What are the barriers to the implementation of advance directives related to the surroundings of the patients with unfixed psychiatric illnesses? A systematic literature review

Patrice Nabbe, Cyril Hazif-Thomas, Delphine Le Goff, Axel Mouster, Bernard Le Floch, Jean Yves Le Reste

Keywords: behavior, behavior mechanism, advance care planning, psychiatric disorders


Advance care planning (ACP) are documents specifying a person’s instructions about care in the event of future loss of deciding capacity. ACP could enhance the communication, the autonomy and the control of patients suffering from mental health problems. Consumers and providers have been proved to be largely supportive for ACP.

Research questions:

What are the stakeholder's barriers to the implementation of PADs, during the mental disorder crisis time?


A Systematic Literature Review was performed in Pubmed, on survey published between 2001/01/01 and 2018/12/31. The search query was focused on “Advance Directives” and “Mental Disorders”. Abstracts exclusion criteria: No availability (I), language used were not French or English (II), no mention of ACP (III), patient was the only subject of the study (IV), patients didn’t suffer psychiatric disease (V), record didn’t talk about the patient’s surrounding (VI). Inclusion of full-articles’ criteria: availability (I), languages used were French or English (II), about the implementation during crisis time (III), patients suffered psychiatric disease (IV), survey talked about stakeholders (V), IMRAD format (VI).
A snowballing was performed on full-articles using same criteria. Articles were submitted to a thematic and a phenomenological analysis, to identify the stakeholders’ barriers to implement the ACP during crisis time.


663 records extracted. 6 records duplicate. 657 abstracts analyzed. 589 excluded. 67 full-articles eligible for inclusion, 1 not found, 52 not included, 14 included.
Using the snowballing, 352 records collected. 196 duplicate. 156 abstracts screened, 15 full-articles selected. 10 articles included.
24 articles were included for thematic analysis.
24 axial codes identified, grouped in 5 themes: Legal system, Health system, Completion phase, Integrity issues, Mistrust and lack of knowledge.


The different stakeholders involved in this process have highlighted various obstacles. To reduce and overcome them, more education and training will be needed.

Points for discussion:

what are your problems with the application of advance directives in your different countries, concerning patients suffering from psychiatric illnesses?