Psychiatric Advance Directives: A “Living Will” for Mental Health Treatment

It’s likely you’ve heard of a “living will,” a legal document that outlines one’s preferences for their medical treatment in the event of a serious or terminal illness which renders them unable to express their wishes.

But did you know there’s something like a “living will” for mental health care? It’s usually called a “psychiatric advance directive” or a “mental health advance directive.” It’s an important tool to know about, especially if you or someone you care about may be facing a serious mental illness.

Let’s review the basics about psychiatric advance directives, including what they are, how to develop one, and how to use it when the need arises.

What is a psychiatric advance directive?

A psychiatric advance directive (PAD) is a legal document written by someone who has a mental illness. The PAD may contain one or both of the following types of information:

  1. You can give instructions about future preferences for mental health treatment should you experience a mental health crisis and have reduced or impaired ability to communicate your wishes during such a crisis.
  2. You can name another person (who may be called a “surrogate,” “agent,” “power of attorney,” or “proxy”) to make treatment decisions for you when you are unable to do so.

What types of instructions can someone list in their PAD?

Depending on the particular state or jurisdiction, types of information in the PAD may include:

  • Medication preferences
  • Preferred hospitals and alternatives to hospitalization
  • Preferred health care providers
  • Preferences about emergency interventions, such as seclusion, restraint, injections, etc.
  • Acceptance or refusal of specific types of treatment, such as certain medications or electroconvulsive therapy (ECT)
  • Information for hospital staff about things that can be upsetting or soothing during a crisis
  • Treatment history, including diagnoses, allergies, current providers, etc.
  • A list of emergency contacts to call (or not call) during a crisis or hospitalization
  • Naming a “surrogate” or individual to make health care decisions for you if you are unable to do so due to your illness

Do the legal requirements for a PAD vary in different jurisdictions?

While all US states permit some form of legal advance directive for healthcare, there are many differences in the details of how a PAD is developed and carried out across different states. It’s critical to find out what these requirements are in your particular area. A helpful resource for this is the National Resource Center on Psychiatric Advance Directives (NRC-PAD).

What are the advantages of having a PAD?

PAD’s can be useful for several reasons, including:

  • You can plan in advance for how to manage a mental health crisis.
  • This advance planning can give you more control over your treatment.
  • Having a plan can improve communication between you and your health care providers.

What do I need to do to develop my PAD?

Your PAD must be prepared while you are in good health. Here are some important steps to take to put a PAD into effect:

  1. Find out the laws regarding PAD’s in your state via the NRC-PAD site. They also have several helpful how-to webcasts and a list of frequently asked questions about PAD’s.
  2. Consider who you would want as your surrogate and ask them if they would be willing to serve in this role for you.
  3. Do a rough draft of your PAD, including your preferences for treatment and your chosen surrogate.
  4. Have a few trusted support persons review your PAD, including a mental health provider and your proposed surrogate.
  5. Have the document completed and witnessed or notarized as required, to make it legal.

Who should get copies of my PAD?

Keep a copy of your completed PAD with you at all times. Give copies of your PAD to:

  • Your mental health providers
  • Your physical health providers
  • Your preferred hospital
  • Your family and close friends
  • Your designated surrogate

If you ever change or update your PAD, make sure everyone listed above gets the most current version.

When would my PAD not be followed?

There are some situations in which the instructions in your PAD may not be followed. These could include:

  • If you are admitted to a hospital by court order.
  • If your preferred treatments or hospital aren’t available.
  • If you need emergency treatment which must override your preferences.
  • If your preferences conflict with general medical practice or relevant laws.

To summarize, PAD’s can be very beneficial, but it does require a little thought, planning and effort to get one completed and placed into effect. While most states now honor some form of PAD’s, they are still greatly underused and also not well publicized.

If you or someone you know could potentially benefit from having a psychiatric advance directive, please take a moment and share this information with them.

Here’s a question: Could I or someone I care about benefit from having a psychiatric advance directive? Please leave a comment. Also, please subscribe to my blog and feel free to follow me on Twitter, “like” my Facebook page, or connect on LinkedIn. Thanks!


National Resource Center on Psychiatric Advance Directives

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