Psychiatric Advance Directives: FAQs

What are the benefits of completing a psychiatric advance directive?

There are many ways a psychiatric advance directive can be helpful.

• A psychiatric advance directive will allow you to take a more active role in your own care and may help influence what happens to you during a mental health crisis
• A psychiatric advance directive communicates your preferences to doctors and other treatment team members in the hospital, which helps them understand what you want, what you don’t want and what helps you. A psychiatric advance directive also helps you communicate your wishes to your family members, community treatment team, support system and friends
• Completing a psychiatric advance directive can make times of a mental health crisis less stressful
• You decide whom you desire to make decisions for you in times of a mental health crisis —otherwise another person could be appointed to make decisions for you
• In order to prepare one, you will need to think about what kind of treatment and care you want and don’t want. Thinking these things through and writing them down makes you better prepared for times when you are not well or in a mental health crisis

Laws for advance directives vary from state to state. In many states, psychiatric advance directives are recognized by state law. In these states, doctors and other health care professionals are generally expected to follow the advance directives of their patients when possible, subject to the doctor’s reasonable discretion and ethical considerations.

When will you need a psychiatric advance directive?

A psychiatric advance directive goes into effect if it has been determined that you lack the capacity to make treatment decisions for yourself. Usually this takes place in a hospital.
By writing your advance directive when you are well and your capacity is not in question, you can make your wishes known should you have a mental health crisis or hospital stay. In an emergency situation, however, it is important to understand that doctors have the authority to make decisions that are necessary to ensure your safety and that of other patients and hospital staff.

What should a psychiatric advance directive include?

A psychiatric advance directive can include any of the following information, as well as other things that are important to you:

• Whom you want to be notified in case of a mental health crisis
• What happens to you during a mental health crisis and what helps you recover after the crisis
• Where you would like to go if emergency treatment or hospitalization is required
• Alternatives to hospitalization
• The health care professionals you want involved in your care or those who should be consulted
• Types of treatment(s) that you want or do not want (and briefly state the reason)
• How you want to be treated in the event of hospitalization
• Medical conditions or allergies doctors should be aware of
• People you would permit as visitors in the hospital
• People to contact who can help with bills, pet care, etc.

You will have a chance to think about and write down what is important to you in Step 1 under How do you complete your psychiatric advance directive, but it will be helpful to read the next 3 sections first.

Should you name a health care agent?

One of the most powerful features of a psychiatric advance directive is your ability to name someone else (called a health care agent) to make decisions for you and speak on your behalf in times of a mental health crisis. You can name that person by stating that only he or she should make decisions for you in the event that you lack the capacity to make medical decisions for yourself.
Your advance directive does not have to name a health care agent, but in some states it may not be legally recognized as enforceable unless it includes one.

Who should be your health care agent?

The person you select as your health care agent should be someone you trust to respect your wishes and advocate for you – a family member or friend. He or she will tell others what kind of treatment you do or do not want and will supervise your care. Depending on state law, you may be able to choose more than one agent. You can make one the primary agent and designate another as a backup, or you could give each person different responsibilities. Perhaps you trust one person to make your health care decisions and another to take care of your household matters (bills, etc.). Be clear about who should do what.

Do you want to be treated over your own objection?

There may be times when you are very ill in which you could fear or refuse treatment that normally you would find acceptable. In a hospital, with the consent of your health care agent or someone else appointed to make decisions for you, you can be treated over your own objection. In an emergency situation, however, it is important to understand that doctors have the authority to make decisions that are necessary to ensure your safety and that of other patients and hospital staff.

You can express your wishes about being treated over your own objection in your psychiatric advance directive. You may decide that you should be able to refuse treatment, even when you are very ill. In that case, you would choose to make your advance directive revocable. This means that if your state law allows it, you can reserve the right to cancel your advance directive even during a mental health crisis. This must be stated in writing. However, if you choose to revoke your advance directive, your agent will no longer be able to advocate for you. Before you decide whether to make your advance directive revocable, you should thoroughly discuss this with your friends, family and health care professionals and an attorney (lawyer) that is knowledgeable about these issues.

You may also decide to make your psychiatric advance directive irrevocable, and that it is best that you be treated according to your psychiatric advance directive, even if you object at the time. Your advance directive cannot be revoked by you while you lack capacity to make decisions, even if you object to treatment at the time. You can include a statement giving your agent the responsibility to make health care decisions for you, even over your objections.

The statement that you allow treatment over your own objection is sometimes known as a "Ulysses clause."

Does your doctor have to follow your psychiatric advance directive?

If your psychiatric advance directive meets applicable state requirements, it is considered legally enforceable.

Whether legally enforceable or not, your doctor may want to follow your advance directive simply because it helps him or her treat you most effectively. However, there are some cases when the health care professional and staff may not be legally required to follow your advance directive or may override your wishes for other reasons.

For example, depending on your condition, there may be times when it is not possible to follow your psychiatric advance directive. Medical providers must always defer to your state’s standards of medical care to provide the care you need, and your document may be overridden if the instructions require unavailable treatment or endanger the life or health of you or another person.

Can you change your psychiatric advance directive?

You can change the contents of your advance directive by making corrections or writing out a new one. However, it is your responsibility to ensure that your contacts have a copy of your most current psychiatric advance directive.