Table 3.

Resolving dilemmas in ADM document, guidance and care pathway design.

Dilemma	Solution	Sources of advice
Misleading name	‘Self binding directive’ changed to ‘PACT’ (Preferences and Advance decisions for Crisis and Treatment)	Problem identified in all focus groups Research team developed name Approved during consultations with service user and professional groups
Detail vs practicability	Adopted a ‘workbook’ style for the body of the main document complimented by final ‘Summary page’ for quick reference in crisis situations. Further explanations about apparent length added to guidance.	Problem identified during Care coordinator and Consultant Psychiatrist focus groups Solution suggested during Consultant Psychiatrist focus group Approved during consultations with service user and professional groups
	Location of mental health history specified on form rather than all information	Problem identified during Care coordinator and Consultant Psychiatrist focus groups Solution suggested in Care coordinator and Consultant Psychiatrist group
	Reduction in legal guidance and content prompts on PACT document whilst retaining full detail in complimentary guidance documents	Problem identified during service user and professional consultation. Balance achieve through iterative process of feedback and refinement during the consultation process
Structure vs flexibility	Structured form with reflective conversation prompts	Need to avoid ‘tick box exercise’ identified by all clinician focus groups Need for structure and prompts identified by Service user focus group Structured preferences and reflective questions developed by research team and approved during all consultations with service user and professional groups
Harnessing the power of clinician endorsement vs authentically representing service user wishes	Advance preferences and requests structured according to the following categories: •Service user preferences with prompts of explanation •Agreed recommendations •Comment boxes for health professional available to endorse service user preferences or raise concerns	Concern about power dynamics raised in Service User and AMHP focus group Extensive discussion about managing power imbalances within the research team Solution developed by research team Approved during consultations with service user and professional groups
	Guidance on legal implications and non-necessity of clinician endorsement of ADRT clarified
Potential for discrepancy between legally (MHA) defined ‘nearest relative’ and preferred crisis contact	Section to document ‘nearest relative’ plus section for service user to specify preferred crisis contacts plus those they would prefer were not contacted	Identified during legal consultation and AMHP focus group Solution discussed amongst research team Approved during consultations with service user and professional groups
Potential to bring ‘peace of mind vs potential to cause distress and disappointment	Explicit discussion of potential for process to cause distress in guidance document Guidance included on the clinical and legal limitations of the document Guidance given around creating supportive meeting environment and process for creating document	Advice in guidance document based on input from Mental Health and Justice Service User Advisory Group
Potential to build alliance during process of making document vs potential for conflict and undue influence	Questions on template designed to prompt whole group reflection Preferences section structured to allow for difference of opinion without losing jointly agreed treatment recommendations Guidance documents emphasise the importance of all voices being heard during discussions and documenting perspectives raised	Problem identified in all focus groups Idea for reflective questions developed within research team Phrasing reflective questions discussed with Consultant Family Therapist with expertise in Open Dialogue approaches to mental health crises Guidance document content informed by consultation with service user led organisations
Potential to enhance quality of clinical decision making vs concerns about clinician liability	Explicit guidance on legal status of document on template and in guidance, including documentation of rationale for deviating from contents of document	Problem identified in Consultant Psychiatrist focus groups Potential for clinician liability discussed during legal consultation and resultant advice used to inform guidance
Ensuring accessibility vs protecting confidentiality	Section on the form to prompt discussions around storage plan including preference around who has a copy Suggestions for ensuring accessibility in crisis included in guidance documents Confidential nature of document explicit on template	Problem identified in all focus groups Ideas around ensuring accessibility offered in all focus groups Potential solutions collated and included in guidance documents by research team Approved during consultations with service user and professional groups
Respecting advance personalised medico-legal assessments and contemporaneous clinical judgement	Structured prompts on template to ensure information relevant to MCA/MHA assessment is clear for future assessors Guidance on legal implications in template and guidance documents	Issue raised during legal consultation and Consultant Psychiatrist focus group Guidance around legal components written based on results of legal consultation and discussion within research team Approved during consultations with service user and professional groups
Standardised care pathway for document creation vs allowing for individual needs	Suggested care pathway included in guidance documents Explicit that the length of time/number of meetings each service user requires to complete document may vary	Ideas for a care pathway discussed in focus groups Research team developed draft care pathway Input for MHJ SUAG refined care pathway Approved during consultations with service user and professional groups