1280 Learning from international experience: best practice legislative models for advance directives for mental health treatment

<h3>Research Question</h3> Is there an international best practice model for regulating mental health advance directives? <h3>Background</h3> Treatment for mental illness can be long-lasting, invasive, and can have potentially serious side effects. However, untreated mental illness can itself have very serious consequences, including self-harm, suicide, violence towards others, and damage to relationships. Given the magnitude of the consequences of both treatment and non-treatment, many people with mental illness wish to make mental health advance directives (MHADs) setting out their instructions for future treatment when they have temporarily lost decision-making capacity. Although many countries have legislation governing advance directives for medical treatment for physical conditions, these laws are generally not appropriately tailored to mental illness. Some are confined to end of life, and others relate only to refusals of treatment. Few specifically include self-binding advance directives, which some people with mental illness (particularly bipolar disorder) would like to make. <h3>Method</h3> The authors conducted international comparative legal research which identified jurisdictions which have enacted specific MHAD laws and analysed the content of those laws. <h3>Results</h3> The paper evaluates MHAD laws in 25 states of the USA, the Netherlands, Scotland, India, the Philippines, the ACT and Victoria. The focus is on the circumstances in which MHADs may be binding, or may be overridden, as well as the interaction with involuntary treatment laws. The strengths and weaknesses of the various legislative approaches adopted in those countries are highlighted. <h3>Unique Contribution</h3> A comprehensive evaluation of MHAD laws internationally has not been attempted before. There is considerable variation between the legislative approaches. This paper explores these differences and identifies aspects of laws which can promote the uptake and effectiveness of MHADs, allowing individuals to be treated in accordance with their directions and preferences. Effective legislation promotes individual autonomy and reduces coercion in the mental health system. The paper also highlights aspects of legislation, particularly broad exceptions, which can undermine the utility of MHADs and hinder recovery. <h3>Implications</h3> The paper concludes with a proposal for legislative change, suggesting a model for other states or countries wishing to regulate this topic in future to promote treatment in accordance with the preferences of persons with mental illness where possible.