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Psychiatric Advance Directives: Planning for Mental Health Care

     

Many people are familiar with advance directives that allow people to provide instructions for their care in the event that are unable to make decisions or communicate preferences. These typically apply in end-of-life care situations.

A psychiatric advance directive (or PAD) is similar in many respects, but is specific to mental health care. A psychiatric advance directive is a legal document allowing a person to give instructions for future mental health treatment or appoint a person to make future decisions about mental health treatment (also called a health care agent, surrogate, or proxy decision-maker). The document is used when the person who created it experiences an acute episode of psychiatric illness and becomes unable to make or communicate decisions about his/her treatment.1

The National Resource Center on Psychiatric Advance Directives notes two main reasons to create a psychiatric advance directive:

  • It makes it possible for you to be treated according to your wishes.
  • It can facilitate a more informed and open dialogue with your treatment provider.

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The psychiatric advance directive allows a person to put in writing and educate others about what works best for them. It can also prompt a discussion with family and friends about planning for care and recovery, expectations, preferences and what works best. Importantly, it offers the opportunity to explain not only preferences, but the reasoning behind them. When providers or family members understand why a certain request is made, they may be more receptive.

The PAD can also be used to identify people who can have access to your health care information. The Health Insurance Portability and Accountability Act (HIPPA) requires specific permission to share an individual’s medical information.

Studies have shown that psychiatric advance directives can improve outcomes, improve treatment satisfaction and reduce the use of coercive crisis interventions (e.g., being transported by the police for psychiatric treatment or evaluation; being involuntarily committed to a hospital)2.

Patricia Siebert with the Minnesota Disability Law Center, emphasized in a recent webinar on psychiatric advance directives that the directives are important component of self-determination.3 Among people with mental illness those with greater self-determination have a better quality of life—better employment, less victimization, more community integration.

In a qualitative analysis of patients’ views of psychiatric advance directives, participants consistently viewed them as a positive tool to promote autonomy with the potential to facilitate stronger patient-provider relationships. They expressed concerns about limited knowledge among service providers and difficulties communicating the directives to inpatient staff.4

Creating a Psychiatric Advance Directive

The specific procedures and requirements for PADs varies from state to state. Generally, you can create a PAD by filling out a form provided by the state or following the criteria in state statute. Most states require that they be formally signed and witnessed or notarized. More on state specific legislation and procedures is available from the National Resource Center on Psychiatric Advance Directives.

Some items that may be included are preferences for treatment and care, including medications, possible causes of your mental health crisis, how you might be expected to react, what helps and what doesn’t in difficult times, behavioral techniques which help calm you, ways to help you avoid hospitalization, and people to involve. It can also include things you do not want, such as certain procedures or medications.

Once complete, give copies to your physician and mental health providers who will make it a part of your medical record. Also, make sure the person you’ve designated as your agent and any key family members have copies.

As Marie Verna noted speaking of her own psychiatric advance directive in a recent webinar, “it gives us that opportunity to take responsibility and with it the control of our destiny. None of us wanted this. None of us would buy a ticket for it. But recovery means responsibility and the concomitant control, and the PAD lets that happen.”

  1. National Resource Center on Psychiatric Advance Directives
  2. Van Dorn, RA, et al. Psychiatric Advance Directives and Social Workers: An Integrative Review. Soc Work. 2010 Apr; 55(2): 157–167. www.ncbi.nlm.nih.gov/pmc/articles/PMC3642872/#R27
  3. SAMHSA Resources on PADs – newsletter and webinars.
  4. Kim MM, et al. Understanding the personal and clinical utility of psychiatric advance directives: a qualitative perspective. Psychiatry. 2007 Spring;70(1):19-29. https://www.ncbi.nlm.nih.gov/pubmed/17492909
  5. Bazelon Center for Mental Health Law - template to create your own PAD and Frequently Asked Questions Duke University Program on Psychiatric Advance Directives

     

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