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Being prepared for a crisis with a psychiatric advance directive

Being prepared for a crisis with a psychiatric advance directive

"We know what’s best for you," the doctors and nurses told Amber after she awoke to find she had been admitted to a psychiatric hospital. When she told them she’d had problems in the past with the medication they were giving her and that another had been more effective for her, no one would listen.

If you are living with depression, bipolar disorder or another mental illness, you may someday require hospitalization. And you may find that you have little say about your treatment. Medical staff will make most of the decisions about your care if your symptoms become severe.

But there’s a way to stay in charge. You and your family members should be prepared for the possibility that you could become incapacitated as a result of your illness.

Putting your preferences in writing can allow you to have more control over what happens to you if you become so ill you cannot make decisions for yourself.

Crisis planning

A legal document called a psychiatric advance directive (PAD) can provide you with this type of protection. It's a tool for documenting your instructions and preferences regarding future mental health treatment. It can ensure better communication between you and your doctor and may prevent hospitals from giving you unwanted types of treatment. The time to plan for such an emergency is when you are well and able to think clearly.

What do I need to know?

Begin by gathering information and considering your preferences.

Find out, for example, what your doctor's procedure is for reaching him/her in an emergency. Will you be seen by your own doctor or someone on call? What hospital(s) is your doctor associated with?

Hospital signGet information about your insurance plan. Are there hospitals your plan will approve and others it won't? Will you need preapproval? Are there limits on your length of stay?

Electroconvulsive therapy (ECT) may be recommended. Do you know enough about it to specify, in advance, whether or not you want to have it? Do you know what medications have been effective for you and which have not, or have had problem side effects?

What's included in a PAD?

A PAD may include any of these and other instructions:

  • Designation of agent(s)

  • Emergency contacts

  • Preference for a court appointed guardian

  • Choice of treatment facility

  • Preference for alternatives to hospitalization

  • Preferences about doctors who will treat you if you are hospitalized

  • Preferences regarding medications

  • Preferences regarding treatments such as electroconvulsive therapy (ECT)

  • Who should be notified of your admission to a psychiatric facility

  • Who should be prohibited from visiting you

  • Preferences regarding who should care for your children

Is my PAD legally binding?

Most states permit some form of legal advance directive (AD) for healthcare, but twenty-five states have specific PAD statutes, each with somewhat different requirements. Learn about the laws in your state. Regardless of state laws, if you have an advance directive, medical staff are more likely to honor your preferences.

How do I prepare a PAD?

Discuss your plan with your family and health care providers. Select an agent, a trusted friend or family member, to represent you. (Most states require this and your PAD is more likely to be honored if you have named an agent.) Describe your preferences in very specific terms. Give copies to your agent, alternative agent, friends or family members and your mental health care provider who will make it a part of your medical record. You can also give a copyto the facility where you might be taken in an emergency.

When would I be considered "incapable"?

Incapacity generally means that, at the time, you are not able to make and communicate decisions about your mental health treatment. State laws vary. Incapacity may be determined by a doctor, a qualified psychologist or a judge. The Bazelon Center for Mental Health Law provides more information and forms you can download.