ADVANCE DIRECTIVES

FOR MENTAL HEALTH CARE

AN OVERVIEW FOR SERVICE PROVIDERS

A DEFINITION

* A mental health care advance directive (MHAD) is a written statement, made by a client, about their treatment choices and preferences, chosen during a time they are capable to make these decisions, anticipating a time when they are not capable.

* Sample excerpts

BACKGROUND

* MHADs stem from advance directives for health care, which are legal documents commonly known as “living wills”.

* Series of “right to die” cases support ADs for health care

* Federal Patient Self-Determination Act (1990) expanded use of ADs for health care

* Mid- 1990’s HCFA interpretation of the Act includes mental health care as a use for ADs

* Study tests feasibility and usefulness of ADs for mental health care

* Recent interest in MHADs in many states.

* Current state Mental Health Division and county requirements to make MHAD information available.

POTENTIAL BENEFITS OF MHADs

* Allows for planned crisis treatment

* Encourages the most desirable treatments by documenting what has “worked” in the past

* Increases client participation in crisis treatment.

* Can provide for a substitute decision-maker -- a health care "agent" named in a Durable Power of Attorney.

* Can inform court proceedings related to civil commitment, guardianship, and psychiatric treatment, which may also shorten lengths-of-stay.

* Can provide information about useful alternatives to hospitalization.

* May increase willingness of consumers to seek voluntary treatment by giving them more control over the process.

* Provides methods for maintaining household while hospitalized

* Provides a method for documenting complex treatment needs

* Offers vehicle for sharing information that would normally be unavailable to crisis/emergency staff.

POTENTIAL BARRIERS TO COMPLIANCE WITH MHADs

* State law, hospital/agency policy, or practice standards may conflict with some instructions in MHADs, and therefore may override the MHAD

-federal regulations regarding restraint, seclusion

-state laws regarding involuntary treatment

-requirement for hearing for use of ECT

* Lack of specific state statutes about MHADs

* Limited legal precedence

* Challenging issues of dissemination and communication of documents.

* Avoiding setting “false” expectations for clients that MHAD provide total control.

* Difficulty finding someone to be an "agent" for a Durable Power of Attorney.

* Concerns of providers regarding competency of person when they created the MHAD.

INSTRUCTIONS THAT MAY BE IN AN AD FOR MENTAL HEALTH CARE

* Naming of a health care “agent”

* Individualized definition of when activate to the MHAD

* Preferences regarding particular medications and treatments and reasons for choices.

* Preferences for emergency use of restraint, seclusion or tranquilization.

* Interventions to be used to avert psychiatric emergencies

* Alternatives to hospitalization and hospital preferences

* Persons to notify of a hospital admission.

* Preferences regarding use of ECT

* Releases of mental health care records.

* Persons not allowed to visit in the hospital.

* Arrangements for care of children, pets, and finances

REVOKING OR CHANGING AN MHAD

* MHADs may be revoked or changed at any time.

TYPES OF MHADs

INSTRUCTIONAL DIRECTIVE

Strengths

* expresses mental health treatment preferences

Weaknesses

* may not foresee all situations, tx options

* limited support under Washington law

DURABLE POWER OF ATTORNEY

Strengths

* specifies "agent", legally empowered to make health care decisions for client when client is not able to do so

* decisions of agent are on a substituted judgment basis

* more clearly enforceable under Washington law and more familiar to providers

* can cover all treatment circumstances

* powers of agent may be expressly delimited

Weaknesses

* it may be difficult to find an appropriate agent

* the agent may not fully understand or follow the client's wishes

* agents cannot consent to: (1) ECT, (2) psychosurgery, (3) restraint, (4) voluntary hospital admission for a non-consenting or incapacitated client

DURABLE POWER OF ATTORNEY W/INSTRUCTIONS

Strengths

* most powerful

* provides the detail of a person's wishes to guide the person designated to advocate for these wishes

Weaknesses

* it may be difficult to find an appropriate agent

STUDY METHODS

YOUR ROLE AS A PARTICIPANT

* Introduce MHAD concepts to eligible clients to determine their interest in creating one -- relay contact information if they would like to hear more about the study (required)

* Attendance at ½-day workshop with client if invited by client.

* Return quarterly postcard about "MHAD Events" (mental health crises or hospitalizations) that would trigger a brief telephone interview.

* Review of MHADs with client every 6 months (with review of treatment and crisis plans).

* Assuring copies of revisions are made in similar fashion to crisis plans.

* Random selection for participation in focus groups conducted annually for 3 years after training.

OPEN DISCUSSION:

MHAD STRENGTHS/WEAKNESSES/CONCERNS