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

Year: 2026

Type: article

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 Déu (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.

Source: International Journal of Law and Psychiatry

DOI: 10.1016/j.ijlp.2026.102224