Psychiatric advance directives
Encyclopedia
A Psychiatric advance directive (PAD), also known as a mental health advance directive, is a written document that describes what a person wants to happen if at some time in the future they are judged to be suffering from a mental disorder in such a way that they are deemed unable to decide for themselves or to communicate effectively.
It can inform others about what treatment they want or don't want from psychiatrists or other mental health professionals, and it can identify a person to whom they have given the authority to make decisions on their behalf. A mental health advance directive is one kind of Advance health care directive.
treatment, or to appoint a surrogate decision maker through Health Care Power of Attorney
(HCPA), in advance of being targeted by coercive mental health laws, during which they may be stripped of legal capacity to make decisions .
In the United States, although 25 states have now passed legislation in the past decade establishing authority for PADs, there is relatively little public information available to address growing interest in these legal documents . In addition in states without explicit PAD statutes, very similar mental health advance care planning can and does take place under generic HCPA statutes—expanding the audience for PADs to all 50 states (see National Resource Center on Psychiatric Advance Directives).
In addition to recognizing the potential benefits of PADs, states are beginning to recognize legal obligations under the federal Patient Self-Determination Act
of 1991, which includes informing all hospital patients that they have a right to prepare advance directives and — with certain caveats — that clinicians are obliged to follow these directive. As such, federal law helps ensure that people labeled as having mental illness
can use medical advance directives to specify mental health treatment preferences or assign proxy decision-makers for mental health decisions.
Finally, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires behavioral health facilities to ask patients if they have PADs. The Centers for Medicare and Medicaid Services
announced that patients have the right to formulate advance directives and to have hospital staff and practitioners who provide coercive interventions in the hospital comply with these directives. Hospitals out of compliance risk loss of Medicare
and Medicaid
revenue. While there are legal reasons to provide good crisis planning using PADs, the clinical reasons are equally compelling.
If followed by treatment providers, crisis planning using PADs will help involuntary detainees gain control over being targeted for substituted decision making — especially during times when they are labeled incompetent. Health care agents will be instrumental in providing inpatient clinicians with information that can be central to patients’ treatment, including history of side effects and relevant medical conditions.
has shown that creating a PAD with a trained facilitator increases therapeutic alliance with clinicians, enhances involuntary patients’ treatment satisfaction and perceived autonomy, and improves treatment decision-making capacity among people labeled with severe mental illness .
Morever, PADs provide a transportable document — increasingly accessible through electronic directories - to convey information about a detainee's treatment history, including medical disorders, emergency contact information, and medication side effects. Clinicians often have limited information about citizens detained and labeled as psychiatric patients who present or are coercively presented and labeled as in crisis. Nonetheless, these are the typical settings in which clinicians are called upon to make critical patient-management and treatment decisions, using whatever limited data may be available. With PADs, clinicians could gain immediate access to relevant information about individual cases and thus improve the quality of clinical decision-making—appropriately managing risk to patients and others’ safety while also enhancing patients’ long-term autonomy
.
For these reasons, PADs are seen as an innovative and effective way of enhancing values of autonomy
and social welfare for detainees labeled with mental illness
. Since PADs are among the first laws that are specifically intended to promote autonomy
among people with detained under mental health laws, wider use of PADs would empower a traditionally disenfranchised group when targeted for coercive psychiatry.
First, some people detained and forcibly drugged under coercive psychiatry laws report difficulty in understanding advance directives, skepticism about their benefit, and lack of contact with a trusted individual who could serve as proxy decision maker. The sheer complexity of filling out these legal forms, obtaining witnesses, having the documents notarized, and filing the documents in a medical record
or registry may pose a formidable barrier.
Second, recent studies of practitioners of coercive psychiatry's attitudes about PADs suggest that they are generally supportive of these legal instruments, but have significant concerns about some features of PADs and the feasibility of implementing them in usual coercive intervention settings. Clinicians are concerned about lack of access to PAD documents in a commitment, lack of staff training on PADs, lack of communication between staff across different components of mental health systems, and lack of time to review the advance directive documents.
In a survey conducted of 600 psychiatrists, psychologists, and social workers showed that the vast majority thought advance care planning for crises would help improve patients’ overall mental health care . Further, the more clinicians knew about PAD laws, the more favorable were their attitudes toward these practices. For instance, while most psychiatrists, social workers, and psychologists surveyed believed PADs would be helpful to people detained and targeted for forced drugging and electroshock when labeled with severe mental illnesses, clinicians with more legal knowledge about PAD laws were more likely to endorse PADs as a beneficial part of patients’ treatment planning.
However, many clinicians reported NOT knowing enough about how PADs work and specifically indicated they lacked resources to readily help patients fill out PADs. Thus, if clinicians knew more about advance directives and had ready assistance for creating PADs, they said they would be much more likely to help their clients develop crisis plans.
groups but that significantly more concerted efforts at dissemination were needed. The community of stakeholders interested in PADs and the broader concept of self-directed care are in need of online resource and gathering place for exchange of views and information.
As a result, in the United States, a collaboration between the Bazelon Center for Mental Health Law
and Duke University
has led to creation of the MacArthur Foundation
-funded National Resource Center on Psychiatric Advance Directives, the only web portal exclusively devoted to developing a learning community to help people targeted for coercive psychiatry, their families, and clinicians prepare for, and ultimately prevent, coercive psychiatry interventions. The NRC-PAD includes basic information, frequently asked questions, educational webcasts, web blog, most recent research, legal analyses, and state-by-state information on PADs and patient-centered crisis planning. The NRC-PAD website thus includes easy step-by-step information to help those targeted for forced drugging, family, and clinicians complete PADs that mirror the provisions in the PAD statutes.
It can inform others about what treatment they want or don't want from psychiatrists or other mental health professionals, and it can identify a person to whom they have given the authority to make decisions on their behalf. A mental health advance directive is one kind of Advance health care directive.
Legal Foundations
Psychiatric advance directives are legal documents used by persons currently enjoying legal capacity to declare their preferences and instructions for future mental healthMental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
treatment, or to appoint a surrogate decision maker through Health Care Power of Attorney
Power of attorney
A power of attorney or letter of attorney is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter...
(HCPA), in advance of being targeted by coercive mental health laws, during which they may be stripped of legal capacity to make decisions .
In the United States, although 25 states have now passed legislation in the past decade establishing authority for PADs, there is relatively little public information available to address growing interest in these legal documents . In addition in states without explicit PAD statutes, very similar mental health advance care planning can and does take place under generic HCPA statutes—expanding the audience for PADs to all 50 states (see National Resource Center on Psychiatric Advance Directives).
In addition to recognizing the potential benefits of PADs, states are beginning to recognize legal obligations under the federal Patient Self-Determination Act
Patient Self-Determination Act
The Patient Self-Determination Act was passed by the U.S. Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990...
of 1991, which includes informing all hospital patients that they have a right to prepare advance directives and — with certain caveats — that clinicians are obliged to follow these directive. As such, federal law helps ensure that people labeled as having mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
can use medical advance directives to specify mental health treatment preferences or assign proxy decision-makers for mental health decisions.
Finally, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires behavioral health facilities to ask patients if they have PADs. The Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
announced that patients have the right to formulate advance directives and to have hospital staff and practitioners who provide coercive interventions in the hospital comply with these directives. Hospitals out of compliance risk loss of Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
and Medicaid
Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
revenue. While there are legal reasons to provide good crisis planning using PADs, the clinical reasons are equally compelling.
If followed by treatment providers, crisis planning using PADs will help involuntary detainees gain control over being targeted for substituted decision making — especially during times when they are labeled incompetent. Health care agents will be instrumental in providing inpatient clinicians with information that can be central to patients’ treatment, including history of side effects and relevant medical conditions.
Clinical Benefits
Recent data from a NIH-funded study conducted by researchers at Duke UniversityDuke University
Duke University is a private research university located in Durham, North Carolina, United States. Founded by Methodists and Quakers in the present day town of Trinity in 1838, the school moved to Durham in 1892. In 1924, tobacco industrialist James B...
has shown that creating a PAD with a trained facilitator increases therapeutic alliance with clinicians, enhances involuntary patients’ treatment satisfaction and perceived autonomy, and improves treatment decision-making capacity among people labeled with severe mental illness .
Morever, PADs provide a transportable document — increasingly accessible through electronic directories - to convey information about a detainee's treatment history, including medical disorders, emergency contact information, and medication side effects. Clinicians often have limited information about citizens detained and labeled as psychiatric patients who present or are coercively presented and labeled as in crisis. Nonetheless, these are the typical settings in which clinicians are called upon to make critical patient-management and treatment decisions, using whatever limited data may be available. With PADs, clinicians could gain immediate access to relevant information about individual cases and thus improve the quality of clinical decision-making—appropriately managing risk to patients and others’ safety while also enhancing patients’ long-term autonomy
Autonomy
Autonomy is a concept found in moral, political and bioethical philosophy. Within these contexts, it is the capacity of a rational individual to make an informed, un-coerced decision...
.
For these reasons, PADs are seen as an innovative and effective way of enhancing values of autonomy
Autonomy
Autonomy is a concept found in moral, political and bioethical philosophy. Within these contexts, it is the capacity of a rational individual to make an informed, un-coerced decision...
and social welfare for detainees labeled with mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
. Since PADs are among the first laws that are specifically intended to promote autonomy
Autonomy
Autonomy is a concept found in moral, political and bioethical philosophy. Within these contexts, it is the capacity of a rational individual to make an informed, un-coerced decision...
among people with detained under mental health laws, wider use of PADs would empower a traditionally disenfranchised group when targeted for coercive psychiatry.
Barriers
National surveys in the United States indicate that although approximately 70% of people targeted by coercive psychiatry laws would want a PAD if offered assistance in completing one, less than 10% have actually completed a PAD . What explains the difference between interest in and completion of PADs?First, some people detained and forcibly drugged under coercive psychiatry laws report difficulty in understanding advance directives, skepticism about their benefit, and lack of contact with a trusted individual who could serve as proxy decision maker. The sheer complexity of filling out these legal forms, obtaining witnesses, having the documents notarized, and filing the documents in a medical record
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
or registry may pose a formidable barrier.
Second, recent studies of practitioners of coercive psychiatry's attitudes about PADs suggest that they are generally supportive of these legal instruments, but have significant concerns about some features of PADs and the feasibility of implementing them in usual coercive intervention settings. Clinicians are concerned about lack of access to PAD documents in a commitment, lack of staff training on PADs, lack of communication between staff across different components of mental health systems, and lack of time to review the advance directive documents.
In a survey conducted of 600 psychiatrists, psychologists, and social workers showed that the vast majority thought advance care planning for crises would help improve patients’ overall mental health care . Further, the more clinicians knew about PAD laws, the more favorable were their attitudes toward these practices. For instance, while most psychiatrists, social workers, and psychologists surveyed believed PADs would be helpful to people detained and targeted for forced drugging and electroshock when labeled with severe mental illnesses, clinicians with more legal knowledge about PAD laws were more likely to endorse PADs as a beneficial part of patients’ treatment planning.
However, many clinicians reported NOT knowing enough about how PADs work and specifically indicated they lacked resources to readily help patients fill out PADs. Thus, if clinicians knew more about advance directives and had ready assistance for creating PADs, they said they would be much more likely to help their clients develop crisis plans.
Resources
It thus has become clear that the potential significance of PADs is becoming widely recognized among those targeted for coercive psychiatry, survivors of coercive psychiatry, influential policy makers, clinicians, family members, and patient advocacyPatient advocacy
A Patient Advocate acts as a support structure and if legally contracted to do so may act as a liaison between a patient and their Health Care Provider. Most health care professionals see themselves as advocates for their patients, however their time and scope are limited by their job function...
groups but that significantly more concerted efforts at dissemination were needed. The community of stakeholders interested in PADs and the broader concept of self-directed care are in need of online resource and gathering place for exchange of views and information.
As a result, in the United States, a collaboration between the Bazelon Center for Mental Health Law
Bazelon Center for Mental Health Law
The Bazelon Center for Mental Health Law is a national legal-advocacy organization representing people with mental disabilities in the USA. Originally known as The Mental Health Law Project, the Center was founded as a national public-interest organization in 1972 by a group of specialized...
and Duke University
Duke University
Duke University is a private research university located in Durham, North Carolina, United States. Founded by Methodists and Quakers in the present day town of Trinity in 1838, the school moved to Durham in 1892. In 1924, tobacco industrialist James B...
has led to creation of the MacArthur Foundation
MacArthur Foundation
The John D. and Catherine T. MacArthur Foundation is one of the largest private foundations in the United States. Based in Chicago but supporting non-profit organizations that work in 60 countries, MacArthur has awarded more than US$4 billion since its inception in 1978...
-funded National Resource Center on Psychiatric Advance Directives, the only web portal exclusively devoted to developing a learning community to help people targeted for coercive psychiatry, their families, and clinicians prepare for, and ultimately prevent, coercive psychiatry interventions. The NRC-PAD includes basic information, frequently asked questions, educational webcasts, web blog, most recent research, legal analyses, and state-by-state information on PADs and patient-centered crisis planning. The NRC-PAD website thus includes easy step-by-step information to help those targeted for forced drugging, family, and clinicians complete PADs that mirror the provisions in the PAD statutes.