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Advance Directives

Overview | Clinical Scenarios | Additional Tips | References
By Peter Ash, MD

OVERVIEW

General Principles

  • Psychiatric advance directives (PAD) were developed for those patients whose condition can be expected to wax and wane, and allows patients, when competent, an opportunity to give directions and authorize treatment for those times when they become incompetent (e.g., psychotic, manic, or grandiose). PADs are an extension of the concept of a medical advance directive focused on mental health care.
  • About half the states have passed statutes authorizing PADs. A listing of state laws is available.1 These statutes vary from state to state, but typically include a form for the patient to complete specifying treatment preferences, preauthorized consent, and appointment of an agent. Typically, a finding by a psychiatrist that the patient is incompetent to make treatment decisions triggers a PAD; a judicial finding of incompetence is not necessary.

Table 1.

Purpose of Psychiatric Advance Directive
Allow patient to provide for voluntary care when the patient becomes incompetent
Specify preferred and non-preferred treatments
Provide informed consent when patient is incompetent
Allow appointment of an agent who can decide for the incompetent patient
  • PADs have been found by research to increase patients’ sense of autonomy, reduce involuntary treatment, and increase treatment adherence after discharge.2-4
  • While PADs appear to have few downsides, a major challenge has been to get patients to complete them. Mental health systems should educate and encourage appropriate patients to complete a PAD.
  • In order to utilize a PAD, the clinician needs to know the patient has completed one. Some states have or are developing state-wide databases so that all clinicians (most especially ED clinicians) will have access to the PAD for any patient who presents in a mental health crisis.

CLINICAL SCENARIOS

Scenario #1: A 35 year-old married man with bipolar disorder functions well between manic episodes, but when manic, thinks he is President of the World, can read other peoples’ minds, and has no mental illness. After being arrested during an episode for disturbing the peace and resisting arrest, when euthymic he completes a PAD laying out his preferred medications and appointing his wife as his agent. When he has his next manic psychotic episode, his wife brings him to the Emergency Department where he loudly proclaims he has no problem and does not want to be in a hospital. A psychiatrist finds him incompetent and his wife consents to his admission to a psychiatric hospital as a voluntary patient.

  • This patient may not meet dangerousness criteria to justify involuntary hospitalization, but his wife acting as agent can admit him as a voluntary patient.
  • If the PAD did not include appointment of an agent but did specify that he would consent to admission at a named hospital, he could also be hospitalized as a voluntary patient at that hospital.

Scenario #2: A 46-year-old woman who suffers from paranoid schizophrenia has a PAD which specifies that she prefers treatment with risperidone or fluphenazine injections and gives prospective consent for treatment with those antipsychotics. She suffers an exacerbation of her symptoms and is hospitalized. While in the hospital, she refuses all medication claiming, “It will infect my mind with toxic blue rays.”

  • If a psychiatrist determines that she is incompetent to provide informed consent because of her delusion, she can be treated with her preferred antipsychotic medications.

ADDITIONAL TIPS

  1. The PAD should be in the patient’s chart and made available, with the patient’s release, to clinicians and institutions that may be involved in the patient’s care.
  2. The clinician should document discussing the PAD with the patient when competent to ascertain the patient’s willingness to complete one and to be clear what the patient intends in completing one.

REFERENCES

  1. National Resource Center on Psychiatric Advance Directives. NRC PAD. 2022 [Nov. 11, 2022]. Available from: https://nrc-pad.org.
  2. Srebnik D, Brodoff L. Implementing psychiatric advance directives: service provider issues and answers. J Behav Health Serv Res. 2003;30(3):253-68. PubMed PMID: 12875095.
  3. Swanson J, Swartz M, Ferron J, Elbogen E, Van Dorn R. Psychiatric advance directives among public mental health consumers in five U.S. cities: prevalence, demand, and correlates. J Am Acad Psychiatry Law. 2006;34(1):43-57. PubMed PMID: 16585234.
  4. Murray H, Wortzel HS. Psychiatric Advance Directives: Origins, Benefits, Challenges, and Future Directions. J Psychiatr Pract. 2019;25(4):303-7. doi: https://dx.doi.org/10.1097/PRA.0000000000000401. PubMed PMID: 31291211.
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