Effectively Implementing Psychiatric Advance Directives

描述（由申请人提供）：精神病学预先指示（pad）允许有能力的人在精神健康危机之前宣布他们的治疗偏好，并指定代理决策者，当他们可能失去做出可靠医疗保健决定的能力时。15个州已经通过了PAD立法，但很少有研究来回答新出现的政策问题：消费者对PAD的需求是什么？是否需要正式援助来促进有效的PADs？pad是否符合临床对适当治疗的判断？pad在实践中是如何使用和执行的？具有某些特征的pad是否增强了治疗参与，改善了围绕精神危机的护理过程，并为重度精神疾病（SMI）患者提供了更大的自主意识？pad是否会产生负面后果，例如，如果准备时没有充分的理解或指导，或者如果没有按计划实施？建议的研究将解决这些问题如下：(1)进行一项随机试验，促进精神病学预先指示（F-PAD），这是一种手动的，试点测试的干预措施，以帮助消费者完成pad；(2)在北卡罗莱纳的N=400名重度精神障碍消费者的样本中检查pad在1年内的实施情况。受试者将被随机分配到FPAD干预组或“常规护理”对照组。F-PAD受试者将被给予个性化的指导和帮助，以完成模板结构的PAD和医疗授权书（HCPA）文件，如果他们愿意的话。对照受试者将获得pad的简要介绍（作为本研究知情同意的一部分）、书面材料、参加pad小组教育会议的机会以及提供pad咨询的消费者组织的电话号码。临床医生和代理人也将获得有关pad的指导。受试者及其临床医生将在1个月和12个月进行结构化访谈，以检查pad /HCPA的完成率、结构和内容、后续治疗参与和危机管理结果。PAD/HCPA文件将以电子方式存储在美国生前遗嘱登记处，该登记处提供对预先护理文件的自动访问。拟议的研究将提供有关一个州在pad方面的经验的信息，以便指导政策制定者在其他地方实施pad。

DESCRIPTION (provided by applicant): Psychiatric advance directives (PADs) allow competent persons to declare their treatment preferences and designate a proxy decision maker in advance of a mental health crisis when they may lose capacity to make reliable healthcare decisions. Fifteen states have adopted PAD legislation, yet little research has been conducted to answer emerging policy questions: What is the demand for PADs among consumers? Is formal assistance necessary to facilitate effective PADs? Do PADs conform with clinical judgments of appropriate treatment? How are PADs actually used and enforced in practice settings? Do PADs with certain features enhance treatment engagement, improve the process of care surrounding psychiatric crises, and provide a greater sense of autonomy for persons with severe mental illness (SMI)? Might PADs have negative consequences, e.g., if prepared without adequate comprehension or instructions, or if not implemented as planned? The proposed study will address these questions as follows: (1) Conduct a randomized trial of Facilitated Psychiatric Advance Directives (F-PAD), a manualized, pilot-tested intervention to assist consumers in completing PADs; (2) Examine the implementation of PADs over 1 year) in a sample of N=400 consumers with SMI in North Carolina. Subjects will be randomly assigned to the FPAD intervention or a "usual care" control group. F-PAD subjects will be given individualized orientation and assistance in completing a template-structured PAD and healthcare power of attorney (HCPA) document if they wish. Control subjects will receive a brief orientation to PADs (as part of informed consent to the study), written material, an opportunity to attend a group education meeting about PADs, and the telephone number of a consumer organization that provides consultation regarding PADs. Clinicians and proxies will also be given orientation regarding PADs. Subjects and their clinicians will be followed up with a structured interview at 1 month and 12 months to examine the rate of completion of PADs/HCPA, their structure and content, subsequent treatment engagement and crisis management outcomes. PAD/HCPA documents will be electronically stored with the U.S. Living Will Registry, which provides automated access to advance care documents. The proposed study will provide information about a state's experience with PADs so that policymakers may be guided in implementing PADs elsewhere.