Prevalence and Implementation of Psychiatric Advance Directives Among Veterans With Serious Mental Illness

Psychiatric advance directives (PADs) are evidence-based tools to increase patient autonomy and reduce coercive practices in inpatient psychiatric settings. No prior research has investigated PAD prevalence or implementation within the Veterans Health Administration (VHA), the largest integrated healthcare provider in the US. Our aims were to (1) determine the prevalence and (2) assess the implementation of PADs among Veterans with serious mental illness (SMI) receiving care at the VHA.

We reviewed electronic health records for Veterans in the Southwestern US enrolled in VHA SMI specialty treatment programs. The study had two phases. During phase one, we collected data on the presence of PADs within Veterans' medical records, along with mental health preferences specified in each PAD. In phase two, we examined evidence of PAD implementation via record review during subsequent psychiatric hospitalizations.

Among 5021 Veterans, 160 had a PAD (3.2%). Zero medical record notes from inpatient hospitalizations contained any explicit evidence of PAD implementation. Medical record notes from inpatient hospitalizations falsely stated that Veterans did not have a PAD in 89% of cases, and care aligned with Veterans' preferences 49% of the time.

Few Veterans with SMI have PADs, and for those who do, their preferences are not consistently implemented during psychiatric crises. Addressing VHA-specific PAD implementation barriers is warranted to improve VHA inpatient psychiatric care.

Despite their potential to increase patient autonomy and reduce coercive crisis interventions in inpatient psychiatric settings, low uptake of PADs within the VHA suggests an important gap in recovery-oriented care delivery.