Easter Michele M, Swanson Jeffrey W, Robertson Allison G, Moser Lorna L, Swartz Marvin S
Dr. Easter, Dr. Swanson, Dr. Robertson, and Dr. Swartz are with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina. Dr. Moser is with the Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Psychiatr Serv. 2017 Jul 1;68(7):717-723. doi: 10.1176/appi.ps.201600423. Epub 2017 Apr 3.
Psychiatric advance directives (PADs) provide a legal mechanism for competent adults to document care preferences and authorize a surrogate to make treatment decisions. In a controlled research setting, an evidence-based intervention, the facilitated psychiatric advance directive (FPAD), was previously shown to overcome most barriers to PAD completion. This study examined implementation of the FPAD intervention in usual care settings as delivered by peer support specialists and nonpeer clinicians on assertive community treatment (ACT) teams.
A total of 145 ACT consumers were randomly assigned, within teams, to FPAD with facilitation by either a peer (N=71) or a clinician (N=74). Completion rates and PAD quality were compared with the previous study's standard and across facilitator type. Logistic regression was used to estimate effects on the likelihood of PAD completion.
The completion rate of 50% in the intent-to-treat sample (N=145) was somewhat inferior to the prior standard (61%), but the rate of 58% for the retained sample (those who completed a follow-up interview, N=116) was not significantly different from the standard. Rates for peers and clinicians did not differ significantly from each other for either sample. PAD quality was similar to that achieved in the prior study. Four consumer variables predicted completion: independent living status, problematic substance use, length of time served by the ACT team, and no perceived unmet need for hospitalization in crisis.
Peers and clinicians can play a crucial role in increasing the number of consumers with PADs, an important step toward improving implementation of PADs in mental health care.
精神科预先指示（PADs）为有行为能力的成年人提供了一种法律机制，用于记录护理偏好并授权代理人做出治疗决策。在一项对照研究环境中，一种基于证据的干预措施，即协助精神科预先指示（FPAD），先前已被证明能够克服PAD完成过程中的大多数障碍。本研究考察了由同伴支持专家和非同伴临床医生在积极社区治疗（ACT）团队中提供的FPAD干预措施在常规护理环境中的实施情况。
总共145名ACT服务对象在团队内部被随机分配，分别由同伴（N = 71）或临床医生（N = 74）协助完成FPAD。将完成率和PAD质量与先前研究的标准进行比较，并在不同协助者类型之间进行比较。使用逻辑回归来估计对PAD完成可能性的影响。
意向性治疗样本（N = 145）的完成率为50%，略低于先前标准（61%），但留存样本（完成随访访谈的对象，N = 116）的完成率为58%，与标准无显著差异。两个样本中，同伴和临床医生的完成率彼此无显著差异。PAD质量与先前研究中的类似。有四个服务对象变量可预测完成情况：独立生活状态、物质使用问题、ACT团队服务时长以及在危机中未察觉到对住院治疗有未满足的需求。
同伴和临床医生在增加拥有PADs的服务对象数量方面可发挥关键作用，这是朝着改善精神卫生保健中PADs实施迈出的重要一步。
