Psychiatric Advanced Directives (PADs)
Psychiatric Advance Directive (PAD) is a legal tool that allows a person with mental illness to state preferences for treatment in case a crisis occurs. This helps to protect a person’s dignity and ability to self-direct care, helps the person identify family or others to be involved, and helps service providers make decisions based on what has or has not worked for the person in the past. PADs are similar to living wills and other medical advance planning documents.
Many states have approved forms and procedures for this best practice, but Wisconsin is not among them.
- National Resource Center on Psychiatric Advance Directives, Wisconsin FAQs: https://www.nrc-pad.org/states/wisconsin-faq/
- A Practical Guide to Psychiatric Advance Directives, SAMHSA: https://www.samhsa.gov/sites/default/files/a_practical_guide_to_psychiatric_advance_directives.pdf
- A psychiatric advance directive (PAD) is a legal document that documents a person’s preferences for future mental health treatment, and allows appointment of a health proxy to interpret those preferences during a crisis and to make treatment decisions on your behalf when you are unable to do so for mental health reasons.
- 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.
Psychiatric advance directives can include preferences like these:
- Medication you’ve tried and do not want again
- Medication you’d like to keep taking
- People you do or do not want involved in your mental health care
A psychiatric advance directive can’t:
- Guarantee certain doctors will work with you
- Give you unrestricted control over your treatment, including medication
1. Can I write a legally-binding psychiatric advance directive (PAD)?
Yes, by appointing an agent. Wisconsin’s Power of Attorney for Health Care statute allows you to appoint an agent (called an “health care agent”) to make healthcare decisions for you if you become incompetent to make those decisions yourself. “Health care” may include mental health care. You must use the state’s standard form, available with instructions here. Further information is available from the Disability Rights Wisconsin (formerly the Wisconsin Coalition for Advocacy): click here for contact information.
2. Can I write advance instructions regarding psychiatric medications and/or hospitalization?
The Wisconsin statute does not allow you to write advance instructions for your psychiatric care in a freestanding document. However, if you fill out a Power of Attorney for Health Care, you may wish to specify how you would like your health care agent to make decisions for you. If there are particular matters that you wish your health care agent to make clear to your treating physicians, it is advisable to discuss them with him/her and document them on page 5 of the standard form, attaching further pages if necessary.
3. Does anyone have to approve my advance instructions at the time I make them?
No. However, you must comply with the following formalities for your Power of Attorney for Health Care to be valid. (1) It must be in writing, on the standard form ; (2) it must be witnessed and signed by two adult witnesses. Your relatives, those directly financially responsible for your health care, your health care agent, employees of your inpatient health care facility (not including chaplains or social workers) and/or beneficiaries of your estate may not serve as witnesses.
4. Can I appoint an agent to make mental health decisions for me if I become incompetent?
Yes, as outlined above. Your health care agent must be someone other than your health care provider, an employee of your health care facility, or a spouse of such a person.
5. If I become incompetent, can my agent make decisions for me about medications, and/or hospitalization?
Your health care agent may consent to or refuse medication on your behalf. However, the statute does not allow a health care agent to consent to mental health research, to psychosurgery, electroconvulsive therapy (ECT) or other “drastic” mental health treatment on your behalf.
6. Does my agent have to make decisions as he/she thinks I would make them (known as “substituted judgment”), or does he/she have to make them in my “best interests”?
Your health care agent must act in accordance with your wishes as far as you have documented them in your form, or as far as he/she otherwise knows them. If your health care agent does not know your wishes, he/she must act in your best interests.
7. Is there any rule that says that I can only make advanced instructions, only appoint an agent, or that I must do both?
Yes. As explained above, it is not possible to write advance instructions only. If you wish to create a PAD, you must use a Health Care Power of Attorney form; the extent to which you also document your decisions is up to you.
8. Before following my PAD, would my mental health care providers need a court to determine I am not competent to make a certain decision?
No. All that is required is that two physicians, or one physician and one psychologist, believe you are unable to receive, process or communicate treatment information well enough to be able to manage your own health care decisions. The physicians must document their decision in your medical records.
9. Does the statute say anything about when my mental health providers may decline to follow my PAD?
No. However, a health care provider is likely to be able to override your health care agent’s instructions if you are considered a danger to yourself or others, or otherwise in an emergency.
10. How long does my PAD remain valid?
Your Power of Attorney remains valid until revoked, or until you create a new one. You may revoke your document at any time. If you name your spouse as your health care agent and subsequently undergo a divorce or legal separation, you are advised to amend your document to make it clear who should act as your health care agent.
Advance Directives Help Clarify Treatment When You Can’t : Useful Tools During A Crisis
Posted: 30 Sep 2016 02:31 AM PDT
By Pete Early: Psychiatric advance directives are more common today than they were when my son suffered his first breakdown in 2002 or when I first posted this blog in early 2010. If you aren’t familiar with a PAD — you should be because it can be an important tool for a person who has a mental disorder and those who love him/her. Here’s my 2010 blog.
Psychiatric Advance Directives Make Sense: You should have one!
You can learn more at the websites operated by the Bazelon Center, NAMI, or the National Mental Health Association listed on my webpage.
Currently only about 50% of states have laws regarding PADs and you need to read the specifics of your state law. But please do. Even if you don’t end up with a PAD, it will be useful for you to hear what your loved one wants done if there is an emergency.
People with mental illness can make psychiatric advance directives. We need to encourage them to do so
By JENNIFER ADAEZE OKWEREKWU @JenniferAdaeze
FEBRUARY 23, 2018
In medicine, we talk a lot about advance directives, mainly in the context of end-of-life treatment. But, recently, while treating a patient with schizophrenia, I realized how powerful and important that same document could be in caring for someone living with mental illness.