Advance directives for behavioral health care
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Advance Directives For Behavioral Health Care . Materials used with Permission From the National Resource Center on Psychiatric Advance Directives. NJ Division of Mental Health Services UMDNJ-University Behavioral HealthCare June 2007. What are Psychiatric Advance Directives (PAD’s)?.

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Advance Directives For Behavioral Health Care

Materials used with Permission From the

National Resource Center on Psychiatric Advance Directives

NJ Division of Mental Health Services

UMDNJ-University Behavioral HealthCare

June 2007


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What are Psychiatric Advance Directives (PAD’s)?

  • Legal documents that allow persons when of “sound mind”

    • To refuse or give consent to future psychiatric treatment.

    • May authorize another person to make future decisions about mental health care on behalf of the mentally ill person, if he/she becomes incapacitated.


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What does it do?

  • Helps consumers control treatment decisions

  • Helps families assist their loved ones in crisis

  • States preferences

  • Provides care guidelines

  • Supports all concerned parties

    • Consumer

    • Family and other supporters

    • Treatment providers


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Goal of an Advance Directive

  • To ensure patients are treated according with their wishes.

  • To encourage a more informed and open dialogue between patients and their treatment providers.


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Why Are PAD’s Important

  • Patent Self-Determination Act (PSDA) of 1990 requires hospitals and clinics to assist in the use of Medical Advance Directives (‘living wills”).

  • In states with PAD’s laws, the PSDA requires hospital and clinics to assist in their use.

  • New Jersey has a PAD law called the “New Jersey Advance Directives for Mental Health Care Act”.


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Why Are PAD’s Important

  • Allows families to speak directly with providers during crisis.

  • Allows families help make decisions during crisis.

  • Still supports consumer autonomy and empowerment in mental health care.

  • May reduce involuntary treatment.

  • May improve continuity of care.


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The Information in PAD’s

  • Crisis symptoms

  • Medication choice

  • Hospital choice

  • Emergency contacts

  • Relapse and protective factors

  • Instructions to staff

  • Other instructions


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The Potential of PAD’s

  • PAD’s can

    • Empower the consumer

    • Enhance communications

    • Facilitate timely interventions

    • Reduce adversarial litigation


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Two Parts to PAD’s

  • Instructional Directive:

    • Similar to a living will.

    • Documents wishes, consent or refusal of future care.

  • Health Care Power of Attorney:

    • Appoints another person to make decisions during crisis.

    • May be designed with limited or broad powers.

  • Not required to have either.

  • Can choose to have both.


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Instructional Directives

  • Usually permits individual to plan for, consent to, or refuse:

    • Hospital admission

    • Medications

    • Electroconvulsive treatment

    • Other treatments for mental illness.

  • Takes effect in the event individual loses ability to make decisions (is “incapable”).


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Instructional Directives:May include additional information

  • Who to contact in case of a crisis.

  • What may cause a mental health crisis.

  • What may help a person to avoid hospitalization.

  • How the person generally reacts to hospitalization.

  • Other instructions.


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Making an Instructional Directive

  • Any adult “of sound mind” can make.

  • Must be in writing.

  • Signed in presence of one witness:

    • Not a relative.

    • Not person’s doctor, mental health provider or other staff.

    • Not staff of a health care facility which the client is a patient.

    • Present to doctor and other mental treatment providers.


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What should the doctors or staff do with the Instructional Directive?

  • Must make a part of medical record.

  • Must act in accordance with instructional directive when patient is determined to be “lack of decision making capacity”.

  • May notify all other providers to follow instructional directive.


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What does “Lacking in Decision Making Capacity” Mean? Directive?

  • …in the opinion of two responsible mental healthcare professionals the person currently lacks sufficient understanding or capacity to make and communicate mental health treatment decisions.”


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Must clinicians always honor the instructions? Directive?

  • Clinicians may disregard instructions:

    • Not consistent with “generally accepted community practice standards.”

    • When treatment requests are not feasible or unavailable.

    • When treatment requests would interfere with treating an emergency.

    • Instructions may be over-ridden by involuntary inpatient commitment.

    • Conflicts with other law.


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If one instruction is not followed, what happens to other instructions?

Generally:

  • If one part of the instructions cannot be carried out, the remaining instructions must still be followed.

  • If not followed, reason for not following instruction must be communicated and documented.


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Can the instructions be changed? instructions?

  • Generally: These documents can be changed or revoked at any time by notifying the physician or treatment team, revising the document, or by destroying the document.


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Health Care Power of Attorney (HCPA) instructions?

  • Allows a person to appoint someone to make treatment decisions when it has been determined that the consumer lacks decision making capacity. Can be combined with instructional directive.

    • But may be two different forms.

  • Any capable adult may execute.


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Health Care Power of Attorney instructions?

  • Someone the consumer trust…

  • Someone to negotiate consumer care…

  • When consumer cannot.


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Who can serve as the health care power of attorney? instructions?

  • Any competent adult 18 or older.

  • Person usually cannot be providing health care to consumer.

  • Consumer can name several people to serve if one unavailable.


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When does health care power of attorney take effect? instructions?

  • When consumer is found to be lacking in decision making capacity and continues during period of incapacity.

  • Determined by two mental health professionals.

  • Must document decision of lacking decision making capacity.


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What powers does the health care power of attorney have? instructions?

  • Can make whatever treatment decisions the consumer could usually make;

    • Unless the consumer limits the authority of the health care power of attorney.

    • Consumer can instruct health care power of attorney on decision about medications, ECT, hospital admission, other.


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What should the health care power of attorney do? instructions?

  • Must make decisions consistent with any statements in instructional directive, if one exists.

  • Can discuss and review treatment information.

  • Can usually consent/refuse admission to hospital.

  • Can usually consent/refuse medication and ETC.


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Examples of Use of PADs instructions?

  • Advance informed consent to future hospitalization in the event of incapacitating mental health crisis.

  • Request or refuse future treatment with medications or other interventions.

  • Authorize health care power of attorney to make future decisions about psychiatric treatment in patient’s best interest.


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Why don’t more consumers have PADs? instructions?

  • Families have not realized they should encourage them!

  • Fewer than half of states have these laws.

  • Some states allow pads under medical advance directives.

  • Advance directives may be difficult to complete for some consumers.

  • Help in completing advance directives may not always be available.


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Where can I get more information about PADs? instructions?

  • New Jersey Division of Mental Health Services

    www.state.nj.us/humanservices/dmhs/index.html

  • National Resource Center on Psychiatric Advance Directives

    www.nrc-pad.org

  • Bazelon Center

    www.bazelon.org

  • NAMI

    www.nami.org

  • National Mental Health Association

    www.nmha.org


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