Transcript My Life! My Treatment! My Plan!

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Client Empowerment: Using Psychiatric Advance Directives
SCDMH Peer Support Continuing Education
June 28, 2013
Katherine M. Roberts, MPH
Director, SCDMH Office of Client Affairs
David likes the beach, his dog, to paint, read, fish and hang out with
buddies. He also has schizophrenia. He knows he needs to take
medication to help control the symptoms of his illness. Complying with this
is hard for him, the meds make him feel zoned out and sleepy, give him dry
mouth and as he puts it makes it hard to focus. Consequently, David
sometimes “accidentally – on purpose forgets” to take them.
His symptom's start to come back and because of the symptoms David
often refuses to take any medication at all for any reason.
The result is always the same; he usually gets picked up by the police - a
scuffle ensues, and David winds up in the ER or in jail. Both outcomes are
bad – if he goes to the ER they “shoot him up with a bunch of mind
numbing drugs to try and control him”, if he goes to jail his symptoms get
worse, resulting in a lot fights - sometimes he starts them but more often
he is the victim of another inmate.
Eventually he winds up receiving emergency psychiatric care but in the
interim a lot of damage has been done. He knows he shouldn’t do this
and that there has to be a better way to handle this problem.
Susan has bi-polar disorder and she takes her medication as prescribed
faithfully everyday. She knows what happens if she doesn’t, she
decompensates quickly and winds up getting committed to the hospital.
There is just one problem, sometimes the medications just stop working
and symptoms re-appear quickly often resulting in a hospitalization. Susan
has a hard time convincing anyone that she just “isn’t complying” and isn’t
doing this on purpose. She understands her illness, wants and is willing to
accept responsibility but dreads having people think she does on purpose.
Sometimes she feels being homeless or going to jail would be better than
being hauled off to the emergency room, given medications to sedate her
but do little else and being committed against her will.
If people would just listen to her and let her explain it might be better but
she rarely sees the same people twice and those she does see thinks she
is just trying to cover up the fact she “refused to take her medications.”
Susan feels that she has enough to deal with and that there must be a way
she can try and protect herself.
Mary has a long history of depression and PTSD. She often feels that
she that should just end it all even though she does not really want to
die. The impulse to her harm herself often overwhelms her and she
knows she needs a safe place to get help.
Mary does not want to go back to the hospital however – she finds the
whole process traumatizing. Sometimes she thinks it makes things
worse to go back. How can she tell them that when people touch her
she is doing her best not to yell or swing at them – they just think she
bad attitude had a violent temper. No one wants to work with her she
can tell by the way the act towards her.
Then there are the medications – some of the ones they use make her
feel worse – she tries to make them understand but when she is really
depressed or scared or both she just can’t talk right. Besides, whose
going to believe her she’s in a mental hospital after all – they will just
say she is “trying to manipulate to process.”
There has to be a better way to deal with this than this!
Some Common Ground
Whether you have psychiatric diagnosis or not most people:
 don’t like being told what to do
 object to being held against their will
 value the right to make decisions for themselves
Some think of this as a freedom, a liberty or right, some see it as
independence, but we all see self-determination central to our idea of
dignity.
BACKGROUND
Historically, PADs are a variation of medical advance directives (ADs), legal
instruments that typically offer three types of self-directed planning of one's
own health care in anticipation of a later time of decisional incapacity: (1) a
competent individual's informed consent to future treatment; (2) a statement
of personal values and general preferences to guide future health care
decisions; and (3) the entrusting of someone to act as a proxy decision
maker for future treatment.
In 1990 the Federal Government enacted the Patient Self-Determination
Act. The intent is to:
 Provide an opportunity for adults to express their desires about medical
treatment in advance
 Balance the power between patients and providers
 Educate the entire population on advance directives.
The federal law requires hospitals and other providers (including psychiatric
hospitals and other mental health providers) and health plans to maintain
written policies and procedures with respect to advance directives.
What are PADs and how can they help you?
Psychiatric Advance Directives or PADs permit you to determine what
treatment you will receive if and/or when you lose the capacity to make
treatment decisions for yourself because of illness.
Basically it is a written statement of your treatment preferences and
other wishes and instructions.
There are two kinds of PADs:
 Instructive PADs, in which an individual gives instructions about
the specific mental health treatment desired should the individual
experience a psychiatric crisis.

Proxy PADs, in which the individual names a health care proxy or
agent to make treatment decisions when the individual is unable to
do so.
In South Carolina, the Department of Mental Health gathered a group of
clients together to help create a PAD for clients to complete that details
your instructions and wishes for your mental health treatment in times
when you are too ill to make your wishes known.
The combined wisdom of the clients and staff who participated in
developing this document represents more than 750 years of recovery
experience.
You can use a PAD to assign decision-making authority to another
person who can act on your behalf during times of incapacitation.
This is a legal document should be respected by private providers inside
and outside of the state of South Carolina.
Why Would You Want to Fill One Out If You're Not
Sick?
It can help to improve communication between you and your doctor,
you and other staff and you and your family members involved in your
recovery.
Having a psychiatric advance directive may
 Shorten a hospital stay or help you avoid one all together
 Gain more control of your treatment
 Improve the likelihood of receiving helpful, informed care
 Consent to or refuse certain treatments
 Enhance understanding and communication with your treatment
providers and family members
What’s Usually Included in a PAD?
The information that may be included in a PAD varies by state. In
general, PADs allow you to agree to, refuse and give your preferences
about such as:





Psychiatric medications
Hospitalization
Alternatives to hospitalization
Seclusion and restraint
ECT (electroconvulsive therapy)
One of the more important aspects of a PAD is that it can help to
explain why you made the choices you did so your doctors and others
will understand your reasoning. It’s to your advantage for them to know
the basis for your preferences.
For instance, you might explain that certain medications have given you
severe side effects, that you prefer a certain hospital because of its
therapeutic programs, or that certain self-care methods have helped
you through mental health crises in the past.
What Specifically does the SCDMH PAD Include?

A statement of Intent – your desires/instructions

Psychiatric History including:



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Diagnosis,
Doctors and case managers name
Who you want informed
Agents name if one was chosen
Your wishes, instructions, special provisions and limitations for your
mental health treatment and care including:




Choices Regarding Emergency Interventions
Choices about Medication(s)
Choices about Personal Interventions
Choices Regarding Release of Information about My Health
Are there any special rules that apply to a PAD in
SC?
Yes, there are five things to remember:
1. S.C. does not recognize Statements of Desires without appointment
of an agent/surrogate under a Health Care Power of Attorney.
Forms for a Health Care Power of Attorney can be found at:
http://www.state.sc.us/dmh/client_affairs/advance_directive.htm
2.
Your case manager or other mental health worker cannot be your
agent.
3.
It is important that you understand that in an emergency situation, a
doctor can do something different from what you have stated in your
Declaration for Mental Health Treatment, but the doctor must go
through certain steps to do this.
Five things…
4.
It is up to you or your agent to make sure that the hospital has a
copy of your Declaration for Mental Health Treatment. You may
want to have a copy placed in your outpatient record so that
outpatient staff are aware of what hospital or crisis stabilization
approaches you would prefer, if you are not able to express your
own choices at the time.
5.
You can substitute the Crisis Portion of your WRAP (Wellness
Recovery Action Plan) Plan if you have completed one and so
desire. You should attach a copy of your WRAP Crisis Plan to this
form.

What is a Health Care Proxy or Agent?
A Health Care Proxy is someone you appoint to make your
treatment decisions when you cannot make them yourself. Naming
a proxy may be optional; some states require it. Some states only
let you appoint a proxy; you may not give your own treatment
preferences. In those cases, however, the individual usually may
give instructions directly to the agent.

Generally, a Health Care Proxy can be any capable, competent
adult (18 years or older) who is not your health care provider. Often
you can name more than one proxy, though only one can be active
at a time.
What does a Health Care Agent/Proxy Do?
If you become unable to make your own treatment decisions due to
psychiatric symptoms, your Health Care Agent/Proxy would make them
for you following your instructions about your desire for care spelled out
in your PAD.
The Agent/Proxy should follow the instructions and make the same
decisions you would about medications, hospitalization, health care
provider, ECT and anything else you have covered in the PAD.
Remember the law in S.C. does not recognize Statements of Desires
without appointment of an agent/surrogate under a Health Care Power
of Attorney.
Who can I appoint to be my Health Care Power of
Attorney?
You can appoint any capable and competent adult who is 18 years or older
but they cannot be providing your health care. You can appoint more than
one Health Care Agent. However, only one can serve as your Health Care
Agent at a time. You must indicate your order preference.
When does my Health Care Agent make treatment
decisions for me?
When your health care provider determines that you are incapable of
making decisions, your health care agent will be consulted about your
treatment. If your health care provider is not available, then the attending
physician or eligible psychologist decides when to consult your health care
agent. The decision to consult your health care agent must be put into
writing.
If I am unable to make decisions, can I choose
someone to speak for me?
Yes. This is done through a document called a Health Care Power of
Attorney, or a Durable Power of Attorney for Health Care, sometimes
also called a health care agent, surrogate, or proxy decision maker.
You can appoint any capable and competent adult who is 18 years or
older who is not your health care provider.
What if I want to change my Agent/Proxy?
You can change or revoke your Agent/Proxy choice at any time as you
are considered “capable” at the time of change.
If I am involuntarily committed will my PAD be followed?
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.
Are there reasons my PAD might not be followed?
Yes, your 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.
Can a provider refuse to follow an advance
directive?
Technically yes, under certain conditions:
 If permitted under state law, providers can refuse to implement
provisions of an advance directive, based on conscience
objections. The facility must make clear when instructions of an
advance directive would not be followed due to a conscience
objection and:

• Provide a clear and precise statement of limitations if the provider
cannot implement the advance directive based on conscience;

• Clarify any differences between institution-wide conscience
objection and those that may be raised by individual physicians;

• Identify the State legal authority permitting a conscience objection,

• Describe the range of medical conditions or procedures affected
by the conscience objection.
Once I have created a PAD, what do I do with the
document?
You should give it to your mental health care provider who will make
it a part of your medical record.
 You should give a copy to agent.
 You might want to consider giving a copy to a trusted friend or
family member.
 You should keep a copy for yourself.

Do I have to use the SCDMH PAD?
No, you may use any for you – remembering that to enforce your
directives you must have appointed an health care agent
Does the SCDMH have a policy on Advanced
Directives?
Yes, policy 850-05 (5-100) Advance Directives states that while
competent, individuals may anticipate the possibility of later incapacity
and may prepare Advance Directives stating their desires regarding the
provision or withholding of medical care in such event.
It is the Department's policy to encourage the use of advance health
care directives and to honor Advance Directives.
However, no Departmental facility shall condition the provision of care
or otherwise discriminate against an individual based on whether or not
the individual has executed an advance health care directive.
The purpose of this directive is to implement the "Patient Self
Determination Act" and the State's public policy to encourage the
execution of advance health care directives.
The Patient Self Determination Act requires that each hospital and
nursing facility receiving federal Medicare or Medicaid funds must
provide information to every patient/resident, about the facility's policies
concerning implementation of Advance Directives, and distribute a
written description of State law concerning Advance Directives to the
patient/resident.
It is also the declared policy of the State of South Carolina to promote
the use of Advance Directives as a means of encouraging patient selfdetermination and avoiding uncertainty in a health care crisis.
A look at the Directive Developed for
Mental Health Clients by Mental Health
Clients in SC
My Declaration for Mental Health Treatment (Psychiatric Advance Directive)
Summary
If I am in crisis or in case of a psychiatric emergency:
1. My case manager’s name is: __________________________________________
2. Doctors I want notified are:
A. ________________________________________________
B. ________________________________________________
C. ________________________________________________
3. Persons I want notified are:
A. ________________________________________________
B. ________________________________________________
C. ________________________________________________
4. ___ I have completed a Psychiatric Advanced Directive and/or a WRAP Plan and wish
treatment providers follow the instruction I have laid down in it to the fullest extent possible.
5. ___ I have appointed an agent to make decisions for me in the event I am not capable of
communicating my preferences for treatment at this time. That person is:
Agents Name: _______________________________________________________
Address: ___________________________________________________________
City: __________________________ State:_______ Zip:_____________________
Day Phone: ___________Night Phone:____________ Cell Phone______________
Agent’s Acceptance:
I hereby accept the appointment as agent for (your name) _____________________
Agent’s Signature: ____________________________________________________
These Are My Wishes, Instructions, Special Provisions and Limitations in My Mental Health
Treatment and Care (__________________________ your name)
I. My choice of Treatment Facility or other alternative to hospitalization if it is medically
necessary for me to have 24-hour care for my safety and well being.
A. _____ If I am to go into a hospital for 24-hour care, I choose to go to the following
hospitals:
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
B.____ If my condition requires 24 hour psychiatric care but it is not necessary to be in a
hospital, I choose to have this care in programs and facilities that are considered
alternatives to psychiatric hospitals listed below:
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
C. _____I choose to receive crisis stabilization at the following programs/facilities:
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
D._____I do not want to be committed to the following hospitals or programs/facilities for the
following reasons (optional) if I need psychiatric care.
Facility’s Name and Reason (optional):
1. ________________________________________________
2. ________________________________________________
II. My Choices Regarding Emergency Interventions:
If I engage in behavior that requires an emergency intervention (such as
seclusion, restraint or medications), I choose the interventions in the order
listed below.
Most preferred is 1, next is 2 and so on until there is a number by each
option
_____seclusion
_____physical restraints
_____seclusion & physical restraints _____medication by injection
_____medication in pill form
_____liquid medication
_____other__________________________________________________
Put your initials by this section if you agree; if you don’t agree, leave it
blank.
_____If after considering the choices I have listed above, the doctor
attending me decides to use medication to tranquilize me quickly (rapid
tranquilization) in an emergency situation I expect the doctor to use
medication that reflects the choices I have stated in this Declaration. The
choices I agree to concerning emergency medications do not give consent
for using these medications for non-emergency treatment.
III. My Choices about Medication(s):
A. I prefer medication given to me:
Orally
Pill
Liquid
Injection
B. The following medications have been the most helpful to me in the past and I would consent
to taking them, if appropriate:
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
C. If I am hospitalized and am not considered able to consent or refuse medications related to
my mental health treatment, my wishes are as follows:
(I) _____I consent to and give permission to my agent to consent to the use of the following
medication(s):
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
(II) _____I specifically do not consent to and I do not give permission for my agent to consent
to me taking the following medications, no matter what their brand name or generic equivalent:
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
(III)_____I consent to the medications that are considered appropriate by
Dr. ____________________________ whose address and phone number is:
Address ______________________________________________________
City _______________________________State: ____ Zip:______________
Phone Number:_________________________________________________
D. I am concerned about the side effects of medications. I wish to
be told about the possible medication side effects if any of these
side effects listed below are possible or to be told how these side
effects can be managed.
_____tardive dyskinesia
_____motor restlessness
_____blurred vision
_____sleep problems
_____tremors
_____neuroleptic malignant syndrome
_____dizziness
_____sexual dysfunction
_____loss of sensation
_____seizure
_____cognitive (thinking) problems
_____aggressiveness
_____nausea/vomiting/diarrhea
_____muscle/skeletal rigidity
_____mood swings
_____other
F. I am allergic to the following medications: (medication and
reaction if known)
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
IV. My Choices about Personal Interventions:
A. Others will know when I am having a hard/difficult time or when I am upset if I am;
_____________________________________________________________________________________
_________________________________________________
B. Approaches that I and others can use to help me when I’m having a hard time or when I’m expressing
anger inappropriately: (Check all that apply)
voluntary time out in my room
voluntary time out in a quiet room
sitting by staff
talking with a peer
talking with staff
having my hand held
going for a walk
punching a pillow
writing in a journal
lying down
listening to music
reading
watching TV
pacing the halls
calling a friend
talking with my therapist
pounding some clay
exercising
deep breathing exercises
taking a shower
praying
meditation
singing
getting a hug
yelling or screaming
being silent
being outside
calling crisis hotline
being given an opportunity to be heard and validated without being offered advice/suggestions
talking to (name) (phone)
recreational activities:
other
other
C. Special Wishes about Touch/Body Space (check all that apply)
____I do not wish to be touched.
____I wish to be asked permission before being touched.
____I wish to be told the reason why I am being touched.
____I wish special attention be given to allowing me extra personal body space.
____I do not need special attention given to my body space.
____Other:________________________________________________________
V. My Choices Regarding Release of Information about My Health
If I am hospitalized, I voluntarily give permission for the following information about me to be given by
the hospital where I am currently admitted to the people listed below.
I realize that I may also have to sign a release of information for the hospital, but this Declaration for
Mental Health Treatment should be followed concerning the limits of information provided to each
person listed. The information can be given in writing or verbally.
1. Name of Individual: _________________________________________________
Address: ___________________________________________________________ City:
_______________________________State:______________Zip:__________
Day Phone: ____________________ Night Phone: __________________________
Type of information to be released:
___Diagnosis
___Discharge Plan
___Medications
___Payment Status
___Treatment Plan
___Other __________________________________________________________
My Life, My Treatment, My Plan
Client Empowerment: Using Psychiatric
Advance Directives
SCDMH Peer Support Continuing Education
June 28, 2013
Katherine M. Roberts, MPH
Director, SCDMH Office of Client Affairs