Advance directives as a care planning tool for patients with complex mental health needs: service evaluation

This study investigated the prevalence of advance directives among patients receiving community care within the East London NHS Foundation Trust (ELFT), and to identify factors associated with their clinical application.We analysed data from electronic health records of 4807 patients (aged 18-75 years), managed under the Care Programme Approach (CPA) in ELFT during 2021-2022. Demographic, clinical, service-level and patient-reported measures were analysed (binomial logistic regression).

A total of 31.2% of patients on the CPA had an advance directive. Black ethnicity, treatment in the forensic service or Newham, Luton and Bedfordshire localities, housing in socio-therapeutic facilities, diagnosis of personality disorder, ten or more previous admissions and engagement with DIALOG+ were positively associated with having an advance directive. DIALOG+ is the first approach that has been specifically developed to make routine patient-clinician meetings therapeutically effective. It is based on quality of life research, utilising the DIALOG scale (a patient-reported outcome measure), concepts of patient-centred communication, IT developments and components of solution-focused therapy, and is supported by an app.

This study highlights a complex interplay of cultural, social and systemic factors that influence advance care plan status. Structured communication, stronger therapeutic relationships and staff facilitation are likely to encourage advance care planning.