Position Paper No. 2: - Advance Directives

1. 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

2. 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. Great, then we are all singing the one tune! Sure that’s what we do Fool!

3. 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….

4. Help me I think I am going mad! Ok imagine this then…?

5. 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!

6. Well no actually!

7. 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….

8. Segregation From community Asylum Objectification Socialised Relief from destitution Diagnosed Treated Institutionalised Shelter

10. Community care Autonomy Recovery Model The Self as expert! Self Determination We’re free At last… Walls All gone Now!

11. Care In the community Home treatment Hostels Assertive Outreach MHA Acute inpatients OPD clinics Day Hospital Specialist Teams/therapists Social centres

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. Bring on the wave of change..