Transcript Advance Directive Presentation - Irish Institute of Mental Health

Irish Institute of Mental Health Nursing
Position Paper No. 2: - Advance Directives
This position statement was prepared by Dr Richard
Lakeman and Dr Liam Mac Gabhann and endorsed by
the IIMHN Executive on the 8th of March 2011
Position Statement
Nurses should encourage and facilitate
users of mental health services to prepare
and implement advanced directives
relating to their care and well-being.
Sure that’s what we do
Fool!
Great, then
we are all
singing the
one tune!
Imagine this………….
 Person referred to service
 They have worked out with trusted family, friends and
professionals the best way of keeping well and getting
back on track if they become unwell
 They have even written it down just in case
 A bit like a diabetic or alcoholic carrying instructions on what to
do or not to do in case of accident
 They give it to the receiving team (e.g. nurse, doctor)
 And everyone is happy and knows what to do to make
everything alright again….. or at least to get people
back in the saddle
Ah yes it’s just like
that in my service….
Help me I think
I am going
mad!
Ok imagine
this then…?
Response!
We are here to help you……
This is what we will do……
No need to worry …………..
Just go with the treatment and we will
help you stay well……..
You have a psychiatric problem and we
have been successfully treating these for
over 150 years
Yep!
Well no actually!
In reality for many…
No choice
Predetermined responses to their experiences
Standard approach to ‘one size fits all’
Interpretation of peoples experiences through
very narrow lens – and subsequent response
Connection with services creates more
problems than solutions
Habitualisation, Routine practice.. Nurse knows
best…… In the best interest of the client….
Segregation
Asylum
From community
Objectification
Relief from
destitution
Diagnosed
Socialised
Treated
Institutionalised
Shelter
Autonomy
Community
care
Recovery
Model
The Self as expert!
Self
Determination
We’re
free
At last…
Walls
All gone
Now!
Hostels
Assertive
Outreach
Care
In the
communit
y
Home
treatment
MHA
OPD
clinics
Acute
inpatients
Social
centres
Specialist
Teams/therapists
Day
Hospital
So ok it is not like that where you come
from…… and there are realities such as
crisis……. Anyway we use advance
directives all the time…………
But just in case you
don’t it might be good
to think about them….
•Vision for
Change
•MHC
Quality
Framework
Advance Directives
Advance directives are collaboratively formulated
documents which express the preferences of
competent people and provide guidelines
regarding the process of care in relation to
foreseeable mental health or psychosocial
challenges that may involve professional mental
health services
Advance Directives
 An advance directive as a descriptive term is frequently
associated with a legal document and subsequent
process (Hoge 1994; Shrebnic et al. 2003
 However, the key objective has to provide a process for
people with mental health problems to exercise control
of their potential future care if intervention becomes
necessary; for example maintaining autonomy in
choosing their care options even if in crisis, through
appointed proxies (Lipton 2000; Amering et al. 2005)
An advance directive is
characterised by
 A commitment to and recognition of the principle of personal autonomy and
responsibility
 A collaborative process, that seeks to explore, clarify, and articulate a person’s:
 Hopes, wishes, plans, preferences and agreements with others for the timely recognition
and best response to a potential crisis and / or
 Responsibilities, expectations and agreements with others regarding on-going
maintenance and promotion of wellbeing
 A negotiated process, whereby when an advance directive requires specified
services or responses from others, then whenever practicably possible the terms of
service provision, and specific treatment preferences should be discussed and
negotiated with named representatives from services
 A careful consideration of how the how the person has arrived at this point, what
has helped and hindered, and how the person’s resources and capacities can be
drawn upon and enhanced
 Sharing with all service providers as needed and the honouring of the terms of the
advance directive in as far as practicably possible, even when the individual may be
deemed to lack decisional capacity until such times as capacity for decision making
is regained
Nurses and other health professionals should be
supported by their employers and professional
organisations to honour advance directives as
long as they are legal, ethical, and even when
the directive appears to conflict with prescribed
treatment. Advance directives should only be
over-ridden in the most exceptional
circumstances and in such cases a strong
ethical and legal justification is required and
must be documented in every instance
Essentially an advance directive requires a
collaborative future orientated care planning
process that places the person that may be
receiving care as the decision maker in
relation to how they utilise services in the
future
So it is about the imagined perfect
service then…….?
Some examples of existing practice
frameworks and care processes within the
Irish mental health services settings that
facilitate advance directives include:
Relapse Prevention
Crisis planning
Wellness Recovery Action Planning
Bring on the
wave of
change..