Transcript Marvin Swartz - Advanced Directives

What Consumers and Families Need
to Know about Psychiatric
Advance Directives!
Marvin Swartz, M.D.
Department of Psychiatry and Behavioral Sciences
Duke University Medical Center
Durham, NC
Supported by a grant from The John D. and
Catherine T. MacArthur Foundation
1
What are Psychiatric Advance
Directives (PADs)?
• 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.
Goals 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.
Why are Psychiatric Advance
Directives important?
• Patient Self-Determination Act (PSDA) of
1991 requires hospitals and clinics to assist
in the use of Medical Advance Directives
(“living wills”).
• In states with Psychiatric Advance
Directives laws, the PSDA requires hospital
and clinics to assist in their use.
Why are Psychiatric Advance
Directives important?
• Allows families to speak directly with
providers during crises.
• Allows families help make decisions during
crises.
• Still supports consumer autonomy and
empowerment in mental health care.
• May reduce involuntary treatment.
• May improve continuity of care.
Two parts to Psychiatric Advance
Directives
• 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
crises.
– May be designed with limited or broad powers.
• Not required to have either, in some states can
have either or both.
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”).
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.
Making an Instructional Directive
(Example from North Carolina)
• Any adult “of sound mind” can make.
• Signed in presence of two witnesses:
– Not a relative.
– Not person’s doctor, mental health provider
or other staff.
– Not staff of a health care facility in which
the client is a patient.
• Must be notarized.
• Present to doctor and other mental health
treatment providers.
What should the doctors or staff do
with the Instructional Directive?
(Example from North Carolina)
• Must make a part of medical record.
• Must act in accordance with
instructional directive when patient is
determined to be “incapable”.
• May notify all other providers to
follow instructional directive.
What does “Incapable” Mean?
(Example from North Carolina)
“…in the opinion of a physician or eligible
psychologist the person currently lacks
sufficient understanding or capacity to
make and communicate mental health
treatment decisions.”
Must clinicians always honor the
instructions?
(Example from North Carolina)
• Clinicians may disregard instructions:
– Not consistent with “generally accepted community
practice standards.”
– When treatments 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.
If one instruction is not followed, what
happens to other instructions?
Generally:
• If one part 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.
Can the instructions be changed?
• Rules for changing instructions may vary
across states.
• Generally: Instructions may be changed
whenever the person is “competent” or
“capable.”
Health Care Power of Attorney (HCPA)
• Allows a person to appoint someone to
make treatment decisions when consumer
is “incapable” or “incompetent”.
• Can be combined with instructional
directive,
– but may be two different forms.
• Any capable adult may execute.
Who can serve as the health care
power of attorney?
• Any competent adult 18 or older.
• Person usually cannot be providing
health care to consumer.
• Consumer can often name several people
to serve if one unavailable.
When does health care power of
attorney take effect?
• When consumer is found to be
“incapable” and continues during period
of incapacity.
• Usually determined by physician or
psychologist.
• Finding that consumer is “incapable”
must be in writing.
What powers does the health care
power of attorney have?
• 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.
What should the health care power
of attorney do?
• 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 medications and
ECT.
Examples of Use of PADs
• 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.
Why don’t more consumers have
Psychiatric Advance Directives?
• Families have not realized they should
encourage them!
• Fewer than half of states have these laws.
• Some states allow psychiatric advance
directives under medical advance directives.
• Advance directives may be difficult to complete
for some consumers.
• Help in completing advance directives may not
always be available.
Options for Sharing PADs in NC
• Can place in Medical record
• Can place in North Carolina Department of the
Secretary of State Advance Health Care Directive
Registry—secure web site
NORTH CAROLINA DEPARTMENT OF THE
SECRETARY OF STATE
ADVANCE HEALTH CARE DIRECTIVE REGISTRY
Welcome to the North Carolina Advance Health
Care Directive Registry! We are pleased to offer
this service of registering your Advance Health
Care Directives online for easy accessibility
Internet: www.sosnc.com
NORTH CAROLINA DEPARTMENT OF THE
SECRETARY OF STATE
ADVANCE HEALTH CARE DIRECTIVE REGISTRY
Standard Forms:
• Registration Form
• Health Care Power of Attorney Form
• Advance Instruction for Mental health
Treatment
• Revocation Form
NORTH CAROLINA DEPARTMENT OF THE
SECRETARY OF STATE
ADVANCE HEALTH CARE DIRECTIVE REGISTRY
Steps to register:
• Print a registration sheet from the website
• Fill in the required information.
• Witness (2) and notarize forms.
• For each directive you wish to register with the North
Carolina Secretary of State, please attach a $10.00 fee.
• Submit one (1) cover sheet for each directive to be filed.
• Mail to:
North Carolina Secretary of State
Attention of Advance Health Care Directive Registry,
Post Office Box 29622,
Raleigh, North Carolina 27626-0622.
NORTH CAROLINA DEPARTMENT OF THE
SECRETARY OF STATE
ADVANCE HEALTH CARE DIRECTIVE REGISTRY
Next Steps:
• Will receive a registration card and
password
• Copies should be given to people who might
need them
• Password will provide access to website
• Revocation will remove forms
Where can I get more information about
Psychiatric Advance Directives?
• National Resource Center on Psychiatric Advance
Directives
http://nrc-pad.org
• NAMI
www.nami.org
• Bazelon Center
www.bazelon.org
• National Mental Health Association
www.nmha.org
• NC Mental Health Consumers Organization
www.naminc.org/consumer.htm
• NC Secretary of State—Advance Health Care Directive
Registry
www.sosnc.com
Thank you!
Visit us at:
The National Resource Center on Psychiatric
Advance Directives
www.nrc-pad.org