Is the anticipated consent to treatment in advance directives a solution to coercive treatment (in forensic psychiatry)?

As a result of a Federal Constitutional Court decision on coercive treatment, in its state law on hospital order treatment the federal state of Hesse has newly regulated the possibility of coercive treatment (Section 7 Paragraph 2 of the Hesse Forensic Commitment Act, HMRVG) and expressly incorporated the observance of a patient decree as defined by Sections 1901a and 1901b of the German Civil Code (BGB). Having been sentenced to hospital order treatment ( 63 Strafgesetzbuch), in the Vitos Haina Forensic Psychiatric Hospital thirteen patients with schizophrenia stated in a patient decree that they wished to be treated with certain antipsychotic medication in case of a recurring psychotic episode. In particular, the patient decree stated that this treatment should be compulsory if necessary. Based on a case vignette this article delineates both the motivation of the patients for such a patient decree as well as the legal limitations and the enforceability of such a decree. There is no prevailing view in the jurisdiction or literature on the utilization of a patient decree to guarantee an explicitly desired treatment in case of incapacity for consent. This article highlights the perspectives of those directly affected and to encourage discussion. Being of special interest for forensic psychiatry, these considerations may also be of importance for treatment considerations in general psychiatry.