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What Is a Psychiatric Advance Directive?

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A woman cares for her mother who lives with mental illness and requires a psychiatric advance directive.

A psychiatric advance directive (PAD) is a legal document that serves a similar purpose to a living will but is tailored specifically to psychiatric care. It grants people the ability to express their choices concerning medications, hospitalization options and even the selection of mental health professionals. The significance of a PAD lies in its capacity to preserve an individual’s autonomy and ensure that their mental health care resonates with their personal values, even during periods of vulnerability.

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Understanding Psychiatric Advance Directives

PADs are legal documents that individuals can use to specify their preferences for future mental health treatment, including medications and hospital settings. A PAD can also be used to appoint a healthcare proxy or agent to make decisions on a person’s behalf. This advance planning is particularly relevant for individuals with serious mental illnesses, who may experience periods when making informed health decisions independently is challenging.

As of 2024, 25 states in the U.S. have adopted statutes specifically related to PADs, reflecting a growing recognition of their importance in mental health care. These states are:

  • Alaska
  • Arizona
  • Hawaii
  • Idaho
  • Indiana
  • Illinois
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Michigan
  • Minnesota
  • Pennsylvania
  • Montana
  • New Jersey
  • North Carolina
  • Oregon
  • Ohio
  • Oklahoma
  • South Dakota
  • Texas
  • Utah
  • Washington
  • Wyoming
  • New Mexico

These statutes vary from state to state, covering aspects such as the legal requirements for creating a PAD, the scope of decisions that can be included, and how these directives are implemented in clinical settings. Despite these variations, the underlying goal remains consistent: to respect and uphold the treatment preferences of individuals when they are most vulnerable.

PADs vs. Advance Directives

An advance directive can outline a person's preferences for medical care in the event that they become unable to make decisions for themselves.

Both PADs and regular advance directives (ADs) serve as legal tools designed to protect individuals’ preferences regarding their medical treatment, but they cater to different needs and circumstances.

ADs allow individuals to outline their preferences for medical care in the event that they become unable to make decisions for themselves. These directives typically cover a wide range of medical interventions and end-of-life care options, including the use of life-support systems, resuscitation efforts, and preferences for or against certain types of treatments. The primary goal of an AD is to ensure that a person’s medical treatment aligns with their values and wishes, especially in situations where they cannot communicate those preferences due to illness or incapacitation.

PADs, on the other hand, are a specific subset of advance directives tailored for individuals with mental health conditions who may experience periods when they are unable to make informed decisions about their care. These legal instruments can be especially useful for people with illnesses like bipolar disorder or schizophrenia.

One of the key differences between PADs and ADs lies in their focus. While ADs address a broad range of medical treatments and end-of-life care issues, PADs specifically concentrate on psychiatric care. As a result, PADs offer a level of specificity and customization that general ADs cannot provide for psychiatric care.

Moreover, the implementation of PADs and ADs can differ significantly. The legal recognition and enforceability of PADs vary by jurisdiction, with some states in the U.S. having specific laws governing their use. In contrast, ADs are widely recognized and supported by federal legislation, including the Patient Self-Determination Act, which mandates healthcare facilities to inform patients of their right to make advance directives.

Pros and Cons of Psychiatric Advance Directives

While PADs represent a step forward in psychiatric care, understanding their benefits and limitations is crucial for individuals, families and healthcare providers.

Pros

  • Patient autonomy: By delineating their preferences in advance, patients can ensure that their care aligns with their values, particularly during times when they may lack decision-making capacity. PADs empower individuals with mental illness by allowing them to have a say in their treatment during times when they might not be able to communicate their wishes. This autonomy can lead to increased satisfaction with treatment, a sense of control over one’s own life, and potentially better compliance with treatment plans.
  • Improved communication: By outlining treatment preferences in advance, PADs can improve communication between patients and healthcare providers. The clarity provided by PADs can not only grant peace of mind to those they protect but also act as a critical guide for healthcare providers and chosen proxies.
  • Crisis management: During a psychiatric crisis, decision-making can be chaotic and stressful for everyone involved. PADs can serve as a guide to healthcare providers and families, outlining the individual’s preferred treatment options and interventions, thus facilitating a smoother, more organized response to the crisis.

Cons

  • Legal and practical limitations: While PADs are legally binding in many jurisdictions, there are practical limitations to their enforcement. Healthcare providers may override PADs if they believe a patient’s chosen treatment is not in their best interest or if the patient poses a danger to themselves or others. This can lead to frustration and a sense of betrayal for the patient.
  • Variability in acceptance and awareness: Not all healthcare professionals are familiar with PADs, and acceptance levels can vary significantly. This lack of awareness and acceptance can hinder the effective implementation of PADs, rendering them less useful than intended.
  • Complexity and accessibility: Creating a PAD can be a complex process, requiring legal assistance and a thorough understanding of one’s own healthcare needs and options. This complexity may deter some individuals from creating PADs, especially those with limited resources or support.

How to Create a Psychiatric Advance Directive

A patient meets with his psychiatrist to talk about his care.

Crafting a PAD is a thoughtful, multi-step process. It begins with choosing a trusted agent, someone who deeply understands the individual’s values and is committed to advocating for their treatment choices should the individual lose the capacity to make decisions.

Subsequently, one must clearly define their treatment preferences in the PAD. These preferences could include approval or disapproval of certain medications, preferred care facilities and directives for handling mental health crises, which can potentially incorporate non-medication-based interventions. Consultation with a healthcare professional is recommended to ensure the preferences are viable and align with the individual’s overall care strategy. Additionally, obtaining legal advice can aid in verifying that the PAD adheres to state-specific laws.

After finalizing a PAD, it’s imperative to make the document accessible and operational. If a state registry for PADs exists, registering the document can facilitate quick access for healthcare providers in emergencies. Health care professionals should also be provided with copies to include in the patient’s records. The chosen agent must be fully briefed on their responsibilities and the specifics of the individual’s care preferences.

Regularly reviewing and updating the PAD is essential to account for any changes in the individual’s wishes or alterations in state laws that might impact the document’s enforceability. These actions are crucial to maintain the PAD’s relevance and effectiveness in guiding treatment as intended.

Bottom Line

Psychiatric advance directives (PADs) are a type of advance directive that enable individuals with mental illnesses or psychiatric conditions to preemptively articulate their treatment preferences. While PADs are not without their challenges, they can empower patients align their treatment with deeply held values, even in times when they cannot advocate for themselves.

Estate Planning Tips

  • Documents like a psychiatric advance directive and power of attorney play important roles in a person’s estate plan. If you’re just getting started with the process of planning your estate, here’s a list of five things you should consider doing.
  • An estate planning attorney can be a valuable resource as you navigate the estate planning process, but so can a financial advisor. Finding a financial advisor doesn’t have to be hard. SmartAsset’s free tool matches you with up to three vetted financial advisors who serve your area, and you can have a free introductory call with your advisor matches to decide which one you feel is right for you. If you’re ready to find an advisor who can help you achieve your financial goals, get started now.

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