Psychiatric Advance Healthcare Directives: How to plan for mental health crises

In an effort to enhance patient autonomy and reduce the likelihood of coercive interventions during mental health crises, many states in the U.S. have implemented psychiatric advance directives (PADs). These legal documents allow individuals to specify their mental health treatment preferences, ensuring that their wishes are respected when they are unable to make decisions for themselves. In this article, we delve into the world of PADs, exploring how they work, their benefits, and the steps individuals can take to create one.

What Are Psychiatric Advance Directives?

A psychiatric advance directive is a legal document that enables individuals to outline their preferences for future mental health treatments. It serves as a guide for healthcare providers during times when the individual may be unable to communicate their wishes due to a mental health crisis. This can include periods of acute psychosis, mania, catatonia, or delirium, among other conditions.

Key Components of a PAD

1. Treatment Preferences: Individuals can specify the types of treatments they would or would not be willing to receive, including medication, hospitalization, and specific treatment facilities.
2. Agent Appointment: A person can appoint a healthcare agent to make decisions on their behalf if they become incapable of doing so. This agent must follow the instructions in the PAD and act in accordance with the individual’s wishes.
3. Background Information: Additional background information about past reactions to treatment can also be included to help healthcare providers understand the individual's history and preferences.

Benefits of Psychiatric Advance Directives

1. Preserves Patient Autonomy
   • PADs empower individuals to maintain control over their mental health treatment, even when they are unable to make decisions themselves.
2. Facilitates Communication
   • By specifying treatment preferences, PADs facilitate clear communication between patients and healthcare providers, potentially preventing crises from occurring.
3. Improves Continuity of Care
   • PADs ensure that treatment aligns with the patient's preferences, improving the continuity of care and reducing the risk of misunderstandings or miscommunications.
4. Reduces Use of Involuntary Treatment
   • By outlining treatment options and preferences, PADs can reduce the need for involuntary interventions such as hospitalization or forced medication.
5. Enhances Collaboration with Treatment Team
   • The document helps healthcare providers understand the individual's specific needs and preferences, enhancing collaboration within the treatment team.

How to Create a Psychiatric Advance Directive

Creating a PAD involves several steps:

1. Understand Your Needs

   • Start by thinking about how you would want to be treated in the event of a mental health crisis. This includes considering where you would want to receive care, whom you want to be notified, and whether you would be okay with hospitalization.

2. Appoint an Agent

   • Choose an agent who you trust to negotiate your care when you are unable. Your agent should be someone who:
     • Will be reachable in case of emergency
     • You can trust to speak on your behalf
     • Understands and is knowledgeable about your mental illness
     • Will ensure that you get the care you want with the people you want by your side.

3. Draft Your PAD

   • Once you have decided on an agent and thought through your treatment preferences, you can begin drafting your PAD. This typically involves filling out a state-provided form, which should be witnessed and formally signed. If your state does not have a specific form, refer to your state’s statues for creating a valid PAD without a form.

4. Review and Update

   • It is crucial to review and update your PAD periodically. This ensures that your preferences remain relevant and that any changes in your treatment needs are addressed.

State-Specific Laws

While PADs are available in many states, the specific laws regarding these directives vary. Currently, only 25 states have laws that allow PADs, but many other states permit patients to write advance legal instructions for their future mental health treatment or appoint an agent to make mental health treatment decisions on their behalf.

For states without specific PAD laws, patients can still draft a PAD under their state’s more general medical advance directive laws. To learn more about the laws in your state, visit the National Resource Center on Psychiatric Advance Directives.

Real-World Impact

The effectiveness of PADs in reducing coercive interventions has been studied extensively. A study examining the completion of Facilitated Psychiatric Advance Directives (F-PADs) found that PAD completers experienced reduced frequencies of coercive crisis interventions such as police transport, involuntary commitment, seclusion, and restraints.

Additionally, PADs that designate a psychiatric healthcare proxy can alleviate concerns about limited treatment options. Most PAD statutes allow for healthcare providers to petition a court to override a patient’s PAD if it runs contrary to the patient’s best interest.

Implementation Challenges

Despite their benefits, PADs face several challenges, including underuse in mental health care. A survey of mental health experts concluded that psychiatric advance directives are underused in the United States, particularly among individuals with serious mental illness receiving public-sector treatment.

However, healthcare organizations can play a crucial role in increasing the prevalence of PADs. Providers should be educated on the importance and process of creating PADs, and resources should be made available to support patients in drafting these documents.

Conclusion

Psychiatric advance directives offer a powerful tool for individuals to plan ahead for mental health crises. By specifying treatment preferences and appointing an agent, individuals can ensure that their wishes are respected when they are unable to communicate them. While state laws and implementation vary, the benefits of PADs are clear: they enhance patient autonomy, facilitate communication, improve continuity of care, and reduce the use of involuntary treatments.

As we continue to advocate for more effective mental health care, it is essential to promote the use of psychiatric advance directives. By making these documents available and accessible, we can empower individuals to take control of their mental health treatment and improve overall care outcomes.

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References

1. Psychiatry.org
2. NCBI
3. Mental Health America
4. National Resource Center on Psychiatric Advance Directives
5. The Joint Commission