Psychiatric advance directives in Switzerland: Knowledge and attitudes in patients compared to professionals and usage in clinical practice

Int J Law Psychiatry. Jan-Feb 2020;68:101514. doi: 10.1016/j.ijlp.2019.101514. Epub 2019 Nov 14.


Background: Psychiatric advance directives (PAD) were shown to be effective in the reduction of coercion and strengthening of the patients` autonomy. Therefore, the Swiss legislation was revised and stipulates that PAD must be taken into account during involuntary hospitalization. This study aimed to analyze knowledge on and attitudes towards this instrument in patients and healthcare practitioners and their usage in clinical practice.

Methods: We developed a structured questionnaire and included patients (n = 110), psychiatrists (n = 205), psychologists (n = 85), nurses (n = 268) and peers (n = 16) to rate their knowledge on and attitudes towards PAD. We registered the existing PAD in patients and peers. The response rate varied between 17% (nurses), 19% (psychologists) 21% (psychiatrists), 33% (peers) and 56% (patients).

Results: Only 7% of the participating patients had a PAD. Compared to the other groups, patients had the least knowledge on PAD. Psychiatrists were significantly more critical towards PAD. Concerns that PAD impede necessary and adequate treatment, restrict professionals and result in conflicts between patients and HCP were most frequently named as reason for critical attitudes.

Conclusions: Although being explicitly mentioned in the Swiss legislation the usage of PAD is small. Proactive information and training of psychiatrists might be helpful for a reduction of skeptical attitudes. This might improve the attitudes and lead to active support of patients during the preparation of PAD.

Keywords: Advance directives; Coercion; Decision-making-capacity; Psychiatry; Recovery; Severe mental illness.

MeSH terms

  • Adolescent
  • Adult
  • Advance Directives / legislation & jurisprudence*
  • Advance Directives / psychology*
  • Aged
  • Attitude of Health Personnel*
  • Coercion
  • Decision Making
  • Female
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Male
  • Mental Disorders / therapy
  • Middle Aged
  • Patients / psychology*
  • Personal Autonomy
  • Surveys and Questionnaires
  • Switzerland
  • Young Adult