Trapped Amongst the Tides: Increasing Access to the Ulysses Clause in Vermont

uvmmedicine bloggers Ryan Landvater '19 and Julia McGinty '19
uvmmedicine bloggers Ryan Landvater ’19 and Julia McGinty ’19

The “Ulysses Clause,” the more colloquial term used for psychiatric advanced directives, is a surprisingly accurate description of the legislative document – just not in the way it was intended. Overtly, the allusion describes what the clause does and why it should be used, by referencing a story from the classic Greek text, the Odyssey. That said, there are subtler and more insidious implications drawn from an analogy between a Greek king, marooned at sea for a decade and leaving his family and life in a state of limbo, and our patients suffering from mental illness.

The term references a story in Homer’s Odyssey, wherein protagonist Ulysses makes a pact with his crew. Wishing to hear the Sirens’ song, but understanding that doing so will render him incapable of rational thought, he asks his crew to put wax in their ears, tie him to his ship’s mast, and, most importantly, ignore his adamant demands to be untied while within hearing distance of the Sirens. The analogy between this story and medicine seems clear: let a patient decide at a time of clarity what they would like for treatment, and care for them accordingly – even if they object to that very treatment because of their compromised mental state.

As compared to patients with other diseases requiring inpatient treatment, mental health patients here in Vermont require the longest hospital stays consistently and by a large margin. From a financial point of view, this is burdensome; from a personal perspective, it is devastating. Inpatient mental health stays erase months and years from a patient’s life, typically ending after the patient acquiesces to treatment, while still in an altered mental state, or by court mandate. Both scenarios are drawn out, but the second is especially tortuous. If there were a sought after “door number three,” the Ulysses Clause is it.

In theory, any mental health patient should be provided with the opportunity to put their treatment preference into writing while they are “themselves” – or feel like they are of a sound mind. In practice, this can be a logistical nightmare due to the requirements imposed by the law –  meant to allow medication of a patient while rightfully protecting patient autonomy as paramount. In short, it is a daunting procedure for anyone to fulfill by design.

But how daunting is “daunting?” Without getting too deep into the specifics, the Ulysses Clause requires the preferences of the patient to be expressed in writing, and for the form to be signed by a health care agent of the patient’s choosing, the patient’s psychiatrist, and a legal witness, such as a lawyer, clergyman, or ombudsman, in a single gathering. If you can image singularly trying to cope with mental health and orchestrate this meeting, you can see why it is unsurprising that the Ethics Committee at The University of Vermont Medical Center estimates that only three forms have been utilized in the last seven years.

Our project, pursued through an Albert Schweitzer fellowship, aims to make this process easier for patients and health care professionals. We hope to accomplish this  in two ways: first, to facilitate the completion and registration of advance directives for the client population of the Howard Center of Burlington, and secondly, to educate medical center staff and affiliates about how to properly fulfill patients’ wishes.

We hope to facilitate this process for interested patients by constructing a supportive framework: educating patients about psychiatric advanced directives, working directly with the patient’s treatment team at the Howard Center and UVM Medical Center, and orchestrating meetings with the various parties needed for signing. We also would like to be able to assure the patients that their wishes will be fulfilled by staff by thorough training sessions related to the proper implementation of this uncommon document.

In short, we want a patient’s only concern to be whether or not a Ulysses Clause is right for them.

Mental illness touches each and every one of us in some way or another. While not as openly discussed as heart disease or diabetes, the impact on friends, neighbors, and colleagues is no less substantial. We don’t believe that mental health can be cured by advanced planning, but we do believe that the impact on patients’ lives can be transformational.

A Ulysses clause is not for everyone. It is a document that demands mutual understanding and respect. That said, for some, this simple piece of paper holds the power to revolutionize the course of their treatment. It has the capacity to return patients to their lives outside of the hospital in a fraction of the usual time for conventional inpatient psychiatric treatment. It gives them the capacity to undergo treatment on their own terms. And, to take a page from the Odyssey, it has the power to rescue some patients who find themselves trapped amongst the tides.

What are your thoughts about this topic?