Psychiatric advance directive: Patients plan for when they're not competent
Advocates say advance planning gives mentally ill patients autonomy
When the first psychiatric advance directives (PADs) began to appear in state legislation more than 20 years ago, they were largely considered to be an end-of-life tool, much like general advance directives. But as more states have passed PAD laws — 25 states now have laws specifically providing for PADs — their usefulness has expanded.
A PAD is a witnessed legal instrument that documents a person's specific instructions or preferences regarding future mental health treatment, in preparation for the possibility that the person may lose capacity to give or withhold informed consent to treatment during acute episodes of psychiatric illness. To be binding, a PAD must be executed when the person is mentally competent. PADs often are used in concert with a general advance directive for health care to ensure that an individual's wishes regarding care and hospitalization are known and acted upon.
"Psychiatric advance directives were originally developed for use in the context of end of life, but now they are also being promoted as a way to enable patients with severe mental illness to retain control over their care if they become seriously impaired [regardless of whether they are at the end of life or not]," according to Susan Bowers, MBA, director of the Veterans Health Administration (VA) Integrated Service Network in the Southwest. "Advocates say [PADs] not only respect patient autonomy and choice, but can provide benefits to patient care in other ways."
By bolstering autonomy, PADs can improve care
Bowers, who spoke recently as part of a VA Ethics Center teleconference on PADs, says that, specifically, PADs have proved to be useful by:
- increasing patients adherence to therapy;
- decreasing the need for involuntary treatment.
PADs, like advance directives for health care, trace their roots to the Patient Self-Determination Act (PSDA) of 1991, which introduced a new set of federal requirements intended to implement advance directive policies at all health care facilities that receive federal funding through Medicaid and Medicare programs. Ethicists, attorneys, health scholars, and consumer advocates soon began talking about PSDA's implications for psychiatric treatment, and the act became part of the patient empowerment armament.
Specifically, the PSDA requires all hospitals — both general hospitals and psychiatric facilities — to:
- Inform patients of their rights to determine their own care, including right of refusal.
- Document the presence or absence of an advance directive.
- Have in practice policies for implementing patient rights.
- Comply with state laws on advance directives.
- Educate staff and the community about advance directives.
PDSA's intent — that patients have the right to declare in advance what their preferences for care are should they become incapacitated — applies equally to those suffering from mental illness who are competent or have periods of competency in which they can execute a directive letting their providers and representatives know their wishes.
Federal law does not require any form of advance directive, and it expressly forbids requiring an advance directive as a requirement for treatment.
Health care advance directives, particularly ones executed using a generic template, are not specific to mental illness, and in some cases are not even effective until a patient is determined to be terminally ill, according to William Van Stone, MD, associate chief for psychiatry for the VA.
A PAD can contain any stipulation that the individual might encounter as part of treatment. For example, it can include consent to, or refusal of, particular medications or inpatient admission; spell out who can or cannot visit the person when he or she is hospitalized; or designate who can make decisions regarding treatment when the patient is not competent to make those decisions on his or her own.
In all states, involuntary commitment to a treatment facility takes priority over the wishes expressed in a PAD about hospitalization; for example, a request "never to be involuntarily committed" would not be a viable, legal inclusion in a PAD. However, preferences regarding medication and treatment while hospitalized should be followed during an involuntary commitment.
According to the National Resource Center on Psychiatric Advance Directives (NRCPAD), PADs can make patients feel more in control and confident in the care they'll receive during a mental health crisis, and, therefore, might lead to greater compliance with treatment.
Advantages to a PAD, according to NRCPAD, include:
- the individual has more control over what happens to him during periods of crisis;
- providers and others will know what the person wants even when he can't express himself well;
- case managers and others can draw on the PAD for information as they craft a treatment plan;
- confidence that state law requires providers to respect what is included in a mental health advance directive to the fullest extent possible.
"We respect autonomy when we respect decisions made when the patient had decision-making capacity," says Van Stone.
Check for expiration
While health care advance directives never expire (unless they're revoked by the person who executed them), 10 states have legislated that advance directives for psychiatric care expire after a period ranging from two to five years. (See table, below.)
Michael Ford, JD, an attorney for the National Ethics Committee at the National Center for Ethics in Health Care in Washington, DC, says mental health advocates have taken issue with the expiration provision of some PADs.
"When a [PAD] expires, the patient has to execute a new one, and if it expires and the patient isn't aware of it, he or she might lose the ability to guide their own treatment when they lose decision-making capacity," says Ford. "We're not aware that there's evidence that a patient with a mental illness should be treated differently [than a physically ill patient] by letting their advance directive expire. That seems ethically unjustified, and seems unfair to single out mentally ill patients when advocates are trying to reduce the stigma attached to mental illness."
Another concern among mental health advocates is that if a PAD is in place, it could lead to coercion into treatment of a patient by his or her appointed representative. For that reason, 24 of the 25 states that have PAD legislation have restricted who can be a witness to the PAD, excluding family members and members of the person's treatment team, to avoid potential coercion from those groups.
Whether their state imposes a mandatory expiration, individuals in any state are permitted to revoke their PADs at any time they are competent.
Ford says some clinicians have expressed concern that their patients will revoke their PADs after they lose decision-making capacity, based on the fact that all states permit patients with general advance directives to revoke them at any time.
But Ford points out that 18 of the 25 states with PAD laws allow revocation of PADs only when the patient is determined to have decision-making capacity; some states allow individuals to indicate that they wish to have revocation powers even if not deemed competent.
(Editor's note: For more information on psychiatric advance directives, go to the web site of the National Resource Center on Psychiatric Advance Directives, www.nrc-pad.org.)
Sources
For more information, contact:
- Susan Bowers, MBA, director, Veterans Health Administration Integrated Service Network 18 (VISN 18), Mesa, AZ. Phone: (602) 222-2681.
- Michael Ford, JD, National Ethics Committee, VA National Center for Ethics in Health Care. Phone: (202) 501-0364.
- William Van Stone, MD, associate chief consultant for psychiatry, VA Mental Health Services, Washington, DC. Phone: (202) 273-5400.
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