Competence to complete psychiatric advance directives: effects of facilitated decision making

Abstract

Psychiatric advance directives (PADs) statutes presume competence to complete these documents, but the range and dimensions of decisional competence among people who actually complete PADs is unknown. This study examines clinical and neuropsychological correlates of performance on a measure to assess competence to complete PADs and investigates the effects of a facilitated PAD intervention on decisional capacity. N=469 adults with psychotic disorders were interviewed at baseline and then randomly assigned to either a control group in which they received written materials about PADs or to an intervention group in which they were offered an opportunity to meet individually with a trained facilitator to create a PAD. At baseline, domains on the Decisional Competence Assessment Tool for PADs (DCAT-PAD) were most strongly associated with IQ, verbal memory, abstract thinking, and psychiatric symptoms. At one-month follow-up, participants in the intervention group showed more improvement on the DCAT-PAD than controls, particularly among participants with pre-morbid IQ estimates below the median of 100. The results suggest that PAD facilitation is an effective method to boost competence of cognitively-impaired clients to write PADs and make treatment decisions within PADs, thereby maximizing the chances their advance directives will be valid.

Fig. 1

Study protocol: CONSORT flow diagram

Fig. 2

Effect of F-PAD Intervention on Competence to Write a PAD, Reasoning Domain stratified by estimated pre-morbid IQ (above median vs. below median) Note. Participants in the intervention group below the median IQ of 100 showed significantly greater improvement on the reasoning scores compared to their counterparts in the control group (F (1, 171) = 7.36, p < .01). However, among participants with estimated pre-morbid IQs > 100, there was no effect of randomization.