health is health."