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Provider Utilization of Advance Directives in the Psychiatric Setting: PAD's. Yad M. Jabbarpour, MD, DFAPA Chief of Staff Catawba Hospital Clinical Assistant Professor of Psychiatric Medicine University of Virginia School of Medicine ADVANCE DIRECTIVES TRAINING November 5, 2009

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Provider utilization of advance directives in the psychiatric setting pad s l.jpg

Provider Utilization of Advance Directives in the Psychiatric Setting: PAD's

Yad M. Jabbarpour, MD, DFAPA

Chief of Staff

Catawba Hospital

Clinical Assistant Professor of Psychiatric Medicine

University of Virginia School of Medicine

ADVANCE DIRECTIVES TRAINING

November 5, 2009

Richmond, Virginia


Do we have psychiatric advanced directive s in virginia l.jpg
Do we have Psychiatric Advanced Directive’s in Virginia? Psychiatric Setting: PAD's

  • Legally: Advance Directives (AD): Yes (§ 54.1-2981 et seq)

    “Psychiatric” AD (PAD): No

  • Clinically & for the Consumer: Yes, one can look at the PAD in Virginia as an advance directive for mental health care

  • Virginia: AD’s are not disease-specific

  • A person is free to draft an advance directive that only addresses one particular type of health situation if he/she chooses

  • AD law allows instruction & proxy directives across the continuum of one’s life


What is a pad psychiatric advance directive l.jpg
What is a PAD, Psychiatric Setting: PAD'sPsychiatric Advance Directive?

… a relatively new legal instruments that may be used to document a competent 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.

http://pad.duhs.duke.edu/ obtained 8/13/07


What does a psychiatric advance directive direct l.jpg
What does a (Psychiatric) Advance Directive direct? Psychiatric Setting: PAD's

I. Instructional Directive

  • Medications, specific treatment; ways to handle emergencies; restraint/seclusion, release information; visit list; preferences, persons to take care of pets, house, child care; medical care

  • e.g., living will

  • Drawback: difficult to predict future situations

    II. Proxy Directives

  • “health care power of attorney”

    III. Both: Proxy + Instruction (2 in 1)


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What does The Joint Commission say about AD’s? Psychiatric Setting: PAD's

Definition:

A document or documentation allowing a person to give directions about future medical care or to designate another person(s) to make medical decisions if the individual loses decision-making capacity.

Advancedirectives may include living wills, durable powers of attorney, do-not-resuscitate orders (DNRs), right to die, or similar documents listed in the Patient Self-Determination Act which express the patient's preferences.

The Joint Commission Manual, July 1, 2009


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What does The Joint Commission say about PAD’s? Psychiatric Setting: PAD's

“The hospital determines if the patient has a behavioral health advance directive and informs the licensed independent practitioner and staff who participate in the use of restraint and seclusion of the directive and its content.”

PC.03.03.09, Element of Performance 5, The Joint Commission Manual, July 1, 2009


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What medical ethical principles apply? Psychiatric Setting: PAD's

  • Respect for Autonomy

  • Non-maleficience “Do No Harm”

  • Beneficience

    • “Do Good”

    • Moral application: “Right to Treatment”

  • Confidentiality

  • Justice

    • Safety of Others


  • What are some of the possible ethical challenges l.jpg
    What are some of the possible ethical challenges? Psychiatric Setting: PAD's

    • Person lacks capacity to prepare a PAD

    • Lack of resources

    • Discrepancy between what PAD says & Standard of Treatment

    • MH Clinician doesn’t agree with PAD

    • Assessment of person’s capacity to make informed consent decisions

    • Person with PAD admitted to hospital, lacks capacity & refuses their own PAD instruction

    • Disagreement between patient & power of attorney

    • Accessibility of PAD while also maintaining confidentiality


    Case practice develop a pad for yourself in case of acute psychoses l.jpg
    Case Practice: Psychiatric Setting: PAD'sDevelop a PAD for yourself… in case of acute psychoses

    • Do you think it appropriate to develop a PAD for yourself?

    • What treatment would you agree to?

    • What treatment, if any, would you refuse?

    • Would you want an agent to make healthcare decisions? If so, who?

    • Preferred Hospitals

    • Hospitals to Avoid

    • Methods to de-escalate crisis to prevent restraint

    • Would you want a directive and/or agent that was irrevocable by yourself during periods of incapacity?

    • With whom would you share your PAD?


    How would clinicians write their own pad s l.jpg
    How would clinicians write their own PAD’s? Psychiatric Setting: PAD's

    Amering M, et al, Soc Psychiatry Psychiatr Epidemiol, 1999

    • UniversitätWien, Austria

    • N=101 psych nurses & psychiatrists

    • Asked to anonymously draft PAD’s for themselves “in case of acute psychoses”


    Who is likely to be interested in complete a pad l.jpg
    Who is likely to be interested in & complete a PAD? Psychiatric Setting: PAD's

    Swanson J, Swartz M, et al; J Am Acad Psychiatry Law, 2006

    • Survey, N=1,011 5 U.S. Cities

    • 4-13% had completed PAD

    • 66-77% interested in completing PAD if given assistance

    • Higher demand in participants who were ♀, non-white; had h/o self-harm, arrest, ↓ personal autonomy; felt pressured to take Rx

    • Completion: ↑ insight, leverage from a payee, external pressure to keep MH outpt appt’s


    What do patients put in their pad s srebnik ds et al psych serv 2005 l.jpg
    What do patients put in their PAD’s? Psychiatric Setting: PAD's Srebnik DS, et al; Psych Serv 2005

    • Srebnik D; Psych Serv, 2005

    • N=106 MH Center outpt with  2 hospitalizations or ED visits within 2 yrs

    • Dx: Schizophrenia (44%); Bipolar (27%); Major Depression (22%)


    What do patients put in their pad s srebnik ds et al psych serv 200513 l.jpg

    Listed preferred meds Psychiatric Setting: PAD's

    Listed meds you would refuse

    No one rejected all medications

    Most preferred

    Antidepressants

    2nd Generation Antipsychotics

    Medications for Medical Conditions

    Medications refused

    1st Generation Antipsychotics

    Mood stabilizers

    Antidepressants

    Reasons for Refused Medications

    Side-effects

    Feeling “doped up & foggy”

    Medications "don’t help”

    81%

    64%

    54%

    53%

    19%

    35%

    15%

    15%

    45%

    32%

    29%

    What do patients put in their PAD’s? Srebnik DS, et al; Psych Serv 2005


    What do patients put in their pad s srebnik ds et al psych serv 200514 l.jpg

    Listed preferred meds Psychiatric Setting: PAD's

    Listed meds you would refuse

    Preference between hospitals & alternatives

    Chose hospital alternatives over hospital

    Preferred hospitals

    Preferred Hospital Alternative

    See prescriber to help with medications

    Have someone I could call

    Stay overnight in crisis bed or respite bed

    Have MH provider visit me

    Have someone who would call me

    Preferred Hospitals

    Specific preferred hospital listed

    Specific hospital to avoid

    Reasons for hospitals to avoid

    Poor quality of care

    Staff not treating clients with respect

    Problems with patient being hurt or abused

    Inconvenient location for family and friends to visit

    81%

    64%

    68%

    25%

    47%

    42%

    42%

    39%

    38%

    80%

    48%

    29%

    21%

    16%

    8%

    What do patients put in their PAD’s? Srebnik DS, et al; Psych Serv 2005


    What do patients put in their pad s srebnik ds et al psych serv 200515 l.jpg

    Listed preferred meds Psychiatric Setting: PAD's

    Listed meds you would refuse

    Chose hospital alternatives over hospital

    Specify methods to de-escalate crises

    Refuse ECT

    Surrogate decision maker

    Directive that was irrevocable during periods of incapacity

    How many of the PAD’s were rated as feasible, useful and consistent with practice standards?

    81%

    64%

    68%

    89%

    72%

    46%

    57%

    ___

    What do patients put in their PAD’s? Srebnik DS, et al; Psych Serv 2005


    What is the clinical utility of what people put in their pad s srebnik ds et al psych serv 2005 l.jpg

    Instruction Psychiatric Setting: PAD's

    Preferred Medications

    Meds refused

    Willingness to try meds not listed in directive

    Preferred hospital alternatives

    Hospital preferences

    ECT

    Deescalation methods

    seclusion, restraint, sedating meds

    Person to care for dependents

    Person to care for pets

    Person to care for finances

    Designation of surrogate decision maker

    Consistent Feasible (%) Useful (%)

    with standard

    of care (%)

    94 99 97

    96 96 96

    57 59 59

    100 100 100

    100 100 100

    100 100 100

    100 100 100

    99 100 100

    98 99 100

    100 100 100

    100 100 100

    100 100 100

    96 96 96

    What is the clinical utility of what people put in their PAD’s?Srebnik DS, et al; Psych Serv 2005


    If a person comes with a pad what do i do next l.jpg
    If a person comes with a PAD, what do I do next? Psychiatric Setting: PAD's

    • If a person is determined to lack capacity to make his/her own decisions about treatment, the health care provider must generally follow the treatment instructions that are written in your PAD or given by your health care agent. Your health care provider may notify all other providers of the instructions in your PAD.  

    • However, the health care provider is not required to follow your PAD instructions if they conflict with accepted standards of medical care or are contrary to the patient’s needs during an emergency. 


    Are there times when a pad would not be followed l.jpg
    Are there times when a PAD would not be followed? Psychiatric Setting: PAD's

    Yes, A PAD would not be followed

    • If it conflicts with generally accepted community practice standards.

    • If the treatments requested are not feasible or available.

    • If it conflicts with emergency treatment.

    • If it conflicts with applicable law.   

      http://www.nrc-pad.org/content/view/32/25/ obtained on 10/12/2009


    What happens if a part of my pad cannot be followed l.jpg
    What happens if a part of my PAD cannot be followed? Psychiatric Setting: PAD's

    • If PAD instructions are not followed, the mental health care provider must notify the patient or the person’s health care agent,

    • then document this notification in the medical record with the reason for not following your PAD.

    • If the conflict remains unresolved, the physician must make reasonable efforts to transfer the patient to another physician who is willing to comply with the PAD.

      http://www.nrc-pad.org/content/view/35/25/ obtained on 10/12/2009


    If a part of a pad can t be followed does that mean all of it should be ignored l.jpg
    If a part of a PAD can't be followed, does that mean all of it should be ignored?

    No.  The PAD will be followed as closely as circumstances and the law allow.


    Does the pad apply if the person is involuntarily committed to a hospital l.jpg
    Does the PAD apply if it should be ignored? the person is involuntarily committed to a hospital?

    Involuntary commitment to a treatment facility takes priority over what your PAD says about hospitalization. 

    However, your preferences regarding medication and other aspects of treatment while hospitalized should be followed even while you are involuntarily committed unless other provisions of law apply – e.g., preferences may be overridden in an emergency.

    http://www.nrc-pad.org/content/view/32/25/ obtained on 10/12/2009



    Can a person change his mind and either change or end his pad23 l.jpg
    Can a person change his mind and either change or end his PAD?

    Yes… if a person is capable of understanding the nature and consequences of his actions,

    • An advance directive may be revoked at any time by the declarant by a signed, dated writing;

      OR

    • By physical cancellation or destruction of the advance directive by the declarant or another in his presence and at his direction;

      OR

    • By oral expression of intent to revoke.


    Can a person change his mind and either change or end his pad ulysses clause l.jpg
    Can a person change his mind and either change or end his PAD?Ulysses Clause

    Ulysses and the Sirens by John William Waterhouse


    Can a pad be revoked in virginia ulysses clause l.jpg
    Can a PAD be revoked in Virginia? PAD?Ulysses Clause

    No if a person is incapable of understanding the nature and consequences of his actions

    • Ulysses Clause is legally supported if the patient made it explicit in the AD to i) support the agent even over later protest

    • Ulysses Clause is legally supported if the patient made it explicit in the AD to i) support the agent & ii) the AD instructions (including for admission) even over later protest & iii) have a doctor/LCP sign off on language specifically supporting the TREATMENT over later protest.

    • If the patient is now incapacitated and didn’t choose and agent, or removed a particular agent, but he has a signed Ulysses clause regarding specific treatment, then whoever the statutorily appointed agent is (by default) could authorize the treatment over protest instead.


    Can a person change his mind and either change or end his pad26 l.jpg
    Can a person change his mind and either change or end his PAD?

    Generally, the answer is yes, you may change or end your PAD at any time you are considered “capable.”  For more detailed information about how to revoke or modify your PAD, you should click on your state and refer to either the statute or the frequently asked questions for that state.


    Why don t more consumers have pad s l.jpg
    Why don’t more consumers have PAD’s? PAD?

    • Families and consumer’s don’t know the benefits

    • Some hospitals don’t request and/or implement PAD’s

    • Only about ½ of states have PAD laws

    • PAD’s may be difficult to complete

    • Help to complete PAD’s is not always available


    What about pad s for persons of other cultures van dorn et al psych serv oct 2009 l.jpg
    What about PAD’s for persons of other cultures? PAD?Van Dorn, et al; Psych Serv, Oct 2009

    • N=85 Latinos with mental illness

      N=25 family members

      N=30 their clinicians

    • 92% wanted either a healthcare agent or

      agent + advance instruction

    • Strong preference for prescriptive function

    • 89% thought bilingual document would improve communication between families & clinicians

    • 93% of clinicians thought PAD could convey cultural preferences


    What are clinician s attitudes regarding the barriers to implementations of pad s l.jpg
    What are clinician’s attitudes regarding the barriers to implementations of PAD’s?

    Van Dorn RA, Swartz MS, et al, Adm Policy Ment Health, 2006

    • N=591 psychiatrists, psychologists, SW’s

    • Operational Barriers > Clinical Barriers

      work environment inappropriate treatment requests

      lack of communication among staff consumers’ desire to change their mind

      lack of access to document about treatment during crises

    • ↑ Perceived Barriers: psychiatrists, legal defensiveness, public sector employment, belief that risk of Tx refusals > benefit of PAD’s

    • ↓ Perceived Barriers: age, positive perception of PAD’s


    How do docs view pad s developed with facilitated sessions and more l.jpg
    How do docs view PAD’s developed with facilitated sessions?and more…

    Swanson, Swartz, et al, AJP, 2006

    • “Psychiatrists rated the advance directives as highly consistent with standards of community practice.

    • “Most participants used the PAD to refuse some medications & to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment

    • “A 1-month f/u, participants in facilitated sessions

      • had a greater working alliance with their clinicians and

      • were more likely than those in the control group to report receiving the MH services they believed they needed.”


    How can a person share a pad how can a clinician find a patient s pad l.jpg
    How can a person share a PAD? & sessions?How can a clinician find a patient’s PAD?

    • Medical Record

    • Health System Electronic Registry

      • Meaningful Use term to be associated with increased reimbursement by CMS if AD registry kept (up for public comment)

    • VDH: Advance Health Care Directive Registry

      • Early 2010 “go live”

      • free

    • U.S. Living Will Directory

      • Free if there is a partner

      • $59 one time fee

        http://www.uslivingwillregistry.com/default.asp


    Slide32 l.jpg

    What is WRAP sessions?(WellnessRecoveryActionPlan)?http://mentalhealth.samhsa.gov/publications/allpubs/SMA-3720/crisis.asp obtained on 3/19/07

    • Developing a Wellness Toolbox

    • Daily Maintenance Plan

    • Triggers

    • Early Warning Signs

    • When Things Are Breaking Down or

    • Getting Worse

    • Crisis Planning

    • Using Your Action Plans


    How can i make a wrap also a pad l.jpg
    How can I make sessions?a WRAP also a PAD?

    • A writtenadvance directive shall be signed by the declarant in the presence of two subscribing witnesses

    • An oral advance directive shall be made in the presence of the attending physician and two witnesses.


    How consistent is crisis care with pad s srebnik ds russo j psych serv 2007 l.jpg
    How consistent is Crisis Care with PAD’s? sessions?Srebnik DS, Russo J; Psych Serv, 2007

    • N=90 crisis events in which advance directive accessed

    • Average rate of care consistent with PAD:


    How consistent is crisis care with pad s srebnik ds russo j psych serv 200735 l.jpg
    How consistent is Crisis Care with PAD’s? sessions?Srebnik DS, Russo J; Psych Serv, 2007

    Treatment Instructions

    • ECT 100%

    • Rx agreed to 90%

    • Rx refused 89%

    • Hospital Alternatives 81%

    • Hospitals to Avoid 68%

    • Emergency Service: seclusion & restraints 50%

      NonTreatment Personal Care Instructions

    • Care for dependents 100%

    • People not authorized to visit 100%

    • Surrogate Decision Maker 60%


    Why have a pad l.jpg

    Advantages: sessions?

    Alternative to coercion, forced treatment or no treatment

    You pick the agent you want, instead of defaulting to the statutory hierarchy

    Agent must take your preferences into consideration

    Agent under an advance directive/POA trumps other LARs that may be appointed by a provider under the human rights regulations

    Why have a PAD?


    Why have a pad adapted from srebnik la fond 1999 l.jpg

    More Advantages: sessions?

    ↑ consumer empowerment, self-determination & choice

    ↑ functioning

    ↑ Communication among patients, family members and providers

    ↑ support for autonomy and recovery at the organizational level

    ↑ relapse prevention

    ↓ use of hospital services and judicial proceedings

    Why have a PAD? Adapted from Srebnik & La Fond, 1999


    How can a pad be best implemented l.jpg
    How can a PAD be best implemented? sessions?

    • Involve Service Providers

    • Not too vague but not overly restrictive

    • Designate a Proxy/Surrogate Healthcare Decision Maker

    • Dissemination

    • Support system strategies to facilitate development & implementation of PAD’s


    How can a system support pad s l.jpg
    How can a system support PAD’s? sessions?

    Swanson, Swartz, et al, AJP, 2006

    • N=469 pt’s with SMI randomly assigned

      • Facilitated PAD Session

      • Control Group: written info, referral to resources in public MH system

    • Completion rate with PAD

      Control Group 3 %

      Facilitated sessions 61 %

    • “Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the PAD to refuse some medications & to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment”

    • “A 1-month f/u, participants in facilitated sessions had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the MH services they believed they needed.

    • Take-Home Message: System-Level Policies and Programs “to embed facilitation of these instruments” may help us “achieve the promise”


    What are some pad resources l.jpg
    What are some PAD Resources? sessions?

    • The National Resource Center on Psychiatric Advanced Directives:http://www.nrc-pad.org/index.php

    • The Duke Program on Psychiatric Advanced Directives:http://pad.duhs.duke.edu/

    • Bazelon Center:http://www.bazelon.org/issues/advancedirectives/index.htm

    • NAMI:

      • http://www.nami.org/Template.cfm?Section=Issue_Spotlights&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=5&ContentID=8217

    • WRAP

      • http://www.mentalhealthrecovery.com/art_wrap.php


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