Advance healthcare directives in mental health: A qualitative analysis from a Spanish healthcare professional's viewpoint

Abstract

WHAT IS KNOWN ON THE SUBJECT?: Advance care planning (ACP) in mental health is a useful tool to avoid human rights violations in mental health settings. However, ACP is not yet a reality in the Spanish context. The advance healthcare directive (AHD) is a document reflecting healthcare preferences, drafted within the framework of the ACP process, to be applied in situations in which an individual's legal capacity may be questionable. No study has explored the viewpoint of Spanish mental healthcare professionals towards AHDs in the mental health field. Considering their extensive use, further study of providers' knowledge and attitudes is warranted. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The study adds knowledge about the viewpoint of Spanish mental healthcare professionals towards the implementation of AHDs in their clinical practices. This study illuminates the prevailing paternalistic provider-user relationship as the main barrier surrounding AHD management in terms of decision-making. Our findings support the need for broader awareness, staff training regarding the documentation, the conversation process and communication skills, and personalized assistance in the mental health services to implement AHDs in everyday practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Advance healthcare directives are a recovery tool that offers major information regarding mental health user preferences. Although they pose challenges for clinical practice, AHDs should be incorporated into interventional mental health care. Obtaining up-to-date perspectives held by mental healthcare professionals regarding AHDs allows the administration to determine the aspects requiring reinforcement. The implementation of AHDs in the Spanish mental health system requires macro- and micro-changes, both ethically and structurally, so that mental healthcare professionals relinquish their paternalistic approach and embrace new ways of relating to users. Abstract Introduction An advance healthcare directive (AHD) is a written document that contains a patient-in-care's will and preferences concerning the treatment options available to them, should they lack decision-making capacity. AHDs are completed within a broader framework known as advance care planning. No study has explored the viewpoint of Spanish mental healthcare professionals towards AHDs. Aim To explore the viewpoint of mental health professionals towards the implementation of AHDs in mental health. Method A qualitative study was conducted using semi-structured interviews that were thematically analysed. Findings Three main themes were identified: care planning culture; barriers for the practical management of AHDs; and reasons to not honour patient-in-care AHDs. Discussion Professionals find it pragmatically difficult to stop applying traditional paternalistic practices. To implement AHDs, improving the knowledge and awareness of AHDs and management of non-technical skills through training is required. Such training should include users and families and allow for compliance with United Nations requirements. Implications for practice Advance healthcare directives offer important information regarding user preferences, although they pose challenges for practices. Acquiring an up-to-date perspective on the attitudes of professionals towards AHDs allows organizations to attend to particular aspects that require reinforcement. Wider awareness, staff training and new ways of relating to users are necessary to implement AHDs in Spanish context. Relevance statement A better understanding of the attitudes of Spanish mental health professionals towards AHDs was achieved. Despite the implementation of AHDs being an important and potentially beneficial initiative, mental health professionals find many pragmatic issues that need addressing before AHDs become a reality in their clinical practice. Wider awareness, staff training, personalized assistance and new ways of relating to users are required to implement AHDs in everyday practice.

Keywords: advance directives; living wills; mental health; mental illness; nursing; professionals.