Advance directives

Definition

An advance directive is a written document in which people clearly specify how medical decisions affecting them are to be made if they are unable to make them, or to authorize a specific person to make such decisions for them. These documents are sometimes called "living wills." Psychiatric advance directives serve the same purpose as general medical advance directives, but are written by mental health consumers as a set of directions for others to follow, made in advance of an injury, psychiatric illness, or crisis.

Description

Many consumers of mental health services know which treatments work best for them and, over the past several years, their opinions have become increasingly valued by those providing services. However, when a mental health consumer becomes unable to make decisions or to give informed consent for treatments offered, others (including family, friends, judges, or care providers) make the decisions for the individual in crisis. In these kinds of crisis situations, advance directives may be beneficial for the person receiving care, because the advance directive is a legal document that may protect him or her from unwanted treatment.

Psychiatric advance directives usually fall into two categories: instruction directives and agent-driven directives.

Instruction directives

An instruction directive is a written document that specifies which treatments an individual does and does not want, in the case that that individual becomes unable to make decisions about his or her care. These documents may indicate the affected individual's preferences about many aspects of treatment, including:

people who should be contacted at a time of psychiatric crisis
activities that reduce (and heighten) anxiety for the individual
effective alternatives to restraint or seclusion for the individual
acceptable and unacceptable medications and dosages
other interventions that might be considered during a time of crisis (such as electroconvulsive therapy )

Agent-driven directives

An agent-driven directive may also be called a durable power of attorney. This directive is a signed, dated, and witnessed document that authorizes a designated person (usually a family member or close friend) to act as an agent or proxy. This empowers the proxy to make medical decisions for a person when the person is deemed unable to mak e these decisions him/herself. Such a power of attorney frequently includes the person's stated preferences in regard to treatment. Several states do not allow any of the following people to act as a person's proxy:

the person's physician, or other health care provider
the staff of health care facilities that is providing the person's care
guardians (often called conservators) of the person's financial affairs
employees of federal agencies financially responsible for a person's care
any person that serves as agent or proxy for 10 people or more. The person who is to act as the proxy should be familiar with the individual's expressed wishes about care, and should understand how to work within the mental health system.

These two distinct documents may, in some cases, be combined into one form.

Special concerns

In the United States, each state has laws about general medical advance directives and how those laws apply to psychiatric advance directives; a few states exclude psychiatric advance directives from their statutes. The specific form the advance directive should take, the language it should use, and the number of witnesses required to make the document legal and binding vary from state to state. In general, according to the National Mental Health Association, physicians and other health care professionals are expected to comply with the instructions of an advance directive, as long as those instructions are within the guidelines of accepted medical practice. Currently, however, few laws require providers to comply with an advance directive. It is recommended that people speak to their attorney or physician to ensure that their wishes are communicated in a form that is legally acceptable in their state.

Resources

BOOKS

Clayman, Charles A., M.D. American Medical Association Home Medical Encyclopedia. New York: Random House, 1989.

Doukas, David J., and William Reichel. Planning for Uncertainty, A Guide to Living Wills and Other Advance Directives for Health Care. Baltimore, MD: Johns Hopkins University Press, 1993.

National Mental Health Association. Psychiatric Advance Directives Issue Summary.

ORGANIZATIONS

Advance Directive Training Project. Resource Center, Inc. Albany, NY. (518) 463-9242. <www.peer-resource.org> .

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Telephone: (888) 357-7924. Fax (202) 682-6850. Web site: <http://www.psych.org/> .

Judge David L. Bazelon Center for Mental Health Law. Washington, D.C. (202) 467-5730. <www.bazelon.org/advdir.html> .

National Association of Protection and Advocacy Systems. Washington D.C. (202) 408-9514. <www.protectionandadvocacy.com> .

National Mental Health Association. (Produces a Psychiatric Advance Directives Toolkit ). (800) 969-6642.

Joan Schonbeck, R.N.