30th November 2018, Volume 131 Number 1486

Jessie Lenagh-Glue, Anthony O’Brien, John Dawson, Katey Thom, Johnnie Potiki, Heather Casey, Paul Glue

Consumer engagement is well documented as an important step in facilitating mental health recovery.1 One means of increasing consumers’ experience of participation in decisions regarding their mental healthcare is through advance care planning. This has become a feature in mental health systems in the US, the UK and other European countries, and in Australia and New Zealand.2 It may take the form of joint crisis plans, psychiatric advance directives, wellness recovery action plans or advance statements. The central premise is that consumers and carers are both major stakeholders in the planning and delivery of healthcare.

Studies have shown that while consumers are motivated to collaborate in care-planning, they still face substantial barriers.3–6 Poor information exchange and insufficient participation in decision-making may leave consumers feeling marginalised in both inpatient and community settings.3 Similarly, Farrelly et al showed that although consumers “with psychotic disorders make clinically reasonable requests for specific treatments in crisis/relapse situations”,4 clinicians were ambivalent about care planning, and were concerned that consumers’ choices would not be clinically appropriate.5 Failure by clinicians to engage constructively in the process undermined consumers’ experience of joint crisis planning.5

A systematic review by Bee et al6 explored how consumer involvement in care-planning was operationalised in practice as compared to theory. Consumers reported having insufficient information and support to contribute in a meaningful way. They also consistently reported a persistent failure to provide them with pharmacological information, or choices about their medication. Many said they lacked confidence in their ability to participate in a meaningful manner, experienced a strong power imbalance, or felt that staff displayed an “inherent disregard for their views”.6 Cree reported that carers also felt that patient confidentiality was used to create a barrier between them and service providers.7

One theoretical framework used in this field is that of procedural justice, an idea derived from legal and psychological scholarship.8 In the current context, this idea concerns fair processes in clinical decision making, being particularly concerned with how decisions are made, not just the outcome. The concepts of voice, dignity and respect for the consumer are central. It has consistently been found that when principles of procedural justice are followed, consumers feel affirmed and are more likely to trust the process, even if ultimately the decisions are not those they prefer. The notion fits well with the use of instruments like MAPs, where the processes of development and implementation are explicitly aimed at eliciting consumers’ preferences and following them as far as possible. Generally, research shows that adherence to procedural justice is associated with greater satisfaction with care.8–10

While New Zealand law acknowledges the right of all consumers to use advance directives (AD),11 in practice there has been limited uptake of this by mental health consumers.12–13 Consumers and their whānau we spoke with reported that even if they had an AD, these were disregarded by service providers or not followed during periods of crisis. Policy makers in New Zealand are conscious of the perception that the Mental Health (Compulsory Assessment and Treatment) Act 1992 (MHA) fails to comply with New Zealand’s obligations under the Convention of the Rights of Persons with Disabilities, and recent recommendations by the Ministry of Health include the need to encourage a shift towards more collaborative decision-making and a greater use of ADs.14–15 This is in line with the United Nation’s Committee on the Rights of Persons with Disabilities emphasis away from substitute decision-making towards prioritising respect for a person’s “wills and preferences”.14

The challenge, therefore, is to create an instrument and a process that will produce an advance care plan that is meaningful for all service consumers and has sufficient “buy in” from clinicians and service providers. To this end, we now prefer the term “MAP” (Mental-health Advance Preferences statement), rather than AD, as a more collaborative and less proscriptive approach.

The current paper reports on a survey designed to ascertain what consumers and providers felt was important to include in a MAP. The survey is part of a wider project to create a MAP instrument and process which will be implemented in the Southern District Health Board Mental Health Addictions and Intellectual Disability Services (SDHB-MHAID). An evaluation of this implementation will be reported in a subsequent publication.

Method

This study was approved by the Auckland University Ethics Committee and was registered with the ANZ Clinical Trial Registry (ACTRN12618001720202). The study was informed by an earlier exploratory survey16 which demonstrated strong support for the use of ADs within mental health services in New Zealand, but with limited consensus on what should be included in the instrument, and no guidance on processes for completion.

To determine what both consumers and service providers felt would be the key elements of a MAP instrument, we developed two online Qualtrics surveys, one for consumers and their whānau, and the other for service providers. The general format of the two surveys was the same. They used Likert-rated items concerning participants’ familiarity with the concept of a directive, followed by 26 questions that asked participants to rank their views—from strongly agree to strongly disagree—concerning the content, value, utility and legal status of ADs, and two questions regarding general support for ADs. The service-provider survey had seven demographic questions compared to five for consumers. Both surveys included an open-ended question on the participant’s personal experience with ADs, as well as opportunity for participants to provide free text comments about ADs. A second arm of the study was a series of focus groups for service users, their whānau and peer support workers. This was aimed at getting specific feedback on both past experience with ADs and aspirations for what a future instrument should contain. These data will be presented in a forthcoming manuscript.

Participants in the service-provider survey were recruited by email invitation. This was sent initially to all clinical and non-clinical staff of the SDHB-MHAID (approximately 700 individuals). It was followed with a reminder two weeks later. Recruitment of consumers and their whānau was coordinated by a member of the research team who is the Consumer Advisor for SDHB-MHAID. He approached coordinators of local mental health support services and NGOs, who were requested to inform their members of the survey and to distribute flyers detailing the project. In addition, an email was sent to the adult services manager and the specialist services manager who then forwarded the link to staff. The link was also sent to a list of 20–30 providers. All these providers were asked to forward the information and link to their consumers or clients. Data from the surveys were entered in an Excel spreadsheet and were analysed using a Chi2 (X2; asymptotic, two-sided) analysis to compare the scores of consumers and service providers. Excerpts from the free text comments are included to further illustrate the findings.

Results

Demographics

The 23 consumer participants in the survey were almost evenly divided between men and women. Half the respondents were either current or previous outpatients of SDHB’s mental health services, with the balance either previous inpatients, or reported they were in the ‘other’ category. Almost half the consumers had been in contact with mental health services for more than 20 years (n=11, 45.8%). The clinicians and consumers responding were predominantly New Zealand European. Half of the 75 clinicians said they currently worked in inpatient settings (n=37, 49.3%); 68% were nurses (n=51); and 16% psychiatrists (n=12). Most clinicians (n=55, 73%) had been working in mental health services for more than 11 years, with the majority of those having more than 20 years experience (n=31, 41.3%).

Knowledge of ADs

The majority of consumers surveyed (83%) were aware of the existence of ADs but only about 20% had made one personally or been involved in their use (n=5, 21%). Sixty-two percent of clinicians who responded had been involved in the process of creating an AD, while almost 15% said they had been involved in provision of services that overrode an AD.

Content of MAPS

We divided the potential content of an AD (that we have subsequently come to call a MAP) into two separate categories: ‘treatment-related options’ and ‘personal support choices’ (see Table 1). The Likert scale was collapsed from seven down to three categories: ‘agree’ (‘strongly agree’ + ‘agree’); ‘neutral’ (‘somewhat agree’ + ‘neutral’ + ‘somewhat disagree’); and ‘disagree’ (‘disagree’ + ‘strongly disagree’). Comparing service providers’ and consumers’ responses identified statistically significant differences for two items only: “it would be useful if consumers specified the medications they prefer not to have in their advance directives” (X2=6.39, p=0.04) and “an advance directive could allow consumers to state a preference that seclusion is not used” (X2=8.34, p=0.02). These were items where there was least agreement between consumers and service providers.

Table 1: Content of MAPS. Collapsed Likert scale (strongly agree + agree) (somewhat agree + neutral + somewhat disagree) (disagree + strongly disagree).

Treatment-related options

 

Agree (%)

Neutral (%)

Disagree (%)

X2

p

It would be useful if consumers specified the medications they prefer not to have in their advance directive.

Consumers

Clinicians

91

64

9

32

0

4

6.39

0.04

It would be useful if advance directives included a choice about alternatives to hospital admission.

Consumers

Clinicians

87

75

13

20

0

5

2.03

0.36

It would be useful if advance directives allowed consumers to initiate a mental health service response when they become aware of early warning signs.

Consumers

Clinicians

96

87

4

12

0

1

1.48

0.48

It would be useful if an advance directive allowed consumers to detail specific medications they would prefer to have.

Consumers

Clinicians

83

75

17

21

0

4

1.20

0.55

An advance directive could allow consumers to state a preference that seclusion is not used.

Consumers

Clinicians

83

50

17

36

0

14

8.34

0.02

Consumers should be able to make rank-ordered preferences among seclusion, seclusion + restraint, and sedating medication.

Consumers

Clinicians

65

51

30

39

4

14

1.78

0.41

It would be useful if consumers detailed what methods of de-escalation they would prefer to be used in emergency situations in their advance directives.

Consumers

Clinicians

96

79

4

18

0

3

.351

0.17

Personal support choices

It would be useful if advance directives specified persons who consumers do not wish to visit during hospitalisation.

Consumers

Clinicians

100

91

0

7

0

3

2.31

0.32

It would be useful if the name of the consumer’s preferred legal representative were included in their advance directives.

Consumers

Clinicians

96

88

4

9

0

3

1.96

0.38

It would be useful if the contact details of persons to take care of finances, dependents and pets during hospitalisation were specified in an advance directive.

Consumers

Clinicians

91

92

4

7

4

1

0.94

0.63

It would be useful if advance directives include options for cultural support.

Consumers

Clinicians

91

85

9

12

0

3

0.86

0.65

It would be helpful if advance directives specified persons to be notified on hospitalisation.

Consumers

Clinicians

96

96

4

3

0

1

0.47

0.79

It would be useful if advance directives included a consumer’s choice of support person.

Consumers

Clinicians

96

87

4

11

0

3

1.54

0.46

It would be useful if dietary preferences were specified in advance directives.

Consumers

Clinicians

74

57

26

37

0

7

2.96

0.23

There was strong support for all items in the ‘personal support’ category from both consumers and providers. There was also strong support from consumers for all the choices listed in ‘treatment options’. Consumers and providers were most strongly in agreement with the statement that “advance directives should specify persons to be notified on hospitalisation” (96%, n=22 of consumers and 96%, n=72 of service providers). Service providers and users also strongly agreed that ADs could specify persons they did not wish to have visit if they were hospitalised (Table 1). There were a further four categories that more than 95% (n=22) of consumers considered should be included in an AD: choice of support person; name of legal representative; the ability to initiate a mental health service response when they became aware of early warning signs; and detail on the methods of de-escalation preferred. More than 90% of consumer responders (n=21, 91%) also believed that an AD should list specific medications they preferred not to have, and 83% thought they should detail preferred medications.

While there was general agreement between providers and consumers regarding the content of ADs, Table 2 shows some significant differences in the perceived value and utility of such instruments. Although both groups agreed that ADs increase consumers’ sense of responsibility, empowerment and autonomy, service providers were much less likely to agree that ADs helped consumers engage with mental health services or increased their self-management skills. This was reflected in some of the free text comments included in the survey.

Table 2: The content of MAPS. Collapsed Likert scale (strongly agree + agree) (somewhat agree + neutral + somewhat disagree) (disagree + strongly disagree).

The value of advance directives

 

Agree (%)

Neutral (%)

Disagree (%)

X2

p

Advance directives increase consumers’ sense of responsibility.

Consumers

Clinicians

87

58

13

19

0

3

1.45

0.49

Advance directives increase consumers’ sense of empowerment.

Consumers

Clinicians

96

85

4

15

0

0

NC

NC

Advance directives increase consumers’ sense of autonomy.

Consumers

Clinicians

93

76

9

23

0

1

2.60

0.27

Advance directives help people engage with mental health services.

Consumers

Clinicians

100

64

0

33

0

3

11.43

0.003

Advance directives increase consumers’ self-management skills.

Consumers

Clinicians

100

68

0

27

0

5

9.75

0.008

The utility of advance directives

Clinicians generally follow the instructions of an advance directive.

Consumers

Clinicians

14

11

82

74

5

15

2.62

0.27

Consumers would use advance directives to refuse hospital admission.

Consumers

Clinicians

0

18

82

70

18

12

0.62

0.27

Advance directives are ineffective because clinicians do not know whether they have been completed.

Consumers

Clinicians

27

18

64

70

9

12

1.06

0.60

Clinicians should make their own assessment about whether the instructions of an advance directive should be followed.

Consumers

Clinicians

14

32

50

55

36

12

7.83

0.02

Consumers would use advance directives to refuse medication.

Consumers

Clinicians

9

16

77

72

14

12

.69

0.71

Advance directives are necessary because mental health consumers are at risk of their rights being breached.

Consumers

Clinicians

78

18

17

52

4

30

29.45

<0.0001

Legal status of advance directives

The Mental Health (Compulsory Assessment and Treatment) Act 1992 should override instructions contained within advance directives.

Consumers

Clinicians

17

42

53

55

30

3

17.34

0.002

I have an ambivalent attitude towards (advance directives). Whilst I see them as potentially empowering, and able to give a consumer a greater sense of autonomy/efficacy in negotiating their treatment with health providers, I am also aware they can be overridden. I hate the idea of setting up a false expectation. However, I think they are under-utilised, and can be very useful in enabling people to get the kind of help they would prefer when they are unable to articulate this due to illness. [Service provider respondent].

Perceptions of utility

Consumers’ and providers’ perceptions varied concerning the utility of ADs (Table 2). Interestingly, only 11% (n=8) of service providers agreed with the statement that they generally followed the instructions in an AD, while 15% (n=11) disagreed. One provider gave the following example:

…one consumer I have worked with several times has an advance directive that specifies which treatments are effective and tolerable for her. This has (in my opinion) really helped her to get better quickly and get out of hospital. A couple of times I have had to override advance directives that are mainly negative requests and exclude treatments that could be more effective.

While not statistically significant, consumers were less decided on whether clinicians generally followed the provisions of an AD, with 82% (n=18) neutral. Some consumers who have ADs reported these were effective: “I have used advance directives in the past. My wishes were adhered to in my subsequent times of crisis.” Others were less positive, with one consumer reporting: “I created my advance directive with non-DHB services. Unfortunately, no DHB staff follow it, and never have.”

There were significant differences in the responses of consumers and providers on two items in this category: the belief that “clinicians should make their own assessment about whether the instructions of an advance directive should be followed” (X2=7.83, p=0.02); and the idea that “advance directives are necessary because mental health consumers are at risk of their rights being breached” (X2=29.45, p<0.0001).

Legal status of ADs

Consumers and providers also differed in their views on whether the MHA should override instructions in an AD. These differences were statistically highly significant (X2=17.34, p=0.002), with 42% (n=31) of clinicians agreeing that the MHA should be able to prevail, while only 17% (n=4) of consumer respondents felt this should be the case. In addition, a significant majority of consumers (n=11, 78%) agreed that ADs were necessary because mental health consumers were at risk of having their rights breached.

These findings illustrate a continuing perception that clinicians hold significant power over mental health consumers in this context. One family member of a patient who died in inpatient care said:

Why do clinicians not offer this to all users of the service and include families in this discussion? Also, are advance directives ever respected since the Mental Health Act overrules everything and gives psychiatrists total power and control over people who are hurting? The power imbalance is huge.

General support for ADs

Table 3 illustrates broad support for ADs amongst the consumers, with the majority reporting they would definitely (n=18, 78%) or maybe (n=5, 22%) create one if given the chance.

Table 3: Support for ADs.

Support for ADs

 

 

Agree (%)

Maybe (%)

Disagree (%)

X2

p

I would be interested in supporting an advance directives initiative in the SDHB area.

Consumers

Clinicians

78

66

22

26

0

8

2.42

0.30

Service providers were also generally positive about ADs. Nevertheless, only 66% (n=48) agreed they would definitely support an initiative to promote their use in the SDHB, while 8% (n=6) said they would not support this. Their support in principle appeared tempered by concerns about their application in practice. One service provider described the situation as follows:

Simple in theory and easy to put together. Much more complex, and sometimes a bit fraught, when it comes to enacting it or overriding it. Need to be clear to what extent the AD replaces the current assessment.

Discussion

This research builds on a preliminary study conducted by Thom et al.16 As noted in that study, all questions concerning potential content of a preferences instrument elicited strongly positive responses: almost all participants agreed or strongly agreed that all the items concerning personal choices should be included in the instrument, and a significant majority supported inclusion of items regarding treatment options. The only two items on which service providers and consumers differed concerned choice of medication and use of seclusion. The finding that consumers are not in favour of using seclusion is unsurprising, based on previous studies4,16,17 and human rights discourse.14,18

Under current New Zealand law, it seems that the MHA can lawfully override consumers’ preferences regarding their ‘treatment for mental disorder’. Partly for that reason, it may be better to avoid suggesting that consumers can ‘direct’ their future care. Advance directives are primarily focused on giving or refusing treatment in future healthcare whereas the MAP also includes personal choices about functions of daily living. This holistic view of treatment aids in engagement with the treatment team and clinicians should work with these preferences to the maximum extent possible notwithstanding that they may ultimately be overridden. For consumers who are not under the MHA and retain capacity in the matter, the Health and Disability Consumers’ Code of Rights (1996) (the Code) already affirms their right to refuse services, including medication.19

This study confirms that both providers and consumers generally support a more consumer-focused policy approach in the provision of mental health services. In Australia, psychiatric ADs are now incorporated into mental health legislation in four states,20 reflecting a stronger recognition of consumer autonomy. The key is to balance respect for individual autonomy with recognition of clinical best practices. Framing the instrument as a MAP, or a statement of preferences, may enable this. Even when a consumer’s preferences are not adhered to in clinical decision-making, these preferences should still inform how the clinician negotiates the treatment provided. This is in accordance with the Code, and also provides an example of how mental health practice can give expression to human rights principles.21

Strengths

This study used an established methodology and confirmed earlier results.16 The impetus for the study came from a collaboration between a Consumer Advocate of the SDHB and a multi-disciplinary team comprised of legal and health academics, clinicians, service users and service management. This research has resulted in the creation of a practical instrument that will be incorporated into service delivery of that DHB.

Limitations

While the results confirmed the 2015 study,16 the overall sample size was relatively small. Of a sample population of 700 service providers, only 75 respondents fully completed the online survey. While we do not have an exact number of potential service users and their whānau eligible to participate, 23 is a very small number and not necessarily representative of the wider population of mental health service consumers. Similarly, this is a local study of one DHB which may not reflect trends in the wider New Zealand population. Although we consulted with Māori, we do not have confirmation that the instrument developed reflects Māori experiences of mental health care, and it does not explicitly incorporate a Pasifika perspective.

Conclusion

Our results notably confirm those of the earlier study by Thom and colleagues.16 Both studies show strong support for the general idea of ADs among clinicians and consumers. The two groups seem to have different expectations, however, as to how far the content of such instruments should be followed in practice, especially concerning medication and seclusion. These differences of opinion are well-documented in the literature. As MAPs are more widely introduced, these different expectations must be kept strongly in mind. This study supports wider implementation of MAPs, but shows the need for the different groups’ expectations to be very carefully considered.

Summary

Advanced Directives are documents that mental healthcare consumers can create, to list treatment and support preferences when they become unwell. Advanced Directives are seldom created in New Zealand as service consumers report these are often ignored by clinicians. We developed a document and a process for creating an advanced directive, based on surveys with service consumers and clinicians. We have called this a MAP (Mental-health Advance Preferences statement). Both groups reported strong overall support for advance directives, particularly around items concerning personal support at difficult times. There was a strong difference of opinion between clinicians and consumers on whether the Mental Health Act powers should be able to override the consumer’s instructions. Using peer support workers as facilitators may be an important step in successful completion of an advance directive.

Abstract

Aim

To document the process of developing a local advance directive for mental health care, which we are calling a MAP (Mental-health Advance Preferences statement).

Method

Data on advance directive preferences were collected from consumers and service providers using online surveys and analysed using quantitative methods.

Results

Both groups reported strong overall support for advance directives. They particularly favoured inclusion of items concerning personal support at difficult times. Consumers strongly advocated inclusion of statements regarding treatment options. There was broad agreement that advance directives could increase consumers’ sense of autonomy and empowerment, but service providers were less inclined to believe they helped consumers engage with mental health services or improve self-management skills. There was a highly significant divergence between service providers and consumers on whether the powers under the Mental Health Act should be able to override the consumer’s instructions.

Conclusion

MAPs aimed at facilitating treatment decisions have good acceptability from consumers and mental health clinicians. The use of peer support workers as facilitators may be an important step in successful completion of an advance directive. Future research will aim to examine national implementation of MAPs.

Author Information

Jessie Lenagh-Glue, Senior Research Fellow, Faculty of Law, University of Otago, Dunedin;
Anthony O’Brien, Senior Lecturer, Faculty of Medical and Health Sciences, University of Auckland, Auckland; John Dawson, Professor, Faculty of Law, University of Otago, Dunedin;
Katey Thom, Centre for Non-Adversarial Justice, Auckland University of Technology, Auckland;
Johnnie Potiki, Consumer Advisor, Southern District Health Board, Dunedin;
Heather Casey, Director of Nursing, Southern District Health Board, Dunedin;
Paul Glue, Professor, Department of Psychological Medicine, University of Otago, Dunedin.

Correspondence

Paul Glue, Hazel Buckland Chair of Psychological Medicine, School of Medical Sciences, University of Otago, PO Box 913, Dunedin.

Correspondence Email

paul.glue@otago.ac.nz

Competing Interests

This research was supported by a grant from the James Hume Fund.

References

  1. Ministry of Health. Rising to the challenge. The Mental Health and Addiction Service Plan 2012-2017. Wellington (NZ): MoH; 2012. Available from: http://www.health.govt.nz/publication/rising-challenge-mental-health-and-addiction-service-development-plan-2012-2017 Accessed 25 September 2018.
  2. Henderson C, Swanson JW, Smuckler G, et al. A typology of advance statements in mental health care. Psychiatr Serv. 2008; 59(1):63–71.
  3. Bee P, Brooks H, Fraser C, Lovell K. Professional perspectives on service user and carer involvement in mental health care planning: a qualitative study. Int J Nurs Stud. 2015; 52(12):1834–45.
  4. Farrelly S, Brown G, Rose D, et al. What service users with psychotic disorders want in a mental health crisis or relapse: thematic analysis of joint crisis plans. Soc Psychiatry Psychiatr Epidemiol. 2014; 49(10):1609–17.
  5. Farrelly S, Lester H, Rose D, et al. Barriers to shared decision making in mental health care: qualitative study of the Joint Crisis Plan for psychosis. Health Expect. 2016; 19(2):448–58.
  6. Bee P, Price O, Baker J, Lovell K. Systematic synthesis of barriers and facilitators to service user-led care planning. Br J Psychiatry. 2015; 207(2):104–14.
  7. Cree L, Brooks H, Berzins K, et al. Carers’ experiences of involvement in care planning: a qualitative exploration of the facilitators and barriers to engagement with mental health services. BMC Psychiatry. 2015; 15:208–19.
  8. Tyler TR. Why people obey the law. Princeton (NJ): Princeton University Press; 2006.
  9. Galon PA, Wineman NM. Coercion and procedural justice in psychiatric care: State of the science and implications for nursing. Arch Psychiatr Nurs. 2010; 24(5):307–16.
  10. McKenna BG, Simpson AI. An analysis of procedural justice during psychiatric hospital admission. Int J Law Psychiatry. 2001; 24(6):573–81.
  11. Code of Health and Disability Services Consumers’ Rights, Right 7(5).
  12. Nicaise P, Soto VE, Dubois V, Lorant V. Users and health professionals’ values in relation to a psychiatric intervention. The case of psychiatric advance directives. Adm Policy Ment Health. 2015; 42:384–93.
  13. Weller P. Psychiatric advance directives and human rights. Psychiatry Psychol Law. 2010; 17(2):218–29.
  14. Ministry of Health. The Mental Health Act and human rights: A discussion document. Wellington (NZ): MOH; 2017. Available from: http://www.health.govt.nz/our-work/mental-health-and-addictions/mental-health/mental-health-and-human-rights-assessment Accessed 28 September 2018.
  15. Ministry of Health. Thematic analysis of submissions. Wellington (NZ) MOH; 2017. Available from: http://www.health.govt.nz/our-work/mental-health-and-addictions/mental-health/mental-health-and-human-rights-assessment Accessed 28 September 2018.
  16. Thom K, O’Brien AJ, Tellez JJ. Service user and clinical perspectives of psychiatric advance directives in New Zealand. Int J Ment Health Nurs. 2015; 24(6):554–60.
  17. Henderson C, Farrelly S, Flach C, et al. Informed, advance refusals of treatment by people with severe mental illness in a randomised controlled trial of joint crisis plans: demand, content and correlates. BMC Psychiatry. 2017; 17(1):376–83.
  18. Shalev S. Thinking Outside the Box? A review of seclusion and restraint practices in New Zealand. Wellington (NZ): New Zealand Human Rights Commission; 2016. Available from: http://www.seclusionandrestraint.co.nz. Accessed 15 September 2018.
  19. Code of Health and Disability Services Consumers’ Rights, Right 7(7).
  20. Ouliaris C, Kealy-Bateman W. Psychiatric advance directives in Australian mental-health legislation. Australas Psychiatry. 2017; 25(6):574–77.
  21. Convention on the Rights of Persons with Disabilities (CRPD), 30 March 2007, entered into force 3 May 2008.