The psychiatric advance directive (PAD), also known as a Ulysses pact, is a document which states an individual's preferences in psychiatric treatment. If desired, the individual may also appoint a surrogate decision-maker, in the event that his/her condition worsens and mental capacity is lost.
PADs are used worldwide but are not incorporated into Singapore law. The closest local equivalent is referred to as advance care planning (ACP), which involves discussions where individuals articulate their values and shape future healthcare decisions. The PAD could be perceived as a subset of ACP, but it is not a formally adopted practice in Singapore.
Ethical bases of PADs
PADs are based upon the four main ethical principles of medical practice: autonomy, beneficence, non-maleficence and justice.
Firstly, PADs fulfil the principle of autonomy by allowing patients to exercise control over their psychiatric healthcare in anticipation of a time when they lack mental capacity. This is done by specifying the desired method of treatment and instructions for future care plans.
Secondly, PADs aim to support the principle of beneficence by allowing patients to receive care according to their personal values and preferences. Treating clinicians can align these preferences to create an optimal treatment plan for each patient, thereby strengthening the therapeutic alliance and enhancing personalised care.
Thirdly, the principle of non-maleficence is achieved by PADs endorsing clear management plans, guiding clinicians in providing their patients' preferred treatment and thereby potentially reducing distress and the use of coercive means. This is especially paramount for psychiatric patients who are unwell, when they are in a vulnerable state.
Lastly, PADs, being legal documents, uphold the principle of justice by ensuring that patients' preferences are consistently respected, promoting access to effective preference-aligned care. This is as opposed to coercive treatment, which involves the use of forced medication. Targeted and appropriate treatment may also potentially lead to reduction in hospitalisation duration and efficient usage of mental health resources.
PAD usage in other countries
PADs are used in many countries across the globe. They function best within healthcare models that support patient autonomy and have legal frameworks to ensure that these directives are adhered to. The use of PADs varies from country to country, including the extent to which they are enforced.
In the USA, individuals may use PADs to specify their preferred medications, methods of treatment and hospitals. Individuals may also appoint someone to make decisions for them, similar to the Lasting Power of Attorney concept used in Singapore. Laws regarding PADs differ from state to state, with many states legally recognising PADs, while others may incorporate the concept of PADs into general medical directives.
In Victoria, Australia, the concept of "advance statements of preference" is similar to the PAD, allowing psychiatric patients to document their preferences for mental health treatment in case they lose mental capacity. An authorised physician is only allowed to deviate from the advance statement of preference if they have reason to believe that the patient's preferred treatment is not clinically appropriate, or if the mental health service is unable to provide the patient's preferred treatment. The psychiatrist who chooses to deviate from the advance statement of preference must inform the patient and provide reasons for his/her decision in writing within ten business days.
In most Asian countries, PADs are not formally endorsed. In theory, PADs could fit under the broader approach of ACP. A notable exception is India, which formally made PADs part of its legislation, with its most recent iteration published under the Mental Healthcare Act 2017. Similar to the USA, PADs give patients suffering from mental illnesses a platform to outline their treatment preferences in advance. They may also appoint a representative to make care decisions for them if needed. PADs must be registered with Mental Health Review Boards to be considered valid. Once registered, PADs are to be adhered to during any interaction with mental health professionals, barring psychiatric emergencies.
Singapore does not have formally legalised PADs. For now, clinicians in Singapore could potentially make use of the concepts of PAD and ACP to formulate an agreement with patients for advance psychiatric treatment plans.
Considering PAD use in Singapore
The following is a case study that illustrates the potential use of PADs in Singapore. The patient, Ms T, diagnosed with Bipolar I Disorder, has been receiving treatment at the Institute of Mental Health (IMH) since 2002.
According to available electronic records, Ms T was hospitalised 13 times between 2007 and 2024, mainly due to acute manic relapses of Bipolar I Disorder. Her manic episodes often exhibited severe symptoms, necessitating admission to IMH's High Dependency Psychiatric Care Unit. During these instances, she would be admitted under the Mental Health (Care and Treatment) Act 2008 and initiated on formalised treatment. Unfortunately, her acute manic symptoms did not respond well to mood stabilisers and antipsychotics. Electroconvulsive therapy (ECT) was the only effective treatment. However, she would often lack insight and decision-making capacity, and thus refuse the life-saving treatment. Therefore, her treating team would seek a second opinion and eventually proceed with ECT in the patient's best interest. This meant delays in the initiation of effective treatment.
During periods of remission, Ms T is a high-functioning individual who is insightful and committed to maintaining her health. She also acknowledges that ECT is the only effective treatment during her periods of acute mania.
Therefore, Ms T and her primary psychiatrist made the decision to sign an agreement consenting to the initiation of ECT in the event of manic relapses. This agreement was modelled after the tenets of PADs used internationally. While it is not a legally recognised document in Singapore, the agreement was made to empower Ms T by involving her in a shared decision-making process, determining her treatment plans for when she loses mental capacity in the future due to a relapse. It not only functions as a valuable reference for clinicians involved in her care, but also enables them to honour her preferences when Ms T lacks the capacity to make treatment decisions.
Conclusion
PADs in Singapore could steer psychiatric care away from more common paternalistic approaches towards one that is collaborative, enhancing doctor-patient relationships. At the same time, PADs support an ethical, patient-centred approach to psychiatric care. In Singapore, while PADs are not yet legal, clinicians may still be able to apply the concepts of PADs in signed agreements with their patients, as seen in the case example above. By empowering individuals with mental health conditions to have a voice in their treatment, we can honour their wishes while preserving their dignity.