What's the difference between an advance statement, an advance directive and a joint crisis plan?

Claire Henderson: Yes, there are lots of terms. I think the easiest place to start is with an umbrella term for all these different things. So they can all be classed as ‘advanced statements’ – where there is some sort of a statement made about what somebody wants to happen in the event of a relapse of their illness.

Now ‘advanced directive’ really implies something that is legally binding – that’s the term that is used throughout the US where there is Advance Directive legislation, both for ‘near end of life care’ and, increasingly, for ‘psychiatric advance directives’ specifically. In this country I think the term is ‘Advanced Decision’ in the Mental Capacity Act, which allows you to refuse treatment in advance and that’s legally binding.

Now, a ‘joint crisis plan’ is a type of advanced statement that doesn’t have any legislative underpinning. Basically it’s the result of a facilitated discussion between a service user and the people involved in their care – so that’s formal providers, psychiatrist and care co-ordinator, and anyone they want to invite into that discussion in terms of friends, advocates.  And the facilitator is a key part of this – it’s a mental health professional who is not part of the treatment team – and their role is to make sure that the service user’s voice is heard in this discussion. So they meet with them ahead of time to prepare them for the second meeting where it’s going to be finalised so they can think about what they want to have on the plan.  Then in the meeting where you finalise it, the facilitator has to make sure the service user is going to be happy with the content because the idea is they are going to carry a copy of it, and obviously if they are not happy they won’t keep it and it will be of no use.

People often worry that the discussion will just result in a stalemate of disagreement because a service user will say: ‘Well I never want to come into hospital again’ – and the care team will say: ‘Well we might have to hospitalise you.’ And the facilitator’s job is to try and find what the areas of agreement are, and what, for example, were the worst things about being admitted?, and can those particular aspects be avoided in the future?, so a more acceptable version of being admitted can be agreed on.

A lot of the difference has to do with the process not just the legal framework. An advance statement or advance refusal of treatment doesn’t require any discussion with the care team.  The service user can write it down, get it witnessed if need be, and obviously they have more autonomy in that situation. But on the other hand they won’t know if people will follow it, they won’t necessarily know if other people are aware of it.