The National Mental Health Consumers' Self-Help Clearinghouse

Mental Health / PsychiatricAdvance Directives

December 18, 2014

Adam Nester, Public Policy Manager, MHASPSue Walther, Executive Director, MHAPA

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Today’s Webinar Will Answer

• What is a Mental Health or Psychiatric Advance Directive?

• Why make one? What are the benefits?

• How to make one? What information is included?

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Federal Law

• The Federal Patient Self Determination Act (enacted in 1990) addresses the rights of health (including mental health) care users to stipulate in advance how they would like to be treated by health care providers when they are incapacitated.

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The Joint Commission

• The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations or JCAHO) addresses advance directives, end-of-life care, and surrogate decision-making standards in the 2006 Comprehensive Accreditation Manual for Hospitals.

• It sets standards for, evaluates, and accredits nearly 19,000 health care organizations in the United States.

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Increasing Demand

• A recent study found that while there was overwhelming interest in completing PADs (70 percent approval), only about 10 percent of those interviewed had completed PADs.

Source: Swanson et al, Journal Amer. Academy of Psychiatry Law 34:43–57, 2006

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Basic Premise

People With Mental Health Conditions Have the Same Rights

That People Without Mental Health Conditions Have.

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What Are A Person’s Rights?

• Examples are:To be treated with compassion, dignity and

respect.Practice your own values and spiritual beliefs.Express your feelings.Choose your friends.Right to Refuse or Consent to

Treatment.Right to choose your provider.

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Choosing Treatment

• Individuals have the right to determine the nature and extent of their medical care.

• Personal autonomy is a fundamental right guaranteed by the Constitution.Right To Informed Consent.Right To Treatment.Right To REFUSE Treatment.

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Informed Consent

• Three Requirements:

Doc’s duty to disclose all significant medical info.

Capacity.

VOLUNTARY consent.

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Capacity

• What is capacity for MH Advance Directives?

Capacity is the basic ability to understand:• Your Diagnosis• Risks and Benefits of Treatment• Alternative Treatments• The Consequences of Not Having Any

Treatment

It is only related to Mental Health Treatment.

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Incapacity

• The legal definition of incapacity varies by state. Some states do not define.

• Incapacity is generally determined by a health care provider, an attending physician or eligible psychologist

• In some states a judge must make the decision. 11

Incapacity

• A determination of incapacity must be put in writing and when made, your advance directive goes into effect.

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Mental Health (Psychiatric) Advance Directives

• A legal document created by a competent person

• Allows you to make choices about mental treatment in advance of incapacitation.

• Describes treatment preferences / provides treatment instructions, or

• Names/appoints an agent to make decisions.

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Mental Health Advance Directives

• Two Types:1. Instructive MHAD

More defined, less flexible.2. Proxy MHAD

More flexible, requires a health care agent/health care power of attorney– an individual to make decisions when you lack capacity

• In some states you can have a combination

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Why Is It Important?

• Taking responsibility for yourself – gain more control of your treatment

• Feel more comfortable seeking treatment• Autonomy – It’s all about you!• Helps ensure better treatment, faster• Consent to or refuse certain treatments• Encourages discussion of preferences• A natural part of a Wellness Plan

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Information Included in MHADs

• Information allowed in the MHAD varies by state

• Generally, MHADs allow you to agree to, refuse or give your preferences re:Hospital admissionPsychiatric medicationElectroconvulsive treatment (ECT)

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Types of Information to Include

• Treatment history

your mental health diagnosis;

other illnesses or conditions that affect your health care;

previous treatments and their outcomes;

medications you have taken and their effectiveness and side effects;

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Types of Information to Include

food or medication allergies;

the name and contact information of your primary physician, psychiatrist and counselor, therapist or social worker;

the name of a back-up physician if your regular one is not available.

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Types of Information to Include

• A person to contact in case of a mental health crisis

• Possible causes of your mental health crisis

• Ways to help you avoid hospitalization

• How you generally react to hospitalization

• Other relevant instructions 19

Include the name of your Health Care Agent

In virtually every state, you can appoint an individual to make health care decisions for you

should you become unable to do so.

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What is a Health Care Agent / Proxy?

• A Health Care Agent is someone you appoint to make your treatment decisions when you cannot make them yourself.

• Generally, a Health Care Agent can be any capable, competent adult (18 years or older) who is not your health care provider. Often you can name more than one agent, though only one can be active at a time.

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Health Care Agent / Proxy

• Naming an agent may be optional; some states require it.

• Some states only let you appoint an agent; you may not give your own treatment preferences. In those cases, however, the individual usually may give instructions directly to the agent.

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What Does the Agent Do?

• Your Health Care Agent will make the same treatment decisions as you would if you were able. Your Health Care Agent must act as you would act if you were capable.

• Your Health Care Agent must do what you instruct in your MHAD.

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What Does the Agent Do?

• Your Health Care Agent can discuss and review treatment information.

• Your Health Care Agent can change your health care provider.

• Your Health Care Agent can decide on your admission to a treatment facility and/or medications and ECT (electroconvulsive therapy).

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What Does the Agent Do?

• You can limit your Heath Care Agent to making only mental health treatment decisions.

• You can tell your Health Care Agent of any medications, treatments or hospital admissions you want

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Choosing an Agent

• Someone you TRUST!• Being available to make treatment

decisions

• Trying to make decisions for you that you would make for yourself

• Getting all the information needed to make decisions

• Advocating for what you need

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How to Make an MHAD

• This varies state by state.

• See your state’s page at the National Resource Center on Psychiatric Advance Directives, www.NRC-PAD.org for specific information about writing a PAD in your state.

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How to Make an MHAD

• Generally, you can create a MHAD by filling out the provided form for your state.

• If your state does not have a specific form, your state's statute should list the criteria for making your own valid form

• You usually are required to have your MHAD form witnessed and formally signed, and sometimes even notarized.

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When completed, what should you do with the MHAD?

• Always keep a copy of your PAD with you.

• Discuss its contents with your mental health care provider(s), family and close friends.

• If those around you are familiar with the document, you may improve your chances of receiving the care you want.

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Who Gets Copies of Your Completed MHAD

• Mental health care providers, including psychiatrist, counselor or therapist, to add to your medical records

• Primary care doctor

• Family members and close friends

• Agent

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Additional Information

• Your MHAD 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.

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Additional Information

• How does having a MHAD affect involuntary commitment?You may still be committed.Treating professionals may do whatever

is necessary to prevent harm to you or others in an emergency.

Your Advance Directive will govern your treatment while you are in the hospital.

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Additional Information

• If for any reason a part of your MHAD cannot be followed, the rest of it will be followed as closely as circumstances and the law allow.

• You may change or end your MHAD at any time you have capacity but the exact details for modifying or revoking your MHAD vary by state. See your state’s page at the National Resource Center on Psychiatric Advance Directives, www.NRC-PAD.org for details. 33

Additional Information

• WRAP can include the information to be considered a legal MHAD.

• For clarity, label that portion as MHAD.

• Provide copies and identify as MHAD.

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It’s a great Idea

• A Mental Health Care Advance Directive Is An Important Tool For Crisis Management.

• A Mental Health Care Advance Directive Is A Natural Part Of A Wellness Plan.

• A Mental Health Care Advance Directive Supports Recovery.

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Additional Information

New MHAD laws in 25 states since 1991:

Alaska, Arizona, Hawaii, Idaho, Indiana, Illinois, Kentucky, Louisiana, Maine, Maryland, Michigan, Minnesota, Pennsylvania, Montana, New Jersey, North Carolina, Oregon, Ohio, Oklahoma, South Dakota, Texas, Utah, Washington, Wyoming, New Mexico

To See where your state stands see: http://www.nrc-pad.org/state-by-state

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Source: NRC-PADS 37

Resource

National Resource Center on Psychiatric Advance Directives - http://www.nrc-pad.org/

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Mental Health Advance Directives

Sue Walther, Mental Health Association in Pennsylvaniaswalther@mhapa.org www.mhapa.org

Adam Nester, Mental Health Association of Southeastern Pennsylvaniaanester@mhasp.orgwww.mhasp.org National Mental Health Consumers’ Self-Help Clearinghouse www.mhselfhelp.orginfo@mhselfhelp.org

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