The capacity to execute an advance directive for psychiatric treatment

When advance directives are used to reject standard psychiatric treatment they have the potential to place civilly committed patients in a catch-22 where they need psychotropic medication to ameliorate their symptoms in order to regain liberty but are bound by their previously expressed wish that medication be withheld. The capacity to make an advance directive is higher than that required to make a contemporaneous treatment decision. Furthermore, unlike the assessment of contemporaneous capacity, it is very difficult to determine a person's capacity retrospectively or to determine if an advance directive was meant to apply in changed circumstances. The author argues that when an advance directive demands a course of action that is contrary to a person's best interests the onus should fall on the person rejecting the care to demonstrate that he or she was capable when executing the directive and that the directive is meant to apply in the current circumstances.