Enhancing Quality of Care with Psychiatric Advanced Directive (PAD) and Peer Support
Publication Date: July 22, 2021
Developed By: South Southwest MHTTC
A Psychiatric Advance Directive (PAD) is a legal document that details preferences for future mental health treatment, services, and supports. This webinar will present the core elements of a PAD, and the role and benefits of Peer Specialists facilitating and supporting their development. Presented by experts in the field, this panel discussion will share how PADs are having positive impacts on mental health and crisis services.
Learning Objectives:
1. List at least 5 core elements of a Psychiatric Advanced Directive (PAD):
2. Identify the benefits of developing a PAD to quality of care, community safety, and cultural responsiveness
3. Describe the role of Peer Specialists and benefits of peer-facilitated PADs
Enhancing Quality of Care with Psychiatric Advanced Directive (PAD) and Peer Support
Publication Date: July 22, 2021
Developed By: South Southwest MHTTC
Presenters from Doors to Wellbeing:
SAKS INSTITUTE SPRING SYMPOSIUM / MHSOAC CONVENING
MAY 5, 2021
Psychiatric Advance Directives and the Importance of Choice
10am - 10:30 pm Welcome
Andrew T. Guzman
Dean Carl Mason Franklin Chair in Law
Toby Ewing Executive Director, Mental Health Service Oversight and Accountability Commission
Opening Video10:35-10:50 amPeer Perspective: Why Choice is Important in Supports and Services
Elyn Saks
Saks Institute Founder and Faculty Director
Tristan Scremin
Community Liaison, Painted Brain
Rayshell Chambers
Co-founder & COO, Painted Brain
11:00 - 11:25 amSupported Decision Making and the Value of Self-Determination
Jonathan Martinis
Senior Director for Law and Policy, Burton Blatt Institute
11:30 am - 12:00 pmOverview of Psychiatric Advance Directives (PADs)
Laurie Hallmark
Special Project Director, Mental Health Programs, Texas RioGrande Legal Aid
12:15 - 12:30 pmOverview of PADs Nationally
Marvin Swartz
Professor and Head, Division of Social and Community Psychiatry at the Duke University School of Medicine
12:35 - 12:50pmCA PAD Innovation Project
Kiran Sahota
President of Concepts Forward Consulting and Program Manager for California's multi-county PAD Innovation project
1:00 - 1:30 pmPeer Reflection on the Day's Proceedings
Claudia Vargas
Mental Health Peer Specialist, TRLA PAD Project
Paul Eisenhauer
Peer Specialist/Advocate/Voice Hearer, TRLA PAD Project
Rayshell Chambers
Tristan Scremin
Moderator: Peter Blanck
University Professor and Chairman, Burton Blatt Institute, Syracuse University
Making A Plan (MAP) – Thinking Ahead helps you think about what care you want and do not want if you cannot speak for yourself. It empowers you to have your wishes known and honored if you are unable to guide your own care because of serious illness including a mental health crisis, frailty or the ending of life. It includes a Workbook, a Forms booklet, and the companion piece titled: Mental Health Supportive Care Plan. Together these materials comprise the “Making a Plan Toolkit.” In addition to helping you express health care wishes, the Making a Plan Toolkit can help clarify what to do with your important possessions if seriously ill or at the ending of life.
Caring Community: Sonoma County, California https://caringcommunity.org/
An Advance Health Care Directive is a legally binding form that lets you exercise your right to give instructions about your own health care and/or to name someone else to make health care decisions for you in the event you are unable to speak for yourself.
Thursday, October 1, 2020 the Substance Abuse and Mental Health Services Administration (SAMHSA) released a new mobile app, My Mental Health Crisis Plan, which allows individuals who have serious mental illness (SMI) to create a plan to guide their treatment during a mental health crisis. The app was developed through SMI Adviser, a project funded by SAMHSA and administered by the American Psychiatric Association.
The app provides an easy, step-by-step process for individuals to create and share a psychiatric advance directive (PAD). A PAD is a legal document that includes a list of instructions and preferences that the individual wishes to be followed in case of a mental health crisis, should they not be able to make their own decisions.
My Mental Health Crisis Plan allows individuals with serious mental illness to:
The app includes state-specific requirements for completing the PAD (such as signatures, witnesses, notary public), and allows it to be shared via PDF or QR code with whomever an individual chooses.
“Individuals living with serious mental illness have been a priority focus of SAMHSA and the Trump Administration,” said Assistant Secretary for Mental Health and Substance Use Elinore F. McCance-Katz, MD, Ph.D. “This app is a great step toward empowering individuals with serious mental illness to make decisions about their care.”
“The My Mental Health Crisis Plan app provides a simple, convenient and effective way to create and share a psychiatric advance directive,” said APA CEO and Medical Director Saul Levin, MD, MPA. “We are pleased to partner with SAMHSA in creating this important technological tool for people with serious mental illness.”
My Mental Health Crisis Plan is available in the Apple App Store and Google Play. View videos on What is a PAD? and How to Use the App. More information at: www.smiadviser.org/mymhcp.
SMI Adviser
SMI Adviser is funded by SAMHSA and administered by the American Psychiatric Association (APA). The APA works closely on this project with a team of experts and 30 other mental health organizations. This team includes individuals, families, clinical experts, peers, and policy makers. For information, visit www.smiadviser.org.
Reporters with questions should send inquiries to media@samhsa.hhs.gov.
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services (DHHS) that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.
Last Updated: 10/07/2020
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An easy way for individuals to create and share a psychiatric advance directive (PAD)
View videos on What is a PAD? and
More information at: www.smiadviser.org/mymhcp.
Ten commonly asked questions about PAD’s for California
Please note: the following 10 FAQs are designed to provide a quick and accessible guide to what your state’s statutes say – or do not say – about PADs. The FAQs do not attempt to provide a complete picture of the law in your state, nor can they take the place of legal advice. The answers were accurate when written in October 2006.
1. Can I write a legally-binding psychiatric advance directive (PAD)?
Yes. California’s Health Care Decisions Law allows you to appoint an agent to make decisions about your treatment if you become incompetent to make decisions; write instructions about how you would like your health care to proceed; or both. This law covers all types of health care, including psychiatric treatment. Disability Rights California has published a helpful guide, which includes the latest version of the statutory Advance Health Care Directive (AHCD) form. This form is not mandatory but is highly recommended. Disability Rights California also offers a detailed Trainer’s Manual on the subject of AHCDs. The state of California maintains a central registry of Advance Directives, which you may wish to use but is not mandatory. Click here for more information on that program.
2. Can I write advance instructions regarding psychiatric medications and/or hospitalization?
Yes. The statute allows you to set out your instructions on any aspect of your health care treatment, which could include advance decisions about psychiatric medications and/or hospitalization. The statutory AHCD form gives a variety of prompts for you to state your instructions in the event of a crisis (for example, you could state that you would prefer to remain in a quiet room). If you wish, you may make advance decisions to refuse medications and/ or hospitalization. If you do this, however, note that that state law may require your hospitalization in an emergency, even if you have declined it in your instructions.
3. Does anyone have to approve my advance instructions at the time I make them?
No. However, the document containing your advanced instructions must be notarized, or signed by two witnesses. Neither witness can be an employee of your health care provider, and one must be a non-relative. If you are a patient in a “skilled nursing facility”, meaning a facility providing skilled nursing care on a long term basis, your form must additionally be signed by a Patient Advocate or Ombudsman.
4. Can I appoint an agent to make mental health decisions for me if I become incompetent?
Yes, in one of two ways:
(1) You may appoint an agent (called a “surrogate” in California), using your AHCD. Your agent must be someone other than an employee of your health care or community care provider, unless he/she is also related to you. If you have a conservator under the Lanterman-Petris-Short Act, you must seek the authorization of an attorney before appointing an agent.
(2) If you are already being treated in a health care facility, you may designate a surrogate to act during your current stay, for a maximum of 60 days in total. To do this, you need only inform your health care provider. The person nominated in this way has priority over any agent you already nominated in an AHCD, but only during that particular period of treatment, or 60 day period in total.
5. If I become incompetent, can my agent make decisions for me about medications, and/or hospitalization?
Yes, with some exceptions. In general, once you are determined to be incompetent (see below) your agent may make decisions about anything that you could decide on if you were competent. However, your agent cannot consent on your behalf to your commitment to, or placement in, a mental health treatment facility; nor can he/she consent on your behalf to psychosurgery, electroconvulsive treatment (ECT), sterilization or abortion. If you wish, you may use your AHCD to limit your agent’s authority to a certain type, or types, of decision.
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 agent must exercise substituted judgment to the extent that he or she can do so, based on your advance instructions and/or on your preferences as known by the agent. If it is not possible to make a decision in that way, your agent must make the decision 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?
No. You may do one, the other, or both.
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. The California statute allows you to choose when your AHCD must be followed. Your AHCD will be followed when your primary physician determines that you do not understand the benefits and/or risks of a particular mental heath care decision. Alternatively, you may state on your form that your AHCD should be followed at all times, whether or not you are competent to make decisions.
9. Does the statute say anything about when my mental health providers may decline to follow my PAD?
Yes. Your providers must decline to follow your AHCD if they would violate professional standards in doing so, or for “reasons of conscience”. In these situations, your provider must assist in trying to find another provider who will follow your AHCD. Additionally, your providers could decline to follow your AHCD if you became subject to compulsory treatment or hospitalization under California law.
10. How long does my PAD remain valid?
Your AHCD is valid as long as you do not revoke it. If you wish, however, you may specify an expiry date for your AHCD.
The Federal Patient Self Determination Act (enacted in 1990) addresses the rights of health (including mental health) care users to stipulate in advance how they would like to be treated by health care providers when they are incapacitated. These wishes can be articulated by consumers in a specific document (an advance directive) or by appointing someone as a health care agent to speak for them.
The intent of the law is to provide an opportunity for adults to express their desires about medical treatment in advance, and to educate the entire population on advance directives. The law was enacted with the intent to offset a perceived imbalance between health care consumers and providers. The federal law does not grant consumers new rights; those specific rights are spelled out in state law. 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.
https://mhanational.org/issues/position-statement-23-psychiatric-advance-directives
Policy
Psychiatric advance directives permit people to determine what treatment they will receive if and when they lose the capacity to make treatment decisions. Mental Health America supports and promotes the use of psychiatric advance directives as a tool for the expression of an individual’s free will and self-determination in coping with mental health and substance use conditions. State laws regulate advance directives, and compliance with these laws is strongly advised. See, generally, National Resource Center on Psychiatric Advance Directives, http://www.nrc-pad.org/ The Bazelon Center for Mental Health Law provides a template for decision making in constructing a psychiatric advance directive at http://www.bazelon.org/LinkClick.aspx?fileticket=Jnjz10lQFPw%3d&tabid=226.
A psychiatric advance directive is a written statement of a person’s treatment preferences and other wishes and instructions. A psychiatric advance directive or a power of attorney (sometimes called a durable power of attorney or a power of attorney for health care) can also be used to assign decision-making authority to another person who can act on that person’s behalf.
Psychiatric advance directives are based upon several important considerations:
Psychiatric advance directives offer several key benefits. Correctly implemented and executed, they can:
People considering the creation of a psychiatric advance directive need to be fully informed about the benefits and limitations of these legal instruments. Anyone creating an advance directive should be able to do so without coercion, with choices regarding implementation and revocability, and with full knowledge and understanding of the implications of his or her decisions. It is particularly important that no treatment, service or government benefit be conditioned on the willingness of an individual to create an advance directive or on the content of an advance directive.
The primary goal and focus of mental health services should be recovery.1 The recovery model recognizes that persons with mental health conditions should be able to live a meaningful, self-directed life in the community. It also recognizes that persons with mental health conditions are able to set their own goals and define what recovery means to them. Psychiatric advance directives can be an important tool in enabling persons with mental health conditions to achieve their recovery goals.
Psychiatric advance directives are an underutilized tool for empowering individuals and offer significant potential for preventing or mitigating crisis situations. While every state has enacted legislation authorizing some form of advance directive for health care, many of these general advance directive laws do not provide adequately for the unique problems relating to the treatment of mental illnesses. Specifically, many states do not allow people to choose whether and under what circumstances they wish their advance directive to be revocable. This choice can be very important in protecting the rights and autonomy of persons with mental health conditions. Barriers to the implementation of psychiatric advance directives, such as state laws that add unnecessary procedural or legal burdens, should be eliminated. Thus, it is a priority for Mental Health America to reform state laws that impede ready access to psychiatric advance directives or reliable compliance with them.
This policy was Approved by the Mental Health America Board of Directors on December 5, 2015. It will remain in effect for five (5) Years and is reviewed as required by the Mental Health America Public Policy Committee.
Expiration:December 31, 2020
1.See MHA Position Statement 11: In Support of Recovery-Based Systems Transformation, http://www.mentalhealthamerica.net/positions/recovery-systems
2.Mental Health America strongly agrees with the decision in Hargrave v. Vermont, 340 F.3d 27 (2nd Cir. 2003), that even a person who is involuntarily committed to a psychiatric hospital has the right to have the hospital comply with her/his advance directive. State laws should expressly recognize this right.
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Learn about advance directives for behavioral health and what certified community behavioral health clinics (CCBHCs) need to know when caring for patients.
An advance directive outlines a person’s wishes in the event that he or she is incapacitated or unable to express wishes for health care and treatments. Under federal law, any facility receiving Medicare or Medicaid reimbursements is required to use advance directives. Individuals with a physical and behavioral health illness are covered under this mandate.
In a behavioral health advance directive, people are able to express their preferences on where to receive care and what treatments they are willing to undergo. They are also able to identify an agent or representative who is trusted and legally empowered to make healthcare decisions on their behalf. These decisions may include the use of all or certain medications, preferred facilities, and listings of visitors allowed in facility-based care. Advance directive laws may vary across states. Therefore, it is important to be sure that any advance directive form meets the requirements of a given state.
The Department of Health and Human Services (HHS) has developed criteria for CCBHC certification. Access the complete CCBHC certification criteria – 2016 (PDF | 789 KB).
The criteria include the following requirements related to advance directives:
Last Updated: 04/22/2020
A Practical Guide to Psychiatric Advanced Directives ( 45 pages) https://www.samhsa.gov/sites/default/files/a_practical_guide_to_psychiatric_advance_directives.pdf
Contents
Practical Guide to Psychiatric Advance Directives……………………………………………………………………….4
Resources and Crisis Planning……………………………………………………………………………………………………..16 References………………………………………………………………………………………………………………………………….18 Appendix, Sample Resources Glossary…………………………………………………………………………………………………………………………………..22 Worksheets……………………………………………………………………………………………………………………………..25 Informational Flyer………………………………………………………………………………………………………………….41
Tips for a Healthcare Agent……………………………………………………………………………………………………..43
Wallet Card……………………………………………………………………………………………………………………………..44
The National Resource Center for Supported Decision-Making (NRC-SDM) builds on and extends the work of Quality Trust's Jenny Hatch Justice Project by bringing together vast and varied partners to ensure that input is obtained from all relevant stakeholder groups including older adults, people with intellectual and developmental disabilities (I/DD), family members, advocates, professionals and providers. The NRC-SDM partners bring nationally recognized expertise and leadership on SDM, representing the interests of and receiving input from thousands of older adults and people with I/DD. They have applied SDM in groundbreaking legal cases, developed evidence-based outcome measures, successfully advocated for changes in law, policy and practice to increase self-determination and demonstrated SDM to be a valid, less-restrictive alternative to guardianship
Recovery to Practice Initiative (RTP) Aired Oct. 4, 2016 Patricia Siebert and Marie Verna discuss psychiatric advance directives and what practitioners and people using services need to know about them.
Psychiatric Advance Directives: A New Tool for Consumer EmpowermentMarvin Swartz, MD; Mary Blake, CRE
(74:26)
In this documentary filmmaker Delaney explores psychiatric advance directives; forms allowing a person to indicate treatment choices in case of a mental health crisis when decision-making may be compromised. How will this tool help her father who lives with schizophrenia? How has it already helped others? Learn more at NRC-PAD.ORG. Watch the PBS film about Delaney and her dad at www.unlistedfilm.com 2015 (12.04)
Break the silence around mental illness: Delaney Ruston at TEDxRainier
Silence around mental illness is common around the world, especially in impoverished countries. Documentary filmmaker Delaney Ruston shares her personal experiences of her father's mental illness, and the discovery that sharing personal stories have the power to inspire compassion and break the silence to create collaboration and action.
Ellen Goodman – Co-founder and Pulitzer Prize Winning Columnist gives shares personal stories about why it is so vitally important to do advance care planning. June, 2014
( 4.5 minutes )
Speak Up: Too many people don't have a plan for their future healthcare. But Advance Care Planning is easy! There are just five steps. (Think, Learn, Decide,Talk, Record) www.advacedcareplanning.ca
(1.25 minutes)
Reflections on End of Life Care: Honoring Wishes )For Raymond Wong, who takes care of his aging mother, the death of his brother left him acutely aware of the need to put his wishes in writing. (CA HealthCare Foundation 2/15 ACP Videos)
(2.13 minutes)
(1.42 minutes)
When foundation is weakened by illness, the palliative care team provides a stronger layer of support. (Center for Advancement of Palliative Care – CAPC , Sept 2014)
Honoring Choices Florida
Young adults talk about the importance.
(5 minutes)
Reflections on End of Life Care: Death A Part of Life, Dr. LaVera Crawley, CHCF 2/12 (2 minutes)
A physician studying to become a chaplain, Dr. LaVera Crawley says the health care industry only markets its successes, making it harder to acknowledge that death is part of life.
1. Advance Care Planning: It’s just 5 steps – animated graphic illustrator. (1.25 minutes)
https://www.youtube.com/watch?v=mPtu-FpY1Kw
2. Reflections on End of Life Care: Honoring Wishes (2.13 minutes)
https://www.youtube.com/watch?time_continue=1&v=qvsXKMWPI-w
For Raymond Wong, who takes care of his aging mother, the death of his brother left him acutely aware of the need to put his wishes in writing. (CA HealthCare Foundation 2/15 ACP Videos)
3. Palliative Care: You are a bridge -- Animated video. (1.42 minutes)
https://www.youtube.com/watch?time_continue=1&v=lDHhg76tMHc
When foundation is weakened by illness, the palliative care team provides a stronger layer of support. (Center for Advancement of Palliative Care – CAPC , Sept 2014)
4. What is Advance Care Planning & Why It Matters Honoring Choices Florida (5 minutes)
Young adults talk about the importance. https://www.youtube.com/watch?v=JLuqywONIO8
5. Ellen Goodman – Mother’s Story and Importance of ACP Conversations ( 4.5 minutes )
https://www.youtube.com/watch?time_continue=6&v=owH-os9I19I
Co-founder and Pulitzer Prize Winning Columnist gives shares personal stories about why it is so vitally important to do advance care planning. June, 2014
6. What about a Psychiatric Advance Directive. What Kind of Information is in that? (12 minutes)
http://webcasts.nrc-pad.org/EricPresentation/042406duke.html
Eric B. Elbogen, PhD, MLS, Duke University Medical Center and PAD Resource Center
7. Reflections on End of Life Care: Death A Part of Life, Dr. LaVera Crawley, CHCF 2/12 (2 minutes)
https://www.youtube.com/watch?time_continue=2&v=vSyiY5gxaCo
A physician studying to become a chaplain, Dr. LaVera Crawley says the health care industry only markets its successes, making it harder to acknowledge that death is part of life.
8. My Care My Plan Speak Up Sonoma County – 3 short videos with community leaders
http://www.mycaremyplansonoma.org/video/video-talk-to.htm
Why it is important to have an Advance Directive? What Should be included in an AHCD? Who should you talk to about your ACP Wishes? (each 1.5 – 2 minutes max)
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