Psychiatric Advance Directive

Hukilau · Sep 23, 2004

As of July 1, 2004 Indiana's Health Care Consent statute was amended to include the psychiatric advance directive (PAD) (IC 16-36-1.7). This directive gives a patient the right to decide which treatment measures will be used during a time when the patient is incapacitated by mental illness. These treatment measures include: 1) admission to an inpatient setting; 2) the administration of prescribed medication, po or IM; 3) physical restraint; 4) seclusion; 5) ECT; 6) mental health counseling. The health care rep is also named in the PAD. This consent is to be written when a person has the capacity to write and understand the implications of PAD. The attending psychiatrist determines this period.
Our advance directive brochures are expected to be revised by Sept 29, 2004 to include info about psychiatric advance directive. Indiana State Depart. of Health has devised a brief paragraph to be included in brochures to explain PAD to patients.
As I understand it, there are 12 states that have implemented PAD. Are there any nurses out there who have experiences with psychiatric advance directives? Do you think this a good thing? Of course, this is all about patient's rights. Nursing staffs would have to be pretty creative to come up with a care plan that would honor a patients right to direct their care and protect the staff at the same time.

My only experience with PAD was in a hospital in Hawaii. Although Hawaii does not yet have laws regarding this, a local advocacy group had presented a workshop to patients at another facility and had helped several patients fill out a PAD. One of these patients subsequently was admitted to my hospital and the PAD was discovered during admission. He said that he had no idea what was in it! He just went along with the person trying to persuade him to fill one out.

This is my main concern about them. I think they are much more likely to serve the needs of families and mental health facilities then the mentally ill consumer. It is a step toward the Orwellian phenomonon of admitting someone on a "voluntary" basis although he is telling you clearly he doesn't want to be admitted! It is an attempt to avoid some paperwork by skipping the steps necessary to treat someone against their will.

I think that most state legislators don't understand the difference between a medical advance directive and this new idea, which is actually a political undertaking by groups like NAMI, which is not really about the mentally ill individual at all, but rather an alliance of family and community members who want more control over treatment decisions.

wam79 · Sep 24, 2004

I work in Hawaii in Acute care. I have patients that refuse meds and treatment. It is the patients right to refuse. On my ward refusing meds is grounds for discharge or if the person is not safe for d/c we get an order to treat. I have mixed feelings about the idea of PAD. There should be a provision that if the person is a danger to self or others they will need to take treatment. Personaly I have never encouraged a pt. to sign a PAD. If they are not competent to understand what they are signing, I question if it would be legal or ethical. Incompitant people cannot sign other legal docs.

Hukilau · Sep 24, 2004

As of July 1, 2004 Indiana's Health Care Consent statute was amended to include the psychiatric advance directive (PAD) (IC 16-36-1.7). This directive gives a patient the right to decide which treatment measures will be used during a time when the patient is incapacitated by mental illness. These treatment measures include: 1) admission to an inpatient setting; 2) the administration of prescribed medication, po or IM; 3) physical restraint; 4) seclusion; 5) ECT; 6) mental health counseling. The health care rep is also named in the PAD. This consent is to be written when a person has the capacity to write and understand the implications of PAD. The attending psychiatrist determines this period.
Our advance directive brochures are expected to be revised by Sept 29, 2004 to include info about psychiatric advance directive. Indiana State Depart. of Health has devised a brief paragraph to be included in brochures to explain PAD to patients.
As of July 1, 2004 Indiana's Health Care Consent statute was amended to include the psychiatric advance directive (PAD) (IC 16-36-1.7). This directive gives a patient the right to decide which treatment measures will be used during a time when the patient is incapacitated by mental illness.
I doubt whether it will actually do this. More accurately, it will allow a person to consent to some form of involuntary treatment in advance. It will not stop hospitals from using meds, restraints, etc. in emergency situations.
Also, mental incompetence is a legal decision, not a medical diagnosis, so a person will not be found incompetent for quite some time after they are admitted, even if they are involuntary. Does the new law actually use the term "incapacitated"? If so, does it say how that is decided? With a medical AD, the patient can revoke it at any time. Does the mental health patient have the same right? When does the right to revoke it end? When the police pick him up? In the ER? Not until the involuntary court hearing?
These are some of the issues that make the idea of a PAD much more complicated than a medical AD.

blue gardenia · Sep 25, 2004

As of July 1, 2004 Indiana's Health Care Consent statute was amended to include the psychiatric advance directive (PAD) (IC 16-36-1.7). This directive gives a patient the right to decide which treatment measures will be used during a time when the patient is incapacitated by mental illness. These treatment measures include: 1) admission to an inpatient setting; 2) the administration of prescribed medication, po or IM; 3) physical restraint; 4) seclusion; 5) ECT; 6) mental health counseling. The health care rep is also named in the PAD. This consent is to be written when a person has the capacity to write and understand the implications of PAD. The attending psychiatrist determines this period.
Our advance directive brochures are expected to be revised by Sept 29, 2004 to include info about psychiatric advance directive. Indiana State Depart. of Health has devised a brief paragraph to be included in brochures to explain PAD to patients.
As of July 1, 2004 Indiana's Health Care Consent statute was amended to include the psychiatric advance directive (PAD) (IC 16-36-1.7). This directive gives a patient the right to decide which treatment measures will be used during a time when the patient is incapacitated by mental illness.
I doubt whether it will actually do this. More accurately, it will allow a person to consent to some form of involuntary treatment in advance. It will not stop hospitals from using meds, restraints, etc. in emergency situations.
Also, mental incompetence is a legal decision, not a medical diagnosis, so a person will not be found incompetent for quite some time after they are admitted, even if they are involuntary. Does the new law actually use the term "incapacitated"? If so, does it say how that is decided? With a medical AD, the patient can revoke it at any time. Does the mental health patient have the same right? When does the right to revoke it end? When the police pick him up? In the ER? Not until the involuntary court hearing?
These are some of the issues that make the idea of a PAD much more complicated than a medical AD.
Hi Hukilau
You have some valid questions. However, I did not quote the complete law regarding PAD in the state of Indiana. If you type in the code, IC 16-36-1.7, in your search engine, it bring up the specific law and addresses PAD including the definition quoted as follows:
IC 16-36-1.7-1
"Psychiatric advance directive" defined
Sec. 1. As used in this chapter, "psychiatric advance directive" means a written instrument that expresses the individual's preference and consent to the administration of treatment measures for a specific diagnosis for the care and treatment of the individual's mental illness during subsequent periods of incapacity.
A PAD is executed by the patient and his treating psychiatrist while the patient is stable and before he is ever admitted to a facility. To be valid, the treating psychiatrist must sign the PAD and verify the the treatment preferences are appropriate. The treating psychiatrist is well qualified to made the decision that testifies to his patient's stability. This directive is comparable to your medical advance directive in that a person can express decisions regarding their care before they become to ill to make their wishes known. Many patients with mental health histories are very capable of making decisions and directing their own lives as long as they are compliant with treatment. Patients with schizophrenia diagnosis, for example, are some of the most intelligent people you would ever want to meet. The minute they stop taking their meds, for whatever reason, their condition excerbates, or worsens. Many times we have had to get a court order just to give them medication. At that point a PAD is invalid.
This law does give a patient the right to make decisions about their mental health care while they are stable. A health care provider can be charged with civil and criminal liability based on the allegation that the provider did not comply with the PAD.
Certainly, PAD is not without limitations. 1) PAD does not apply when a person is involuntarily admitted to a facility on an immediate or emergency detention, or a temporary or regular commitment. 2) If the health care provider is not aware that the individual has executed a PAD then that provider cannot be held liable for non-compliance with the PAD, and 3) There is nothing in our code that says an attending psychiatrist cannot treat the patient in the best interest of that patient.
Our state department of health and JCAHO both support PAD. JCAHO certified health care facilities require that health care providers either assist or refer patients for assistance in formulating a PAD.
I have been a psychiatric nurse (now called Behavioral Health) for well over 10 years. I'm not sure I agree that a patient who is admitted to a health care facility because their mental health has declined is in a position to direct their care in advance.