Letter

To the Editor: In the November Open Forum Deegan and Drake's argument that medication management in the recovery process should take the form of shared decision making between clients and practitioners is most welcome, as is their emphasis on the need for more research on how this can be achieved. We wish to take issue only with one assertion they make—that psychiatric advance directives allow shared decision making to occur.

As documents that can be completed in the absence of any practitioner involvement, psychiatric advance directives are aimed at promoting patient autonomy rather than an agreement with practitioners regarding future emergency mental health care. Their mode of preparation therefore conforms much more closely to the consumer choice model ( 1 ).

However, consumer choice in this context is limited by several provisions of advance directive legislation. For example, the instructions can be overridden by commitment law or if they are unfeasible or in conflict with community practice standards. The operational and service culture barriers to implementation of psychiatric advance directives further limit the extent to which consumer choice can be exercised through their use ( 2 , 3 ). These barriers include having to get the document witnessed and notarized and finding someone to act as a health care power of attorney, as well as practitioners' ignorance about advance directives resulting from the lack of infrastructure to support their dissemination, and practitioners' resistance to being limited by clients' preferences for certain treatments. Thus, although psychiatric advance directives appear to offer consumer choice, they are detached from any mechanism to deliver it.

In contrast, the joint crisis plan ( 4 , 5 ) fits the model of shared decision making much more closely. It is an advance agreement regarding emergency mental health care that is made between a client and a practitioner, with negotiation facilitated by an independent practitioner. Disagreements about care that cannot be resolved are made explicit in the plan. Although the final choice of content is the client's, the involvement of the client's usual care providers increases the chance that they will be aware of and able to act on the preferences expressed. Again, a fragmentary system of care increases the work needed to disseminate joint crisis plans. In the service setting of the United Kingdom, most community psychiatrists are also responsible for their patients during hospitalization. The use of joint crisis plans in the United Kingdom was associated with a 50% reduction in involuntary hospitalization compared with a control group, as well as a reduction in episodes of violence ( 4 ). Economic analysis suggested a high probability of cost-effectiveness. The results suggest that the joint crisis plan allows practitioners to manage risk in a way that is more closely based on patients' preferences.

We suggest that the joint crisis plan is one example of the interventions that Deegan and Drake call for "to help activate clients to become involved in the shared decision-making process."