Issues in the development of advance directives in mental health care

<i>Background</i>: Interest in advance directives in mental health care is growing internationally. There is no clear universal agreement as to what such an advance directive is or how it should function. <i>Aim</i>: To describe the range of issues embodied in the development of advance directives in mental health care. <i>Method</i>: The literature on advance directives is examined to highlight the pros and cons of different versions of advance directive. <i>Results</i>: Themes emerged around issues of terminology, competency and consent, the legal status of advance directives independent or collaborative directives and their content. Opinions vary between a unilateral legally enforceable instrument to a care plan agreed between patient and clinician. <i>Conclusion</i>: There is immediate appeal in a liberal democracy that values individual freedom and autonomy in giving weight to advance directives in mental health care. They do not, however, solve all the problems of enforced treatment and early access to treatment. They also raise new issues and highlight persistent problems. <i>Declaration</i> <i>of</i> <i>interest</i>: The research was funded by the Nuffield Foundation grant number MNH/00015G