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Commentary: The Climate for Physician Adherence to Psychiatric Advance Directives

Dr. Bernstein is Executive Director, Bazelon Center for Mental Health Law, Washington, DC. Address correspondence to: Robert Bernstein, PhD, Bazelon Center, 1101 15th Street, NW, Suite 1212, Washington, DC 20005. E-mail: robertb{at}bazelon.org

Factors that may be significant in rationalizing physician overrides of psychiatric advance directives (PADs) are not only features of individual clinical scenarios, but also are artifacts of the faltering mental health system being navigated by both provider and patient. This system, frequently viewed as hostile to consumer choice and increasingly focused on reacting to recurrent crises, is not predisposed to accepting proactive, person-centered measures such as PADs. In fact, PADs may hold great promise in improving clinical outcomes and even reducing system costs. But to realize the full potentials of PADs requires that providers understand their roles in challenging or perpetuating problems in the larger mental health system.