Creating a Psychiatric Advance Directive

Step 1: Decide your wishes

The first step is to think through and write down how you want to be treated when you have a mental health crisis or are hospitalized. Here, again, are things to consider:

• 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 medical 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.

Finally, consider whether you want to be treated over your own objection when you are very ill.

It is a good idea to talk your wishes over with other people who know and understand you: family members, friends, therapists, case managers, your support system or doctors. They can help you think things through and may give you good suggestions. Just remember, in the end, what you put in your psychiatric advance directive is up to you.

Step 2: Find your health care agent

The second step is to find a person, or people, who know and understand you and are capable of acting as your health care agent (also called a proxy or patient advocate). Explain why you need their help and what you are asking them to do. Remember:

• Your health care agent needs to be reachable in case you have a mental health crisis or if you are hospitalized
• As long as you have the capacity to make medical decisions, your agent will not be needed
• When doctors declare that you lack the capacity to make decisions, your agent will be asked to speak for you
• Your agent will abide by the wishes expressed in your advance directive
• Your agent may also have to make decisions about your care that are not spelled out in your advance directive
• You may give your agent the responsibility to make health care decisions for you over your objections

If you know two people you trust, depending on state law, you can name one to be your agent and the other to be a back-up person. During a crisis, under applicable state law a physician may invoke ethical and community standards and override your wishes in your advance directive and the decisions made by your agent.

Step 3: Write your advance directive

State laws on psychiatric advance directives vary. Psychiatric advance directives may be used in certain states, while in other states you may be able to use a different but similar document such as a health care directive form, or a health care power of attorney. It is very important at this stage to learn if your state has specific requirements or has a form that you can fill out. There are several ways to find out what your state requires:

• You can talk with someone from your state's protection and advocacy (P&A) agency to see what your state allows. To find the P&A system in your state, visit the National Disability Rights Network (www.napas.org), or call 1 (202) 408-9514. Your P&A system also may know of trained people who can help you prepare an advance directive
• Go to www.NRC-PAD.org, the National Resource Center on Psychiatric Advance Directives (NRC-PAD). NRC-PAD is a nonprofit organization that offers a state by state guide to laws, rules, forms and other resources.

You should consult with a lawyer (attorney) in your state that has experience preparing psychiatric advance directives.

If your state has an approved psychiatric advance directive form, be sure to use it for your psychiatric advance directive, adding to it your specific wishes.

A psychiatric advance directive is a legal document, so you should type your responses on a computer if at all possible so your document is clearly legible. Typically, the first section of the form states your intention to complete an advance directive and your desire to have it followed. The subsequent sections then typically state your specific wishes. In the last section, you typically sign and date the form. Depending on state law, you may need one or more people to witness your signature and to have all signatures notarized by a notary public. These requirements vary from state to state so it is important that you understand your state’s specific requirements.

National Resource Center on Psychiatric Advance Directives offers a state-by-state guide to laws, rules, forms and other resources.

Step 4: Give out copies of your psychiatric advance directive

It's important that people know you have completed an advance directive and know where to find it. You will need to make a number of copies. Put a copy in your home where it can be easily found, and put the original in a safe place with your other important papers.

Be sure to give copies to people you trust – your agent and a trusted relative or friend. Give copies to:

• Your health care agent
• Your health care professionals at the mental health center
• Your health care providers that you named in your advance directive
• Any hospital where you have been a patient
• Any hospital where you want to be treated

Make a list of the people and places that have your advance directive and keep it with you.

Some states have created a repository – a central place to keep copies of advance directives. If your state has a repository, you should file a copy there. Check with your state’s protection and advocacy (P&A) agency or the National Center on Psychiatric Advance Directives to find out.