Virginia’s Pioneering Psychiatric Advance Directive Law Getting Slow Uptake

Virginia is the first US state to try to implement psychiatric advance directives statewide, and there is much to be learned from examining what has been happening there, according to a paper in Psychiatric Services by University of Virginia School of Law researchers.

Advance directives are documents that instruct physicians and others ahead of time about what sort of treatment a person does or does not want if the person is ever deemed incapable of making his or her own decisions. “The project began with consensus building among stakeholders (2007–2009), followed by revisions to Virginia’s Health Care Decisions Act (2009–2010) and designation of five of the state’s 40 Community Services Boards as demonstration sites for facilitation efforts,” the researchers explained. “Early implementation efforts quickly showed that psychiatric advance directives are not self-executing innovations.”

The researchers noted that “(d)espite the positive outcomes associated with psychiatric advance directives, the number of consumers completing these documents remains low.” They pointed to surveys indicating that 66−77% of patients wanted a psychiatric advance directive, while only 4−13% actually completed one. In addition, even when the directives existed, they weren’t often being followed.

Consequently, efforts in Virginia have been focusing on ways to increase the awareness and use of advance directives for mental health care in both patients and physicians. In their paper, the authors reviewed such efforts as providing professional support in completing the directives and building oversight mechanisms for implementation. “The first three years of efforts underscored the centrality of these components, and it is our impression that commitment to these components is beginning to translate into noticeable gains in implementation across the state,” the authors wrote. “Virginia’s purposeful and strategic effort to translate psychiatric advance directive legislation into actual use of these empowering tools can serve as a model for other states that wish to undertake a similar effort.”

Another article on the topic of advance directives in the journal by the same authors examined challenges particularly with respect to those people with “serious mental illness.”

(Full text) Advance Directives for Mental Health Care: Innovation in Law, Policy, and Practice (Zelle, Heather et al. Psychiatric Services. January 1, 2015. DOI: 10.1176/appi.ps.201400435)

(Abstract) Embedding Advance Directives in Routine Care for Persons With Serious Mental Illness: Implementation Challenges (Zelle, Heather et al. Psychiatric Services. January 1, 2015. DOI: 10.1176/appi.ps.201400276)