1. Psychiatric Advance Directives
Deb Altschul, Ph.D.
NAMI Community Presentation
February 11, 2018

2. What is a Psychiatric Advance Directive?
A psychiatric advance directive (PAD) is a legal document that indicates a person’s preferences for future mental health treatment, and allows appointment of a health proxy to interpret those preferences during a crisis.
PADs may be drafted when a person is well enough to consider preferences for future mental health treatment.
PADs are used when a person becomes unable to make decisions during a mental health crisis

3. Benefits of Psychiatric Advance Directives (Source: Disability Rights of New Mexico)
An advance directive helps a person maintain choice and control in the treatment received, according to their knowledge of what works best in managing mental health care. This includes medication and treatment they do and do not want.
An advance directive increases the possibility that there will be continuity of care in times of crisis, including place, type, and personnel involved in treatment.
An advance directive may decrease the possibility of involuntary treatment.
If involuntary treatment does occur, a mental health care directive should have a direct impact on the treatment received, including time in the hospital, the use of medications, place of treatment and treatment plan upon release.

4. Benefits of Psychiatric Advance Directives (Source: Disability Rights of New Mexico)
A PAD creates an excellent opportunity to develop an effective crisis intervention plan and to discuss it with family, friends, treatment professionals and others before a crisis arises. This includes the opportunity to discuss approaches that are effective and those that hinder rather than help in times of crisis.
An advance directive allows a person to authorize the release of information at a time when his/her capacity to make authorization is clear. It also enables a person to state whom they do and do not want notified at the time of hospitalization.
An advance directive, particularly the appointment of an agent who a person trusts, can be an effective alternative to the court-appointed guardian.
An advance directive can include how a person wants his/her family, pets, and finances cared for while they are receiving treatment.
The implementation of an advance directive can help restore self-confidence and allay fears and panic in a time of crisis. This helps in terms of stabilization and recovery.

5. Summary of the Benefits of Having a Psychiatric Advance Directive…
Empowers an individual to make his/her own treatment choices
Helps friends and family members to be informed of the treatment choices
Gives providers direction for following through with treatment choices
Helps with stabilization and recovery

6. How Might Family Members Support the Use of Psychiatric Advance Directives?
Know that they exist
Encourage family member to complete
Know where they are located
Advocate for the use in times of crisis
Other?

7. Possible Components of a Psychiatric Advance Directive
Preferences about treatment type, facilities, and providers
Preferences about medications
Preferences about hospitalization and alternatives
Preferences about use of seclusion and restraint
Preferences about ECT
Preferences regarding visitors
Appointment of a mental health care agent or “power of attorney”

8. Three Legal Requirements
Must be signed by the individual.
Must be witnessed and ideally notarized.
If an agent is appointed, the agent must sign that he or she is accepting the appointment. That may be done on a separate piece of paper, but may be helpful to have the signed acceptance as part of the psychiatric advance directive.

9. Psychiatric Advance Directives in New Mexico
New Mexico’s Mental Health Care Treatment Decisions Act  allows you to write instructions for your psychiatric treatment in the event that you are incapable to make or communicate those instructions.
The statute also allows you to appoint an agent to instruct mental health care professionals for you.
In New Mexico, a PAD is known as an “advance directive for mental health treatment”.  The statute includes a standard form, which is not mandatory but is recommended.

10. Power of Attorney
The part of the PAD in which you appoint an agent is known as the “power of attorney”. 
The power of attorney must be in writing and must be signed by an adult witness who knows you personally.  The witness must attest that you “appeared to have capacity” when you created the PAD and that you were not acting under duress or fraud.  The witness must not be your agent, an employee of your health care organization, a beneficiary of your estate or a relative of yours.
The statute says that your agent can make decisions for you about all psychiatric services, including refusals.  The exception is hospitalization: your agent may present you to a psychiatric facility for evaluation but may not formally admit you to that facility.

11. Mental Health Care Providers Responsibility
A qualified health care professional must determine that an individual lacks the ability to understand and appreciate the nature and consequences of proposed mental health treatment, and/or the ability to communicate a choice. 
An individual has the right to challenge this determination and will not be declared incompetent unless and until a court makes a finding of incompetence.
Providers can decline to follow the PAD if: (1) the treatment requested is considered “infeasible” or is unavailable; (2) the PAD requests treatment which the provider is not licensed or authorized to give;(3) the treatment requested conflicts with other law (including involuntary treatment law); or (4) the treatment or refusal of treatment is “medically ineffective” or not in accordance with “generally accepted health care standards”.

12. Real Life Example
Employment Experiences in Colorado and Hawaii: 2 examples of use of benefits of psychiatric advance directives

13. Considerations for New Mexico
How to ensure all people with mental illnesses have advance directives?
Where might be a clearinghouse for advance directives?
How to ensure advance directives are followed?
How can family members help to institute advance directives in New Mexico?

14. Resources Disability Rights New Mexico
Mental Health Care Treatment Decisions Act
UNM Health Sciences Center Institute for Ethics
National Resource Center on Psychiatric Advance Directives: