Kemp Kathleen, Zelle Heather, Bonnie Richard J
Dr. Kemp is with the Department of Child and Adolescent Psychiatry, Rhode Island Hospital, and Brown University Warren Alpert Medical School, Providence (e-mail:
Psychiatr Serv. 2015 Jan 1;66(1):10-4. doi: 10.1176/appi.ps.201400276.
For people with serious mental illness, research demonstrates the potential positive effects of having an advance directive with specific instructions for mental health care. The Commonwealth of Virginia has undertaken efforts to incorporate the completion of psychiatric advance directives into routine mental health services for individuals with serious mental illness. The inherent complexities of advance directives-a single legal tool for use by a heterogeneous array of consumers, providers, and organizations-have led to more barriers than had been anticipated. This article describes challenges encountered in the first three years of implementation efforts. Data are from feedback on early training attempts and experiences of staff at pilot sites and work groups convened for the implementation project. The authors describe a range of challenges, such as how to present a complete and clear message about the nature, purposes, and potential advantages of psychiatric advance directives to various audiences, in particular their use in recovery-oriented care; how to promote cross-system collaboration among potential users of these directives; and how to overcome resource constraints and sustain interest in the process. Virginia's experience reinforces the importance of developing multifaceted implementation strategies, such as the creation of informational and training tools to spread implementation more effectively, the identification of "champions" or staff members who are invested in implementation, and the development of multiple approaches to facilitating completion of advance directives by consumers.
对于患有严重精神疾病的人，研究表明制定针对精神卫生保健的具体指示的预先指示具有潜在的积极影响。弗吉尼亚州已努力将精神科预先指示的制定纳入针对患有严重精神疾病的个人的常规精神卫生服务中。预先指示作为一种供不同类型的消费者、提供者和组织使用的单一法律工具，其内在复杂性导致了比预期更多的障碍。本文描述了实施工作头三年中遇到的挑战。数据来自对早期培训尝试的反馈以及试点站点工作人员的经验，还有为实施项目召集的工作组的经验。作者描述了一系列挑战，例如如何向不同受众完整、清晰地传达有关精神科预先指示的性质、目的和潜在优势的信息，尤其是其在以康复为导向的护理中的应用；如何促进这些指示的潜在使用者之间的跨系统协作；以及如何克服资源限制并维持对该过程的兴趣。弗吉尼亚州的经验强化了制定多方面实施策略的重要性，例如创建信息和培训工具以更有效地推广实施，确定参与实施的“倡导者”或工作人员，以及开发多种方法以促进消费者完成预先指示。
