Psychiatric Advance Directives: An Overview
What is a Psychiatric Advance Directive (PAD)?
A Psychiatric Advance Directive (PAD) is a legal document written by a currently competent person who lives with a mental illness. It describes the person’s mental health treatment preferences, or names an agent to make treatment decisions for the individual, should he or she become unable to make such decisions due to psychiatric illness. There are two kinds of PADs:
- Instructive PADs, in which an individual gives instructions about the specific mental health treatment desired should the individual experience a psychiatric crisis.
- Proxy PADs, in which the individual names a health care proxy or agent to make treatment decisions when the individual is unable to do so.
Most states permit one kind or the other, or a combination of both instructions and a proxy. At times a psychiatric advance directive is combined with a general medical advance directive.
What are the benefits of a PAD?
Creating a PAD allows an individual living with mental illness to plan for a future mental health crisis. If you are such a person, you could state your treatment choices in advance, before a time when you might be incapable of making decisions or communicating effectively. The detailed instructions included in a PAD may help you to:
- Gain more control of your treatment
- Improve the likelihood of receiving helpful, informed care
- Consent to or refuse certain treatments
- Avoid involuntary hospitalization
- Enhance understanding and communication with your treatment providers and family members
- Promote your own recovery by focusing on wellness supports and relapse prevention strategies
What information is included in a PAD?
The information that may be included in a PAD varies by state. To find out what your state allows, see the state-by-state statutes at the National Resource Center on Psychiatric Advance Directives (www.NRC-PAD.org). Generally, PADs allow you to agree to, refuse and give your preferences about such as:
- Psychiatric medications
- Alternatives to hospitalization
- Seclusion and restraint
- ECT (electroconvulsive therapy)
Explain your choices so your doctors and others will understand your reasoning. It’s to your advantage for them to know the basis for your preferences. For instance, you might explain that certain medications have given you severe side effects, that you prefer a certain hospital because of its therapeutic programs, or that certain self-care methods have helped you through mental health crises in the past
What else may be included in a PAD?
This varies from state to state. Some states allow PADs to include:
This could include: your mental health diagnosis; other illnesses or conditions that affect your health care; previous treatments and their outcomes; medications you have taken and their effectiveness and side effects; food or medication allergies; the name and contact information of your primary physician, psychiatrist and counselor, therapist or social worker; the name of a back-up physician if your regular one is not available.
Instructions to hospital staff
- Tips for understanding your symptoms (e.g., “I get agitated when I’m scared), de-escalating emotional outbursts (“Speak to me in a quiet, respectful manner, but don’t touch me”), interventions to help prevent seclusion or restraint (“Invite me to return to my room and write in my journal”).
- What helps you feel comfortable in the hospital, such as spending a certain amount of time alone, getting regular exercise, having your own pillow and blanket)
- Names of people who may not visit you. You have the right to choose your visitors.
An emergency contact(s), such as a doctor or other care provider, family member or friend.
The Name of a Health Care Proxy or Agent
In virtually every state, you can appoint an individual to make health care decisions for you should you become unable to do so.
What is a Health Care Proxy or Agent?
A Health Care Proxy is someone you appoint to make your treatment decisions when you cannot make them yourself. Naming a proxy may be optional; some states require it. Some states only let you appoint a proxy; you may not give your own treatment preferences. In those cases, however, the individual usually may give instructions directly to the agent.
Generally, a Health Care Proxy can be any capable, competent adult (18 years or older) who is not your health care provider. Often you can name more than one proxy, though only one can be active at a time.
What does a Health Care Proxy Do?
If you become unable to make your own treatment decisions due to psychiatric symptoms, your Health Care Proxy would make them for you. The Proxy should follow the instructions in your PAD and make the same decisions you would about medications, hospitalization, health care provider, ECT and anything else you have covered in the PAD.
How do I create a PAD?
A PAD must be prepared when you are in good mental health. It may be difficult emotionally to think about a future psychiatric crisis and possible hospitalization. However, planning ahead while you are in a healthy state of mind can make a big difference in your treatment experience later.
PAD requirements and forms vary by state. See your state’s page at the National Resource Center on Psychiatric Advance Directives, www.NRC-PAD.org for specific information about writing a PAD in your state. Often you can just fill out the form your state provides. If your state doesn’t have its own form, instructions for creating a valid form should be listed. You may need to have the PAD form formally witnessed and signed, and perhaps notarized.
Where can I get help in preparing a PAD?
The National Resource Center on Psychiatric Advance Directives (NRC-PAD) has the most complete information on PADs. Its website, www.NRC-PAD.org, offers a wealth of resources, including step-by-step guides for each state for individuals living with mental illness. Help for families and friends, clinical information for health care providers and comprehensive legal resources for legal professionals are also available.
What should I do with my PAD when it is completed?
You must give copies of your completed PAD form to your mental health care providers, including psychiatrist, counselor or therapist, to add to your medical records. Tell your primary care doctor about your PAD, and share copies with your family members and close friends. Always keep a copy of your PAD with you. You may want to discuss its contents with your mental health care provider(s), family and close friends. If those around you are familiar with the document, you may improve your chances of receiving the crisis care you want.
What should my doctor do with my PAD?
Your doctor should keep your PAD with your medical records. If it is officially decided that you lack capacity to make your own treatment decisions, your health care providers must follow your instructions about treatment as closely as possible. These instructions may be written in your PAD or given by your Health Care Agent. However, should your instructions differ from emergency care you might need, or conflict with accepted standards of medical care, a health care provider is not required to follow your instructions. Even if a part of your PAD cannot be followed, the rest of your instructions should be respected.
When would I be considered “incapable”? When would my Health Care Agent start making treatment decisions for me?
The legal definition of incapacity varies by state. Generally, “incapable” means that your current mental state makes you unable to understand, make or communicate decisions about your mental health care. Your health care provider, or an attending physician or eligible psychologist, usually decides incapacity; however, a judge must make the decision in some states. A determination of incapacity must be put in writing and empowers your Health Care Agent to take over making your treatment decisions.
If I change my mind, can I revise or stop my PAD?
In many states, as long as you are considered “capable,” you may revise or end your PAD. However, this varies by state. For specific information about changing or stopping a PAD, see your state’s statutes or frequently asked questions at www.NRC-PAD.org.
Will my PAD always be followed?
Your PAD would not be followed if:
- You are involuntarily committed to a hospital. Your hospital choices may be disregarded if you are involuntarily committed to a treatment facility. Your other instructions—about medications and other treatment issues—should still be followed.
- Your requested treatments are not available or workable, such as if no beds are available at the treatment facility you prefer.
- Your treatment preferences go against needed emergency treatment: If you need emergency care, your treatment providers may override your requests.
- Your instructions conflict with “generally accepted community practice standards” or applicable laws. If your directives are counter to respected, regular treatment standards or state law, your doctor’s decisions would take priority.
Are there any problems with how PADs work?
The PAD is a relatively new legal tool, and how enforceable it will be isn’t clear yet. Many mental health professionals are not familiar with PADs and how they work. In recent studies, most providers generally supported PADs for crisis planning and improving their clients’ health care. They had concerns, though, about where to get help in writing them, training other health care staff in their use and accessing a PAD in a crisis.