Scholten Matthé, Gieselmann Astrid, Gather Jakov, Vollmann Jochen
Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.
Department of Psychiatry, Psychotherapy, and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany.
Front Psychiatry. 2019 Sep 11;10:631. doi: 10.3389/fpsyt.2019.00631. eCollection 2019.
Psychiatric advance directives (PADs) are documents by means of which mental health service users can make known their preferences regarding treatment in a future mental health crisis. Many states with explicit legal provisions for PADs have ratified the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). While important UN bodies consider PADs a useful tool to promote the autonomy of service users, we show that an authoritative interpretation of the CRPD by the Committee on the Rights of Persons with Disabilities has the adverse consequence of rendering PADs ineffective in situations where they could be of most use to service users. Based on two clinical vignettes, we demonstrate that reasonable clinical recommendations can be derived from a more realistic and flexible CRPD model. Concerns remain about the accountability of support persons who give effect to PADs. A model that combines supported decision making with competence assessment is able to address these concerns.
精神科预先指示（PADs）是一些文件，通过这些文件，心理健康服务使用者可以表明他们在未来心理健康危机中对治疗的偏好。许多对PADs有明确法律规定的州已经批准了联合国（UN）《残疾人权利公约》（CRPD）。虽然重要的联合国机构认为PADs是促进服务使用者自主性的有用工具，但我们表明，残疾人权利委员会对CRPD的权威性解释产生了不利后果，即在对服务使用者最有用的情况下，PADs变得无效。基于两个临床案例，我们证明可以从一个更现实、更灵活的CRPD模型中得出合理的临床建议。对于执行PADs的支持人员的问责制仍然存在担忧。一个将支持性决策与能力评估相结合的模型能够解决这些担忧。
