Services Effectiveness Research Program (SERP)

Duke University School of Medicine
Department of Psychiatry and Behavioral Sciences

Current and Recent Projects

Title: Implementation of the Health Care Decisions Act in Virginia

Sponsor: Robert Wood Johnson Foundation Public Health Law Research Program, subcontract with UVA-Charlottesville

Principal Investigator(s): Christine Wilder, MD; Jeffrey Swanson, PhD

SERP Investigators & Collaborators: Marvin Swartz, MD

Project Description: This project will study the implementation of Virginia 's newly enacted Health Care Decisions Act (HCDA) to identify key barriers and enabling factors determining the law's ultimate impact on health outcomes, safety, and quality of life for persons with severe mental illness (SMI). Virginia 's new law provides a legal mechanism for persons with chronic disabling health conditions including SMI to document, while competent, their preferences and instructions regarding treatment and to authorize a healthcare proxy to make treatment decisions for them during periods of incapacity. These advance care documents may also contain individualized, patient-centered plans to prevent, manage, and recover from crises.

Legal advance directives for mental health treatment represent an innovative and promising approach to the problem of treatment discontinuity in psychiatric patients and could play a significant role in improving long-term health and safety outcomes for this population. A major goal of these directives is to empower psychiatric patients by reducing coercive interventions during mental health crises. Unfortunately, specific psychiatric advance directive statutes in twenty-five states have largely fallen short of achieving their promised benefit due to practical problems in implementation, resistance or misunderstanding from clinicians, and weaknesses in the laws themselves. National survey data suggest that although 66% to 77% of public psychiatric outpatients want a mental health advance directive, only 4% to 13% have completed one.

Whether and how advance directives authorized in the HCDA will work in practice is unknown. A study of the implementation and perceived effectiveness of HCDA advance directives for individuals with SMIóincluding their effectiveness to improve mental health outcomes, protect public safety, and reduce legal coercionówill offer critical public health outcome information for other states that may follow Virginia 's law and policy example.