Perspectives on advance directives in psychiatric practice: A qualitative study from Kerala, India

Context: Advance directive (AD) is being used in psychiatric care in developed countries for the last two decades. Although the AD is bound to offer patient autonomy and beneficence, evidence for its effectiveness and feasibility are limited. By the enactment of the Mental Health Care Act, 2017, India is going to implement AD. Aims: This study aimed to find perspectives on AD in psychiatric practice by different stakeholders in Kerala, India. Subjects and Methods: A qualitative study using focus group discussion and in-depth interview was done among mental health service users such as patients and carers, providers such as psychiatrists, clinical psychologists and psychiatric social workers, and advocates. Transcribed information was coded by R package for Qualitative Data Analysis, a free software. Results: The predominant themes identified were freedom of choice, issues of documentation, suitability in a crisis, apprehension about future care, mental capacity at the time of making the AD, issues about nominated representative, limitations in the exercise of treatment options by doctors, and the possibility of defensive practice in psychiatry. Half of the patients supported the AD, whereas the other half did not. Advocates agreed that patients should be given the freedom to choose and hence supported the AD. Some mental health service providers favored AD, whereas others were apprehensive. Conclusions: Although ADs help patients in preserving their autonomy, many uncertainties, practical issues, and legal issues are to be tackled for its effective implementation.