Barriers and facilitators for mental-health professionals in the management and implementation of advance directives

Abstract

Background: The Advance Directive (AD) serves as a fundamental legal and ethical instrument for safeguarding patient autonomy, ensuring that clinical decisions align with individual values when decision-making capacity is compromised. Despite the established legal framework in Spain since 2002, its practical implementation within mental health services remains largely under-researched. The objective of our study is to describe the barriers and facilitators perceived by mental-health professionals regarding the clinical management and implementation of the Advance Directive (AD). Methods: A descriptive, cross-sectional study was executed between December 2022 and March 2023 at Parc Sanitari Sant Joan de D´eu (Barcelona, Spain). The sample comprised 215 healthcare professionals across various disciplines—including nursing, psychiatry, psychology, and social work—representing a participation rate of approximately 20% of the 1035 eligible institutional staff. Findings: Results reveal a profound discrepancy between theoretical appraisal and clinical practice. Although 96.7% of professionals acknowledge the utility of the AD, practical engagement remains residual: only 20.0% of participants report direct experience with a patient's document. Critical operational barriers were identified, as 74.4% of respondents were unfamiliar with procedures for retrieving an AD from the official registry. Furthermore, 71.6% of professionals perceive an absence of adequate technical or administrative resources provided by their institution. Conversely, facilitators are rooted in ethical commitment; 88.3% maintain that a patient's anticipatory wishes should be respected even when they conflict with clinical advice. Conclusions: Findings underscore a significant gap between the ethical-legal ideal of autonomy and its clinical execution within the Spanish mental health context. Positive professional attitudes are insufficient without robust systemic support. Effective implementation necessitates a multidimensional strategy: strengthening specialized continuing education, streamlining access protocols within electronic health records, and fostering institutional policies that prioritize patient-centered psychiatric care.