Institute of Health & Society, Université catholique de Louvain, Brussels, Belgium.
Health Soc Care Community. 2013 Jan;21(1):1-14. doi: 10.1111/j.1365-2524.2012.01062.x. Epub 2012 Mar 27.
Psychiatric Advance Directives (PADs) are documents that allow users with severe and chronic mental illnesses to notify their treatment preferences for future crisis relapses and to appoint a surrogate decision-maker for a period of incompetence. Despite many supposed clinical and organisational benefits, their take-up rate has remained very low and their clinical evaluation has given contradictory results for organisational outcomes. Intermediary results are available, however, which rely on different theoretical views about how PADs are supposed to work. We carried out a realist systematic review that considered the PAD as a multistage intervention including the definition of the document, its completion and its access and honouring. We identified the theoretical frameworks underlying this kind of intervention and examined the available evidence that supported or contradicted the expectations at each stage of the intervention. Forty-seven references were retrieved, ranging from 1996 to 2009. Three frameworks underlie a PAD intervention: enhancement of the autonomy of the user, improvement of the therapeutic alliance and integration of care through partnership working. Although designed in the first place with a view to sustaining the user's autonomy, results indicate that the intervention is more efficient within a therapeutic alliance framework. Moreover, much is known about the completion process and the content of the document, but very little about its access and honouring. The mixture of expectations makes the purpose of PADs unclear, for example, crisis relapse prevention or management, advance planning of long-term or emergency care, or reduction in the resort to coercion. This may explain their low take-up rates. Hence, frameworks and purpose have to be clarified. The shape of the whole intervention at each stage relies on such clarification. More research is needed, particularly on the later stages of the intervention, as the evidence for how PADs should be implemented is still incomplete.
精神科预先指示（PAD）是一种文件，允许患有严重和慢性精神疾病的用户通知他们在未来危机复发时的治疗偏好，并在一段时间内指定一个替代决策人。尽管有许多据称的临床和组织效益，但它们的采用率仍然非常低，其临床评估对组织结果的结果也存在矛盾。然而，有一些中间结果，这些结果依赖于关于 PAD 应该如何发挥作用的不同理论观点。我们进行了一项现实主义的系统评价，该评价考虑了 PAD 作为一个多阶段干预措施，包括文件的定义、完成以及获取和遵守。我们确定了这种干预措施背后的理论框架，并审查了支持或反驳干预各个阶段预期的现有证据。共检索到 47 篇参考文献，时间范围从 1996 年到 2009 年。有三个框架构成了 PAD 干预：增强用户的自主性、改善治疗联盟以及通过合作工作整合护理。尽管最初设计是为了维持用户的自主性，但结果表明，在治疗联盟框架内，干预措施更有效。此外，人们对完成过程和文件的内容了解很多，但对其获取和遵守知之甚少。期望的混合使得 PAD 的目的不明确，例如，预防或管理危机复发、预先规划长期或紧急护理，或减少强制使用。这可能解释了它们的低采用率。因此，需要澄清框架和目的。整个干预措施在每个阶段的形式都依赖于这种澄清。需要进行更多的研究，特别是在干预的后期阶段，因为关于 PAD 应该如何实施的证据仍然不完整。
