Psychiatric Advance Directives: Pros and Cons

Mental health patients, their advocates and their doctors are increasingly leveraging Psychiatric Advance Directives (PADs) to plan for mental health crises in advance.

A PAD is a legal document a patient uses to declare which treatment they do – and do not – want. The document becomes part of the patient’s medical records on file with hospitals, and doctors must follow the directives unless the preferences are expressly against the patients’ best medical interest. The document can also name another person authorized to make decisions when the patient is in crisis, known as a Proxy PAD. Both instruction and proxy can be combined in a single PAD, along with general medical advance directives. Patients can specify effects specific treatments have, describes their crises, suggest statements that help in a crisis state and appoint a family member or friend to support in time of crisis.

Only about half the states in the U.S. currently permit psychiatric advance directives, according to the National Alliance on Mental Illness (NAMI).

The Pros of Psychiatric Advance Directives

PADs empower patients by allowing them to have a say in their care and engaging them in their treatment plan. Here are some of the other benefits of psychiatric advance directives:

Minimizes hospitalization: Patients can not only specify preferred hospitals, where they may recover more quickly, but they can also recommend treatments and approaches that work well, which can expedite their care.

Minimizes involuntary commitment and coercive treatment: Patients can specify alternatives to hospitalization, electroconvulsive therapy (ECT), medication and emergency interventions.

Minimizes cost: More efficient care and mechanisms to de-escalate crises can reduce expensive court procedures and limit costly hospital stays. PADs may also increase patient satisfaction and motivation to engage in treatment.

Aids the treatment provider: PADs also guide doctors to the most useful treatment, often providing statements to use to help stabilize a patient and indicating which treatments are useful and which have adverse effects.

Increases patient engagement in treatment: Duke psychiatry professor Dr. Marvin Swartz told The New York Times the mere act of creating a directive can engage patients in their care. Dr. Swartz and his colleagues provided 239 patients with an opportunity to create PADs; the 147 patients who participated had fewer crises causing involuntary hospitalization, medication or restraint.

Allows patient preferences to be known: In addition to care preferences, patients can indicate who should be notified in the event of being admitted to a psychiatric facility, who should be assigned as guardian if required by the courts, who should have custody of children, and who should be prohibited from visiting a facility. 

Provides greater care continuity: With a directive, patients are more likely to receive consistent care in times of crisis, as it offers a place to begin to healthcare providers.

Promotes early intervention: With a directive, patients may be more willing to seek early intervention, including hospitalization, if they can specify treatment and duration.

Improves communication between patient and provider: A prewritten document can reduce conflict between patients and providers when the patient is experiencing a crisis because the preferences are already laid out. 

Pre-authorizes family or friend involvement:  An informed family member or friend can also help advocate for the patient and his or her directive, which also helps reduce forced treatments. This also eliminates the common challenge that patients often cannot grant permission during a crisis. 

Provides insight into patient: In many cases, the directives are an opportunity to really understand the patient’s experience. For example, a PAD for a combat veteran indicates, “I have PTSD. I have delusions.” The document goes on to recommend many ways to interact with the individual, including “Please let me know that you are real by saying things like: We drove here. We did not warp here.”

The Cons of Psychiatric Advance Directives

Despite the numerous advantages of PADs, they also have some downsides due to legal complications, low widespread knowledge, and more.

Insufficient education for consumers and hospitals: Patients need to truly understand how to complete a PAD and what its legal limits are. Likewise, healthcare providers also need to understand how to use PADs in treatment.

Logistics: For PADs to have any value, hospitals must request them. And right now, this often isn’t part of standard operating procedure. It can also be unclear how to execute a PAD, or how to revoke one.

Completion is complicated: Since PADs are not yet widespread, not all hospitals have embraced them as routine practice, a fact that keeps some patients from completing them. And, even if they do decide to complete them, they have to follow all the steps (including having the directive notarized) for them to be valid. 

Legality and liability are complicated: If a PAD refuses a type of treatment that is, in time of crisis, determined to be critical by a healthcare provider, the path forward can be murky. In the same way, if a patient authorizes hospitalization in a PAD but refuses it during crisis, the appropriate action can be unclear.

Request for treatment uncertainty: While patients can strive to dictate how they want treatment administrated, predicting what treatments are available and what may work best in a future crisis can be difficult.

Use of psychiatric advance directives offer many potential benefits for patients and their advocates; however, there are still challenges to overcome in making their application standard operating procedure. Hospitals and practitioners need to establish best practices and make the process easier for patients for PADs to become used effectively and on a widespread basis.

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