Most Autonomous Care Versus Least Restrictive Setting and the Role of Psychiatric Advanced Directives

Abstract: Psychiatric advanced directives (PADs) emerged to allow people with mental illness to state preferences for their treatment ahead of a crisis in the interest of promoting their autonomy. One motivation for individuals completing PADs is to avoid coercive interventions. This flash presentation will focus on the role PADs can play in promoting autonomy when restraints become necessary. According to the American Psychiatric Association, patients should receive care in the least restrictive setting possible. PADs, however, create the opportunity to go beyond this standard and instead provide care in the most autonomous setting possible within the constraints of incapacitation and whatever threats precipitated the restraint. I argue that a restraint conducted on a patient who has previously documented their desires about how they wish to be restrained while incapacitated is more autonomous than one conducted on the same patient who has not documented their desires. Moving from a least restrictive setting framework to a most autonomous care framework can motivate care teams to explore patient preferences about escalation and restraint proactively. Additionally, this shift highlights the importance of decision specificity in capacity assessments. Although a patient who is escalating and needs chemical restraint may lack capacity to make most medical decisions, a most autonomous care approach reminds care teams that this patient can likely still make some choices (e.g., where the medication is administered and who administers it). If the patient cannot make that decision at that moment, then this is a preference which can later be communicated in a PAD.