Psychiatric Advance Directive
Similar to a medical advance directive or a health care power of attorney, a psychiatric advance directive is a legal document completed in a time of wellness that provides instructions regarding treatment or services one wishes to have or not have during a mental health crisis, and may help influence his or her care. A mental health crisis is when a person is unable to make or communicate rational decisions.
A psychiatric advance directive allows you to specify considerations about your mental health care treatment and appoint an agent who may make decisions about your treatment in the event of a mental health crisis. In some cases, you may also give further background information about how you have reacted to past treatment.
Despite these benefits, a survey of mental health experts concluded the underuse of psychiatric advance directives in the United States; this study surveyed 1,011 people with serious mental illness receiving public-sector treatment in 5 cities.
A psychiatric advance directive can:
- Promote your autonomy and empowerment;
- Enhance communications between you, your doctor, treatment team and family;
- Protect you from ineffective, unwanted or possibly harmful treatment or actions;
- Help prevent crisis situations and reduce the use of involuntary treatment or safety interventions, such as restraint or seclusion.
An advance directive goes into effect if you are hospitalized and it has been determined that you lack the capacity to make decisions for yourself. By writing your advance directive when your capacity is not in question, you have the opportunity to better influence what happens during a hospital stay. In an emergency situation, however, it is important to understand that doctors retain the authority to make decisions that are deemed necessary to ensure your safety and that of other patients and hospital staff.
You can include the medications and dosages that you know are most helpful to you and those that you do not wish to receive; names of facilities or healthcare professionals you want involved in your care, and people who can help you with important activities (such as paying your bills, and taking care of your children, pets or plants). You can also even identify the people you do or do not want as visitors if you're hospitalized.
One of the more powerful features of an advance directive is your ability to designate someone else (an agent) to make decisions for you if you are admitted to a hospital. You can name that person by stating that only he or she should make decisions for you in the event that you have been determined to lack the capacity to do so.
Duke University maintains a national resource center on psychiatric advance directives that provides background information and a guide to laws in each state.
The person you select should be someone you trust to advocate for you - a family member or friend. He or she will tell others what kind of treatment you do or do not want, and supervise your care. You may wish to choose more than one agent. You can make one the primary agent and designate another as a back up, or you could give each person different responsibilities. Perhaps you trust one person to make your healthcare decisions and another to take care of your household matters (bills, etc.). Be clear about who should do what.
Before naming an agent, discuss your plans with the person(s) you want to designate. Each of them must fully understand your request.
State laws vary. To maximize the enforceability of your advance directive, you may wish to consult with an attorney or someone from your state's protection and advocacy (P&A) program to see what your state allows. To find the P&A system in your state, visit the National Disability Rights Network.
It's important that people know you have an advance directive and know where to find it. Put a copy in your home where it can be easily found; and, put another one in a safe place with your other important papers. Be sure to give copies to people you trust - your agent or a trusted friend or relative; you should also have one on file at any hospital where you have been a patient before.
There may be times when you are very ill in which you could fear or refuse treatment that normally you would find acceptable. In a hospital, with the consent of your health care agent or someone else appointed to make decisions for you, you can be treated over your own objection. In an emergency situation, however, it is important to understand that doctors have the authority to make decisions that are necessary to ensure your safety and that of other patients and hospital staff.
You can express your wishes about being treated over your own objection in your psychiatric advance directive. You may decide that you should be able to refuse treatment, even when you are very ill. In that case, you would choose to make your advance directive revocable. This means that if your state law allows it, you can reserve the right to cancel your advance directive even during a mental health crisis. This must be stated in writing. However, if you choose to revoke your advance directive, your agent will no longer be able to advocate for you. Before you decide whether to make your advance directive revocable, you should thoroughly discuss this with your friends, family and health care professionals and an attorney (lawyer) that is knowledgeable about these issues.
You may also decide to make your psychiatric advance directive irrevocable, and that it is best that you be treated according to your psychiatric advance directive, even if you object at the time. Your advance directive cannot be revoked by you while you lack capacity to make decisions, even if you object to treatment at the time. You can include a statement giving your agent the responsibility to make health care decisions for you, even over your objections.
The statement that you allow treatment over your own objection is sometimes known as a "Ulysses clause."
If your psychiatric advance directive meets applicable state requirements, it is considered legally enforceable.
Whether legally enforceable or not, your doctor may want to follow your advance directive simply because it helps him or her treat you most effectively. However, there are some cases when the health care professional and staff may not be legally required to follow your advance directive or may override your wishes for other reasons.
For example, depending on your condition, there may be times when it is not possible to follow your psychiatric advance directive. Medical providers must always defer to your state’s standards of medical care to provide the care you need, and your document may be overridden if the instructions require unavailable treatment or endanger the life or health of you or another person.
You can change the contents of your advance directive by making corrections or writing out a new one. However, it is your responsibility to ensure that everyone has a copy of your most current advance directive.
Depending on where you live, you can also choose to make your advance directive revocable. This means you can reserve the right to cancel your advance directive even during a crisis. This must be stated in writing. However, if you choose to revoke your advance directive, your agent will no longer be able to advocate for you. Before you decide whether to make your advance directive revocable, you should thoroughly discuss this with your friends, family and healthcare providers.
Steps for creating a psychiatric advance directive
The first step is to think through and write down how you want to be treated when you have a mental health crisis or are hospitalized. Here, again, are things to consider:
- Whom you want to be notified in case of a mental health crisis
- What happens to you during a mental health crisis and what helps you recover after the crisis
- Where you would like to go if emergency treatment or hospitalization is required
- Alternatives to hospitalization
- The health care professionals you want involved in your care or those who should be consulted
- Types of medical treatment(s) that you want or do not want (and briefly state the reason)
- How you want to be treated in the event of hospitalization
- Medical conditions or allergies doctors should be aware of
- People you would permit as visitors in the hospital
- People to contact who can help with bills, pet care, etc.
Finally, consider whether you want to be treated over your own objection when you are very ill.
It is a good idea to talk your wishes over with other people who know and understand you: family members, friends, therapists, case managers, your support system or doctors. They can help you think things through and may give you good suggestions. Just remember, in the end, what you put in your psychiatric advance directive is up to you.
The second step is to find a person, or people, who know and understand you and are capable of acting as your health care agent (also called a proxy or patient advocate). Explain why you need their help and what you are asking them to do. Remember:
- Your health care agent needs to be reachable in case you have a mental health crisis or if you are hospitalized
- As long as you have the capacity to make medical decisions, your agent will not be needed
- When doctors declare that you lack the capacity to make decisions, your agent will be asked to speak for you
- Your agent will abide by the wishes expressed in your advance directive
- Your agent may also have to make decisions about your care that are not spelled out in your advance directive
- You may give your agent the responsibility to make health care decisions for you over your objections
If you know two people you trust, depending on state law, you can name one to be your agent and the other to be a back-up person. During a crisis, under applicable state law a physician may invoke ethical and community standards and override your wishes in your advance directive and the decisions made by your agent.
State laws on psychiatric advance directives vary. Psychiatric advance directives may be used in certain states, while in other states you may be able to use a different but similar document such as a health care directive form, or a health care power of attorney. It is very important at this stage to learn if your state has specific requirements or has a form that you can fill out. There are several ways to find out what your state requires:
- You can talk with someone from your state's protection and advocacy (P&A) agency to see what your state allows. To find the P&A system in your state, visit the National Disability Rights Network (www.ndrn.org), or call 1 (202) 408-9514. Your P&A system also may know of trained people who can help you prepare an advance directive
- Go to www.NRC-PAD.org, the National Resource Center on Psychiatric Advance Directives (NRC-PAD). NRC-PAD is a nonprofit organization that offers a state by state guide to laws, rules, forms and other resources.
You should consult with a lawyer (attorney) in your state that has experience preparing psychiatric advance directives.
If your state has an approved psychiatric advance directive form, be sure to use it for your psychiatric advance directive, adding to it your specific wishes.
A psychiatric advance directive is a legal document, so you should type your responses on a computer if at all possible so your document is clearly legible. Typically, the first section of the form states your intention to complete an advance directive and your desire to have it followed. The subsequent sections then typically state your specific wishes. In the last section, you typically sign and date the form. Depending on state law, you may need one or more people to witness your signature and to have all signatures notarized by a notary public. These requirements vary from state to state so it is important that you understand your state’s specific requirements.
National Resource Center on Psychiatric Advance Directives offers a state-by-state guide to laws, rules, forms and other resources.
It's important that people know you have completed an advance directive and know where to find it. You will need to make a number of copies. Put a copy in your home where it can be easily found, and put the original in a safe place with your other important papers.
Be sure to give copies to people you trust – your agent and a trusted relative or friend. Give copies to:
- Your health care agent
- Your health care professionals at the mental health center
- Your health care providers that you named in your advance directive
- Any hospital where you have been a patient
- Any hospital where you want to be treated
Make a list of the people and places that have your advance directive and keep it with you.
Some states have created a repository – a central place to keep copies of advance directives. If your state has a repository, you should file a copy there. Check with your state’s protection and advocacy (P&A) agency or the National Center on Psychiatric Advance Directives to find out.
Resources and Glossary
National Resource Center on Psychiatric Advance Directives. NRC-PAD is a nonprofit organization that offers a state by state guide to laws, rules, forms and other resources.
Mental Health America.
Advance Directive: A document you write that gives instructions for your care at times when you can’t speak for yourself because of illness or because you lack the capacity — the ability to make informed decisions about your own care. You can also name another person or persons (healthcare agent) to act on your behalf in your advance directive.
Capacity: The ability to make informed decisions about your own medical care. You must be able to take in information, understand your choices and communicate your decision. If you are too sick to do this, doctors can determine that you lack the capacity and turn to other people to make decisions for you. This is when they should consult your psychiatric advance directive and your health care agent. Loss of capacity is usually temporary, until you are well enough to make decisions again. It is important to note that state laws on capacity may differ.
Health care Agent: A person that you instruct to make medical decisions for you when you lack the capacity to make them for yourself. Your psychiatric advance directive should spell out the powers you give to your health care agent to carry out your instructions, advocate for you and make decisions on your behalf. This person can also be called a proxy or patient advocate.
Informed Consent: A decision you make about your treatment based on a good understanding of the choices involved, alternative treatments you could choose and the consequences of the choices you make.
Incompetence: When a judge finds you as incompetent it means that you are incapable of managing your own affairs on a long-term basis. This might include the ability to make health care decisions, handle money or make major decisions about your life. The court then appoints a guardian to make your decisions.
Living Will: A document you write that gives instructions about how you want to be treated when you are terminally ill and not expected to recover. You spell out the treatment and care you want as well as measures you do not want taken. Your living will takes effect when you are unable to speak and make decisions for yourself.
Power of Attorney: Power you give to another person, called a health care agent, authorizing them to act on your behalf when you are unable to do so.
Protection and Advocacy (P&A) Agency: A state agency charged with protecting the rights and advocating for people with mental illness, intellectual disabilities and other disabilities, especially when they are in hospitals or other institutions.
Psychiatric Advance Directive: A special form of advance directive that spells out what treatments you want and don’t want and how you want to be treated when you are in a mental health crisis or hospitalized and unable to make your own decisions. It can also include the naming of your health care agent. You should consult with a lawyer (attorney) in your state that has experience preparing psychiatric advance directives. In an emergency situation, however, it is important to understand that doctors have the authority to make decisions that are necessary to ensure your safety and that of other patients and hospital staff.
Revocable: The ability to change your mind and cancel your advance directive. If your state law allows you may decide to make your psychiatric advance directive nonrevocable, which means it will remain in effect when you are very ill.
Repository: A central location in a state where advance directives are kept safe and made available to doctors and hospitals who need to consult them.
Ulysses Clause: A statement in a psychiatric advance directive that permits doctors to treat you over your own objections when you are very ill.
You can include the medications and dosages that you know are most helpful to you and those that you do not wish to receive; names of facilities or healthcare professionals you want involved in your care, and people who can help you with important activities (such as paying your bills, and taking care of your children, pets or plants). You can also even identify the people you do or do not want as visitors if you're hospitalized.
One of the more powerful features of an advance directive is your ability to designate someone else (an agent) to make decisions for you if you are admitted to a hospital. You can name that person by stating that only he or she should make decisions for you in the event that you have been determined to lack the capacity to do so.
Duke University maintains a national resource center on psychiatric advance directives that provides background information and a guide to laws in each state.
The person you select should be someone you trust to advocate for you - a family member or friend. He or she will tell others what kind of treatment you do or do not want, and supervise your care. You may wish to choose more than one agent. You can make one the primary agent and designate another as a back up, or you could give each person different responsibilities. Perhaps you trust one person to make your healthcare decisions and another to take care of your household matters (bills, etc.). Be clear about who should do what.
Before naming an agent, discuss your plans with the person(s) you want to designate. Each of them must fully understand your request.
State laws vary. To maximize the enforceability of your advance directive, you may wish to consult with an attorney or someone from your state's protection and advocacy (P&A) program to see what your state allows. To find the P&A system in your state, visit the National Disability Rights Network.
It's important that people know you have an advance directive and know where to find it. Put a copy in your home where it can be easily found; and, put another one in a safe place with your other important papers. Be sure to give copies to people you trust - your agent or a trusted friend or relative; you should also have one on file at any hospital where you have been a patient before.
You can change the contents of your advance directive by making corrections or writing out a new one. However, it is your responsibility to ensure that everyone has a copy of your most current advance directive.
Depending on where you live, you can also choose to make your advance directive revocable. This means you can reserve the right to cancel your advance directive even during a crisis. This must be stated in writing. However, if you choose to revoke your advance directive, your agent will no longer be able to advocate for you. Before you decide whether to make your advance directive revocable, you should thoroughly discuss this with your friends, family and healthcare providers.