NRC•PAD
Facilitating Advance Directives for Mental Health Care
Christine M. Wilder, M.D.Department of Psychiatry
Duke University School of Medicine
NRC•PAD
Why Use Advance Directives for Mental Health Care?
• Enhance autonomy and self-directed mental health care
• Provide ER and inpatient doctors with transportable documentation of a patient’s treatment preferences and history Medical disorders, emergency contact
information, side effects of medication
• Improve therapeutic alliance and treatment adherence
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AD Completion Rates by Study Group
Baseline 2 months Control Group (n=230)
1 (0.5%) 8 (3%)
F-PAD Group (n=239)
3 (1%) 149 (62%)
After Swanson et al 2006, Am J Psychiatry 163:1943-51
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“I do not consent to the administration of the following medications . . . [lists 9 meds]”
Excerpts from Unfacilitated AD:
“. . . Episodes are to be managed at home where my special foods are prepared by me or health care aide as no hospital can afford my expensive diet. . .”“. . . DO NOT NOTIFY my son ________ or his family, as they are hostile relatives.”
“I do not consent to being admitted to. . .[lists 4 hospitals] where abusive treatment has occurred . . .I would want a legal aid attorney to see me ASAP.”
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Facilitated AD from Same Participant
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AD Content: Medications• 94% gave advance consent to
treatment with at least one psychotropic medication (mean = 2.4)
• 77% refused at least one psychotropic medication (mean= 1.5)
• No participant refused all medications• On average, participants gave advance
consent to twice as many medications as they refused
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Sample Medication Choices
“I refuse Haldol because it makes me stiff, I get blurred vision, and feel like a zombie.”
“I don’t want Depakote because one time I had it and I got Pancreatitis.”
“They’ve given me Ativan before but I absolutely do not want any medications I could become addicted to.”
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AD Content: Hospitals
• 88% gave advance consent to hospitalization in at least one specified facility
• 62% documented advance refusals of admission to particular hospitals
• 51% gave reasons for refusal
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Sample Hospital Comments
“I want to go to [hospital X] because it is closest to my parents and they treat me well there.”
“I do not wish to go back to [hospital Y], I was thrown in a dark room and am scared and was hurt by another patient last time.”
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AD Content: Emergency Contacts
• Includes family, friends, doctors and counselors that participant would want to have contacted in the event of crisis
• Provides prior consent for communication between inpatient and outpatient treatment providers
• On average, participants listed 3 emergency contacts
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Facilitator Role
• Providing information and education about ADs, including their limitations
• Helping consumers identify appropriate agents to act in their stead during a period of incapacity
• Eliciting preferences and advance consent or refusal for psychotropic medications, hospital treatment, or ECT
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Facilitator Role
• Gathering information about crisis symptoms, relapse and protective factors, instructions for inpatient staff, and other relevant information the consumer thinks is important
• Providing assistance for filing ADs at local health care facilities and storing them in the U.S. Living Will Registry
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Beginning a Facilitation
• Orient the consumer to the purpose of your meeting
• Explain what an AD is and why s/he might want one
• Review the limitations of an AD
• Determine if the consumer would like to complete an AD
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Identifying an Agent
• Clarify what an agent is and why the consumer might want one
• Determine if the consumer wants to identify an agent
• Elicit the consumer’s preferred agents
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Demonstration and Small Group Practice: Identifying an Agent
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Eliciting Preferences
• You are acting as a facilitator, not a provider
• Consumer has ultimate control over his/her AD
• It is appropriate to test feasibility with consumer, clarify consumer statements, and explore reasons for preferences
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Challenges in Eliciting Preferences
• Consumers who have trouble expressing preferences
• Consumers who have too many preferences
• Consumers who have unrealistic preferences
• Conflict between clinical and facilitator role: when you know too much
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Demonstration and Small Group Practice: Eliciting Preferences
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Overcoming Logistical Barriers to Completing ADs
• If consumer wants to sign the “Ulysses clause,” a co-signature from a psychiatrist or clinical psychologist is required
• ADs need to be witnessed by two adults; the facilitator can act as one witness
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Ensuring ADs Are Read by Providers and Family
• Make copies of AD and send to relevant outpatient and inpatient facilities
• Encourage consumer to discuss AD preferences with health care agents, clinicians, and other family members
• Consumers should keep a copy of their ADs with them at all times
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Conclusion
• ADs can help empower consumers with mental illness when they experience crises
• AD facilitation is most helpful when: 1. consumers are educated about how these
legal documents work, and
2. efforts are made by the facilitator to both honor consumers’ preferences and assist in writing a feasible AD
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National Resource Center on Psychiatric Advance Directives http://www.nrc-pad.org
