The descriptive data on competence to complete PADs reveal that, at baseline, the majority of participants were able to score more than half of all total possible points on the different domains of the DCAT-PAD. Further, scores on these domains were shown in multivariate analyses to be significantly related to participants’ cognitive functioning and psychiatric symptomatology. These findings are consistent with prior research showing that (1) patients are generally able to understand, appreciate, and reason adequately with respect to PADs and (2) there is a strong connection between symptom severity and competence to complete PADs (Srebnik et al., 2004
). To our knowledge, the current study is the first to record robust connections between these decisional capacities and neuropsychological status and to demonstrate that an intervention to facilitate PADs substantially improves certain facets of patients’ competence to complete PADs. The findings bear on the implementation of PAD laws as they indicate a systematic method of assisting patients to complete the legal documents itself can affect patients’ abilities to complete them properly. The analyses further imply that for more impaired clients, a facilitation of PADs may be helpful, or even necessary, to augment decisional capacity to a level that maximizes chances the PAD is valid.
In keeping with the usual conceptualization of competence as a multi-dimensional construct (Appelbaum & Grisso, 1995
), the findings indicated that different characteristics were related to different domains of competence to complete PADs. Both of the understanding domains measured were highly predicted by neurocognitive variables whereas the appreciation domains were most strongly predicted by psychiatric symptoms as measured by the BPRS. Reasoning was somewhat different between the two competences assessed: while insight predicted both, estimated pre-morbid IQ was not related to reasoning about how hospitalization would affect one’s life whereas it was significantly related to reasoning about how PADs would affect one’s life. Assessing competence to complete a PAD is a complex task and, if attempted, should involve evaluating understanding, appreciation, reasoning, and choice for the two different types of abilities described above.
Although clinical consideration of these abilities and their correlates may, in some cases, cast doubt on a patient’s ability to complete a PAD, the current data point to a systematic method for improving a patient’s decisional capacity, even if he or she has lower intellectual functioning. We found that when the sample was stratified by estimated pre-morbid IQ, the F-PAD intervention had a significant effect on improving PAD reasoning among lower functioning clients. It may be that higher functioning participants, even before the intervention, were able to think more abstractly about the potential consequences of having a PAD. However, for lower functioning participants, the F-PAD intervention may have been necessary to provide the participant with a concrete experience from which to better grasp how PADs would affect their lives (which, not surprisingly, is specifically measured by the reasoning domain for competence to write a PAD).
The F-PAD intervention also appeared to bolster competence to make treatment decisions within PADs. Going through the F-PAD intervention involved participants actively thinking about their preferences for hospitalization in the event of a crisis as well as how they would want hospital staff to treat them if confined to an inpatient unit. Over ninety percent of participants who completed PADs documented at least one preference about hospital treatment and all wrote how they wished staff to treat them, approximately half describing explicit instructions for reducing restraints and seclusions. As such, the F-PAD afforded participants in the intervention group an opportunity to consider consequences of hospital treatment, and again may have accounted for the increased scores measured by the DCAT-PAD at one month. For these reasons, clinicians concerned that patients may not be competent to complete PADs should consider ways of educating patients about these documents and facilitating their completion. Such efforts will maximize the likelihood that PADs will accurately reflect patients’ preferences for future treatment and also increase the likelihood of clinicians adhering to said requests.
This study had several limitations. First, hospital treatment was selected as the index decision to assess competence to make treatment decisions. Had we chosen something else (e.g., medications), we may have had different findings. Second, it could be argued that higher functioning participants did not show improvement on the reasoning domains of the DCAT-PAD due to ceiling effects. However, at one month, participants above the median estimated pre-morbid IQ had overall mean reasoning scores in the 69th percentile on competence to write PADs and in the 56th percentile on competence to make treatment decisions with PADs, indicating ample room for improvement on both (especially given that the reasoning domain scores showed a normal distribution at baseline). Regardless, none of these considerations negate the actual gains achieved by participants with estimated pre-morbid IQ<100 in the intervention group compared to their counterparts in the control group, all of whom were administered the same scale at baseline and follow-up.
Further, our study cannot answer the question of whether patients are “competent” or “not competent” to complete PADs. Following other empirical studies on decisional capacity (Grisso & Appelbaum, 1996
) and competence to complete PADs (Srebnik et al., 2004
), we maintain that arbitrary, fixed cut-off scores on competence instruments are neither feasible nor desirable. Instead, we believe the data reveal characteristics that may render a person with mental illness more or less likely to be competent. Use of the DCAT-PAD and consideration of the current data on DCAT-PAD means and standard deviations can provide important information, but this evidence is not sufficient to conclude whether someone is competent to complete a PAD.
It is also important to note that, although PAD statutes typically define ‘incapacity’ with respect to activating PADs in a psychiatric crisis, most PAD statutes—including North Carolina’s—simply state that someone must be of “sound mind” to complete a PAD. A few states are more detailed; for example, the Louisiana statute indicates that at the time a principal executes a PAD, “in determining the principal’s ability, the physician or psychologist should consider (1) whether the principal demonstrates an awareness of the nature of his illness and situation; (2) whether the principal demonstrates an understanding of treatment and the risks, benefits, and alternatives; and (3) whether the principal communicates a clear choice regarding treatment that is a reasoned one, even though it may not be in the person’s best interest.” (Advance Directives for Mental Health Treatment, 2001
). To our knowledge, there is no case law defining competence to complete PADs.
In the relative absence of guidance about standards for competence to complete a PAD, we relied on the elements usually associated with decisional competence for medical treatment and developed the DCAT-PAD instrument to operationalize them in this related, but slightly different, context. We can not guarantee that this approach would be taken by a legislature or court that in the future attempted to define competence to complete a PAD. However, the DCAT-PAD has face validity given its similarity to established approaches to competence in related mental health care situations. Moreover, states such as Louisiana appear to have taken a similar conceptualization in writing and passing PAD statutes.
Finally, the data beg the question: Should clinicians assess competence among patients who want to complete PADs? Although the law presumes that people are competent to complete PADs, because mental illness often involves fluctuating decisional capacity, the patient’s ability to write a PAD may be questioned (Varma & Goldman, 2005
). However, some have noted that mandatory screening or placing the burden on people with mental illness to prove competence would amount to discrimination against disabled adults (Srebnik et al., 2004
) Still, people who do not have mental illnesses may elect to have a competence assessment in legal contexts; for example, to ensure a will is followed according to one’s wishes.
From a practical standpoint, clinicians may be most likely to raise the issue of competence to complete a PAD when a patient documents a refusal of standard treatment. If patients exhibit psychiatric symptoms or cognitive deficits while documenting a treatment refusal, the current data suggest a pragmatic need for the patient to undergo a competence evaluation to boost chances that the PAD is later deemed valid. If patients show no such impairments at the time, it may still be advisable for patients to explicitly state in the PAD their reasons for a treatment refusal. This tactic, which in fact was part of the F-PAD facilitation, would help doctors later infer whether the refusal was based on solid reasoning, thereby reducing the chances of doctors overriding the PAD because they perceive that the patient was incompetent when the PAD was completed.
In conclusion, the results elucidate characteristics associated with competence to complete PADs and suggest that cognitively impaired patients are good candidates for PAD facilitation to best ensure that their advance instructions are valid. At the same time, the findings raise important questions about how clinicians should deal with the issue of competence in the context of PADs. Such inquiry is needed if PAD laws are to succeed in meeting their original intent to help people with mental illnesses communicate to doctors important clinical information and become empowered to take charge not only of their own treatment, but ultimately, of their own lives.