自我约束指令的机遇与风险：一项涉及德国利益相关者和研究人员的定性研究。
Opportunities and risks of self-binding directives: A qualitative study involving stakeholders and researchers in Germany.
作者信息
Potthoff Sarah, Finke Marleen, Scholten Matthé, Gieselmann Astrid, Vollmann Jochen, Gather Jakov
机构信息
Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.
Department of Psychiatry, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany.
出版信息
Front Psychiatry. 2022 Oct 21;13:974132. doi: 10.3389/fpsyt.2022.974132. eCollection 2022.
PURPOSE
Self-binding directives (SBDs) are a special type of psychiatric advance directive in which mental health service users can consent in advance to involuntary hospital admission and involuntary treatment during future mental health crises. This study presents opportunities and risks of SBDs reported by users with bipolar disorder, family members of people with bipolar disorder, professionals working with people with bipolar disorder and researchers with expertise in mental health ethics and law.
METHODS
Seventeen semi-structured interviews with users, family members and professionals, and one focus group with five researchers were conducted. The data was analyzed using qualitative content analysis.
RESULTS
Six opportunities and five risks of SBDs were identified. The opportunities were promotion of autonomy and self-efficacy of users, relief of responsibility for family members, early intervention, reduction of (perceived) coercion, positive impact on the therapeutic relationship and enhancement of professionals' confidence in decision-making. The risks were problems in the assessment of mental capacity, inaccurate information or misinterpretation, increase of coercion through misuse, negative impact on the therapeutic relationship due to noncompliance with SBDs, and restricted therapeutic flexibility and less reflection on medical decision-making. Stakeholders tended to think that the opportunities of SBDs outweigh their risks, provided that appropriate control and monitoring mechanisms are in place, support is provided during the drafting process and the respective mental healthcare setting is sufficiently prepared to implement SBDs in practice.
CONCLUSIONS
The fact that stakeholders consider SBDs as an opportunity to improve personalized crisis care for people with bipolar disorder indicates that a debate about the legal and clinical implementation of SBDs in Germany and beyond is necessary.
目的
自我约束指令（SBDs）是一种特殊类型的精神科预先指令，心理健康服务使用者可借此预先同意在未来心理健康危机期间接受非自愿住院治疗和非自愿治疗。本研究呈现了双相情感障碍患者、双相情感障碍患者家属、从事双相情感障碍患者治疗工作的专业人员以及心理健康伦理与法律领域的研究人员所报告的SBDs的机遇和风险。
方法
对患者、家属和专业人员进行了17次半结构化访谈，并与5名研究人员进行了1次焦点小组讨论。采用定性内容分析法对数据进行分析。
结果
确定了SBDs的六个机遇和五个风险。机遇包括促进使用者的自主性和自我效能感、减轻家属的责任、早期干预、减少（感知到的）强制、对治疗关系产生积极影响以及增强专业人员决策的信心。风险包括精神能力评估方面的问题、信息不准确或误解、因滥用导致强制增加、因不遵守SBDs对治疗关系产生负面影响，以及治疗灵活性受限和对医疗决策的反思减少。利益相关者倾向于认为，只要有适当的控制和监测机制，在起草过程中提供支持，并且各自的精神卫生保健机构有充分准备在实践中实施SBDs，SBDs的机遇就大于风险。
结论
利益相关者将SBDs视为改善双相情感障碍患者个性化危机护理的机遇，这一事实表明，有必要在德国及其他地区就SBDs的法律和临床实施展开辩论。
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