Psychiatric advance directives: privilege, inequity and the path toward justice in psychiatry

Psychiatric advance directives (PADs) represent a significant stride towards self-determination in mental healthcare. These legal documents allow individuals with mental illness to articulate their treatment preferences for future psychiatric crises when decision-making capacity may be impaired. Designed to empower individuals and reduce coercive interventions, PADs hold the potential to transform patient–clinician dynamics.

However, the reality of PAD implementation starkly contrasts with this ideal. Research reveals profound inequities: only approximately 25% of individuals with serious mental illness have completed PADs, with usage disparities disproportionately affecting marginalised groups, including low-income individuals, racial and ethnic minorities, immigrants and non-native English speakers.¹ Rather than universally empowering tools, PADs often function as instruments accessible primarily to those possessing the requisite social, educational and economic capital to navigate complex healthcare and legal systems. This article employs a health equity lens to critique these systemic barriers, examines critical tensions such as autonomy versus clinical judgement and regional legal variability and argues for a comprehensive reimagining of PAD frameworks to ensure they serve as genuine tools of empowerment and justice for all.

The role of capital and structural barriers

The inequitable distribution of PAD completion is deeply rooted in disparities of social, educational and economic capital, compounded by structural barriers within healthcare systems. Social capital, or access to supportive networks and relationships, strongly influences an individual’s ability to engage with PADs.² Those embedded in robust social networks are more likely to have trusted relationships with healthcare providers, legal professionals or advocacy organisations who can help them navigate the complex PAD process. These relationships offer critical informational, emotional and instrumental support.

In contrast, marginalised communities often lack such access owing to systemic discrimination across health, education and legal domains. Structural exclusion has historically impacted black Americans and other racial minorities, who are over-represented in coercive psychiatric interventions yet under-represented in PAD usage. One study showed that only 17% of black participants had completed a PAD, compared with 30% of white participants.³ This disparity reflects broader inequities in how mental health systems serve racially and economically marginalised populations.⁴

Educational barriers further restrict PAD access. The legal and medical terminology involved often exceeds the health literacy of individuals in underserved communities. Patients may struggle to understand treatment options or complete complex paperwork without assistance. As one community-health-centre client remarked, ‘It’s just too complicated. I tried to do it once, but there were too many forms, too many rules, and no one to help’.⁵ The lack of clinician support and difficulty designating a proxy are frequently cited as barriers in multisite studies.^{6 7}

Economic capital also significantly impacts PAD accessibility. Legal consultation, notarisation and document storage often incur costs that many low-income individuals cannot afford. Though some public programmes aim to offset these expenses, support is typically incomplete. Furthermore, policy exclusions, such as limited insurance reimbursement for PAD facilitation, further reinforce structural neglect. These challenges mirror bureaucratic obstacles seen in detention settings, where marginalised individuals face barriers to mental healthcare.^{8 9}

Regional legal variability and immigrant-specific barriers

The effectiveness of PADs is shaped not only by clinical practices but also by the legal and sociocultural environments in which they operate. Legal variability across regions, coupled with systemic barriers specific to immigrant populations, significantly undermines equitable access to PADs. In the USA, only half of the states have formal PAD statutes, and those that do differ widely in their provisions. For instance, Oregon and Massachusetts provide robust protections, allowing PADs to be overridden only under narrowly defined circumstances such as imminent harm. In contrast, many states offer vague or minimal guidance, leaving directives open to dismissal during psychiatric crises.¹⁰ This fragmented legal landscape fosters confusion among clinicians and patients alike, eroding trust—particularly among individuals who move between jurisdictions, a common reality for many immigrants.

Globally, these disparities are magnified. European nations, such as Germany and Belgium, have adopted national mental health legislation that includes standardised PAD protocols and emphasises relational autonomy, whereby PADs are drafted collaboratively with families and clinicians. This model has increased uptake among immigrant communities (e.g., Turkish and Syrian populations) by 22% since 2022.¹¹ Conversely, implementation in many Asian countries remains inconsistent. Japan’s artificial intelligence (AI)-enabled PAD platforms have improved urban access for older adults, yet rural regions lag due to infrastructural and cultural disconnects. India’s mobile app pilots show promise, but PAD completion remains over 40% higher in urban than rural zones, underscoring the marginalisation of rural populations.12,14 In the Philippines, integrating barangay (community) leaders into PAD facilitation has improved completion rates among Indigenous groups, demonstrating the efficacy of culturally rooted interventions.

Immigrants face unique intersecting challenges in accessing PADs (e.g., legal, linguistic, cultural and structural). Language remains a major barrier: approximately 65% of undocumented immigrants in the USA avoid healthcare because of deportation fears and a lack of translation services.⁹ The scarcity of linguistically appropriate PAD materials and interpreters compounds this inaccessibility. A California-based study found that only 12% of Spanish-speaking immigrants had completed PADs, compared with 35% of their English-speaking counterparts.^{15 16} Van Dorn et al reported that Latino patients and their families expressed strong interest in PADs, particularly if they involved trusted family members in decision-making; one participant remarked, ‘I didn’t think this was for people like me. No one ever explained it in my language or told me how it could help’.¹⁷

Cultural mismatches further inhibit PAD adoption. Rooted in Western ideals of individual autonomy, PADs often conflict with the collective and familial health decision norms found in many African, Southeast Asian and Latin American cultures.^{18 19} A 2023 study of Somali refugees in Minnesota reported that 78% viewed PADs as misaligned with communal values, fearing that asserting individual preferences could alienate family members.²⁰

Finally, a deep mistrust of psychiatric and legal systems—especially among those from regions with punitive or colonial histories—further deters engagement. United States policies such as the ‘public charge’ rule, which previously penalised immigrants for using public benefits, have amplified these fears.⁹ Together, these barriers render PADs inaccessible to many immigrant communities, demanding urgent, culturally responsive reforms.

Digital innovations: potential and limitations

Digital innovations hold considerable promise for expanding access to PADs by streamlining procedures and enhancing cultural and linguistic inclusivity. AI-based platforms such as Clym and AccessiBe now offer multilingual templates and automated compliance tools, reducing reliance on costly legal services. In Japan, AI-powered chatbots integrated into psychiatric systems have increased PAD completion rates, particularly among older adults and non-native speakers. The European Accessibility Act, effective June 2025, mandates that digital services, including PAD-hosting platforms, be accessible to individuals with disabilities.²¹

However, digital innovations do not guarantee equitable access to services. Disparities persist because of infrastructural limitations and sociocultural dynamics. In India, mobile app PAD pilots saw a 40% higher engagement in urban areas compared with rural areas, attributed to disparities in internet access and digital literacy.12,1422 In Kenya, a 2024 study using tablet-based PAD tools improved documentation rates but revealed persistent challenges such as unreliable internet and cultural resistance. Patriarchal norms in some communities undermined the legitimacy of individual-centred directives.²³

These findings suggest that while digital tools can facilitate broader PAD adoption, they risk reinforcing existing inequalities unless paired with systemic interventions. Addressing infrastructure gaps, improving digital literacy and ensuring culturally resonant designs are essential to realising the full potential of digital PAD innovations.

Balancing autonomy, safety and clinical judgement

PADs are essential tools for promoting patient autonomy in mental healthcare, yet they also raise complex ethical and clinical concerns. Chief among these is the tension between honouring individual treatment preferences and ensuring safety during psychiatric crises.²⁴ Critics argue that strict adherence to PADs, especially when they decline critical interventions such as antipsychotic medication, can endanger patients and place clinicians in ethically precarious positions. While respecting autonomy is vital, doing so during acute episodes may worsen symptoms, whereas overriding PADs risks breaching trust and undermining legal protections.^{10 18} A systematic review found that up to 40% of clinicians in the USA had overridden PADs, citing concerns about outdated instructions, clinical incompatibility or imminent harm.²⁵

These tensions reflect broader concerns about fluctuating decision-making capacity in psychiatric illness and underscore the need for safeguards that balance patient agency with clinical responsibility. One promising solution is relational autonomy, which promotes collaborative PAD development involving clinicians, proxies and community supports. Countries such as Norway, Canada, India and Indonesia have successfully piloted codrafted PADs, incorporating routine review and culturally informed revisions.^{11 19} A notable example is Tinland et al’s multicentre randomised controlled trial in France, in which PADs facilitated by peer workers significantly reduced compulsory hospitalisations while improving empowerment and recovery.¹¹

Legal frameworks are also crucial in clarifying the ethical boundaries of PADs. Oregon law allows PAD overrides only in cases of likely ‘imminent physical harm’ and mandates documentation, as well as the use of the least-restrictive alternatives.¹⁰ This aligns with the guidance from the World Health Organization (WHO) and the Office of the United Nations High Commissioner for Human Rights (OHCHR), which emphasises proportionality, transparency and accountability in PAD-override policies.²⁶ Despite these frameworks, enforcement remains uneven. Inconsistent legal recognition and limited clinician training often result in PADs being disregarded. Conversely, rigid interpretation may reduce PADs to static legal instruments rather than dynamic care tools. Germany’s model, which includes mandatory clinician training in PAD interpretation, shared decision-making and cultural humility, offers a template for a more ethical, flexible and context-sensitive application.²⁷

Strategies for accessible and just PADs

Achieving equity in PADs requires more than policy inclusion—it necessitates a fundamental redesign of their structure, implementation and enforcement through participatory, justice-centred frameworks. Traditionally, PADs have been shaped by top-down, legalistic models that favour those with social capital, health literacy and system fluency. True equity demands shifting from institutional dominance towards community coproduction and sustained systemic reform. A synthesised conceptual framework, drawing on cross-cultural implementation science, advocacy initiatives and participatory research, identifies five core strategies (see table 1).

Table 1. Strategies to advance PAD equity: integrated actions, stakeholders and participatory insights.

Strategy	Key actions	Stakeholders/advocacy roles
Co-design and simplify PAD materials	Develop multilingual PAD templates with community input; simplify legal and clinical language; provide step-by-step guidance.	Advocacy organisations co-lead design efforts to ensure cultural relevance; social workers and legal aid clinics support patients during drafting.
Community education and outreach	Host participatory workshops using accessible methods (eg, photovoice, digital storytelling) to raise awareness and build trust.	Peer specialists, grassroots groups and organisations facilitate community engagement.
Policy harmonisation and advocacy	Advocate for standardised PAD legislation across states and territories; lobby to expand Medicaid reimbursement for PAD-related services.	Policy coalitions work with legislators to address legal inconsistency and regional disparities.
Clinician and institutional training	Implement case-based modules on cultural humility, bias recognition and relational ethics to improve provider competency.	Healthcare institutions and academic–community partnerships (eg, Kaiser Permanente cultural-competence initiatives) lead continuing education.
Digital accessibility and equity	Deploy AI-enabled platforms with rural-friendly and multilingual interfaces; ensure integration into EHR systems for provider access.	Technology developers collaborate with advocacy groups in underserved areas to tailor tools to infrastructural realities.

AI, artificial intelligence; EHR, electronic health record; PAD, psychiatric advance directive.

1. Co-designing PAD materials ensures cultural and linguistic inclusivity. Developing plain-language, multilingual templates with visual aids, guided by cultural brokers, has proved effective. A 2024 Kenyan pilot found that users felt greater confidence using PAD drafting apps when peer support and visual guidance were provided.

2. Community education is essential to address mistrust and invisibility. Participatory methods, such as photovoice and digital storytelling, led by peer specialists in trusted spaces, demystify PADs and improve health literacy, especially in underserved communities.

3. Legal advocacy and policy harmonisation must eliminate the fragmented and exclusionary landscape of PAD enforcement. Adopting regionally consistent PAD recognition policies (inspired by the European Accessibility Act) and removing immigration-related documentation barriers are critical. Medicaid expansions to include PAD-facilitation services in select US states illustrate the power of financing levers.

4. Clinician training is vital to ensure that PADs are not ignored in clinical practice. Training should include cultural humility, relational ethics, legal literacy and case-based simulations. National modules in Germany and frameworks, such as Kaiser Permanente’s cultural-competence model, offer scalable examples of academic–community partnerships that enhance PAD implementation.⁷

5. Digital access must be equitable. AI-based platforms hold great promise, but only if designed for accessibility. Features such as offline functionality, audio–visual instructions, electronic health records (EHRs) integration and localised support are crucial.²⁸ Schwarz et al advocate for embedding PADs into EHRs, arguing that this improves visibility during crises, but caution that development must address digital divides.²⁹ Platforms like Engage Digital and India’s AI-driven pilots12,14 illustrate both potential and the need for infrastructure investment in rural settings.

Together, these strategies inform a comprehensive equity framework centred on three pillars: policy harmonisation, community-driven design and antidiscrimination safeguards. Standardised recognition reduces jurisdictional confusion; co-design fosters cultural trust; and legal alignment with global rights frameworks (eg, the United Nations Convention on the Rights of Persons with Disabilities) ensures protection against coercive overrides. As the WHO–OHCHR guidance stresses, PAD overrides should meet rigorous, documented standards grounded in proportionality and due process.²⁶

Implementation challenges and priority actions for equitable PAD access

Transforming PADs into equitable tools of mental healthcare demands addressing a series of entrenched implementation barriers, particularly in under-resourced settings. Public mental health clinics often lack funding for interpreters, culturally competent staff or roles dedicated to PAD facilitation.⁷ Legal fragmentation across US states and international jurisdictions further undermines PAD efficacy. For immigrants, fears that PADs will be ignored or invalidated are compounded by prior experiences of systemic coercion or neglect.^{8 20} In rural regions, PADs are often excluded from EHRs, limiting their utility during crises. Bureaucratic burdens, such as excessive documentation, mirror those seen in carceral and immigration systems, deterring many marginalised individuals from engaging with PADs.⁸

Addressing these barriers requires multipronged strategies. Scalable, tiered training, including virtual workshops and peer mentoring, can deliver cost-effective education in PAD facilitation, cultural humility and relational ethics.²⁰ Community–clinical partnerships are essential: co-designing PAD tools and outreach efforts with immigrant-led or Indigenous organisations helps tailor implementation to local norms. Policy reforms must include standardising PAD legislation, expanding Medicare/Medicaid reimbursement for PAD-related services and repealing exclusionary policies such as the ‘public charge’ rule.

Targeted resource allocation is equally critical. Grants must prioritise frontline clinics serving historically underserved communities, funding interpreters, legal aid, outreach specialists and technology infrastructure. These efforts should be coupled with rigorous, longitudinal research to identify which interventions (e.g., culturally adapted training or digital PAD innovations) effectively improve PAD engagement and reduce coercion.

Clinicians, particularly psychiatrists and psychiatric-mental health nurse practitioners (PMHNPs), play a central role in promoting equitable PAD uptake. Embedding PAD discussions into routine care helps normalise their use and empowers patients to articulate preferences before a crisis. Providers should guide patients through PAD drafting, clarify legal and clinical language, explore treatment choices and offer connections to legal or community advocacy services. Uploading PADs into EHRs and reviewing them periodically ensure they remain accessible and relevant.

Cultural competence is essential. Initiatives such as the ‘Think Cultural Health’ platform offer practical training that improves cross-cultural communication and reduces clinical bias. Research in Finland and Indonesia confirms that such programmes enhance provider rapport, especially with immigrant patients. Co-designed training with community brokers further builds clinician confidence and sensitivity.²⁰

Finally, embedding relational ethics into PAD practice honours collective decision-making traditions without compromising patient autonomy. Many non-Western cultures view health decisions as communal. Facilitating PAD conversations that respectfully include family or community voices aligns with intersectionality research, which shows how overlapping identities, like race, disability and immigration status, compound vulnerability and require contextualised, culturally grounded responses.^{29 30}

Conclusion: from aspiration to tangible justice

PADs offer substantial potential to promote patient autonomy and reduce coercion in mental healthcare. Yet, their implementation remains marked by persistent inequities, particularly for marginalised populations. Although PADs are designed as tools of empowerment, access remains stratified by race, income, immigration status and health literacy. These disparities reflect deeper structural injustices—intersections of social and economic capital with legal fragmentation and culturally misaligned care models. Immigrant communities face compounded barriers, including language gaps, unfamiliarity with individualistic care frameworks and legitimate mistrust owing to exclusionary policies and inconsistent legal protections.

Advancing equity in PADs demands a paradigm shift grounded in health equity. This includes dismantling systemic barriers, centring participatory design, allocating resources to underserved areas and harmonising legal recognition across jurisdictions. Relational ethics must shape PAD development and implementation, ensuring cultural congruence while preserving individual agency.

Concerns about balancing autonomy with clinical judgement are valid, but they must not justify the erosion of rights. Instead, they call for safeguards: transparent override criteria, robust clinician training in cultural humility and shared decision-making models that support both patient preference and clinical accountability. Digital innovations, while promising, must be deployed with equity in mind to prevent reinforcing digital exclusion. Clinicians, especially PMHNPs, are key to realising this vision; their responsibilities extend beyond clinical care to include systemic advocacy.

Ultimately, transforming PADs into instruments of justice is not aspirational; it is an ethical imperative. Only through sustained, systemic action informed by intersectionality, human-rights frameworks and cultural responsiveness can PADs truly empower all individuals navigating the mental health system.

Biography

Trae Stewart works as a Professor of Psychiatric Nursing and PMHNP Track Coordinator in the School of Nursing at Massachusetts College of Pharmacy and Health Sciences (MCPHS) in the USA. He earned a PhD (2003) from the University of Southern California, an MPH (2015) from Texas A&M University, an MS in Forensic Psychology (2019) from Arizona State University, and an MSN (2021) from Case Western Reserve University in the USA. He has also held prior academic roles at the University of Colorado Anschutz Medical Campus, Texas State University, and the University of Central Florida. Dr Stewart’s current research spans psychiatric nursing education, digital mental health, decolonial scholarship, epistemic justice, mental health equity, and community-engaged research. In addition to his university role, Dr Stewart is a practicing Psychiatric-Mental Health Nurse Practitioner.