CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Psychiatric Advance Directive 

ClinP-01
 
Category: Clinical Programs
Published Date: December 2021
  1. PARAMETER GOAL
    1. Increase knowledge of creating and utilizing Psychiatric Advance Directives (PADs)
    2. Create PADs with clients when they are not under psychiatric distress
       
  2. TERMINOLOGY
    • Psychiatric Advance Directive (PAD): A legal form that documents a person's preference for future mental health treatment and allows the appointment of a health proxy to interpret those preferences during a crisis.
    • PAD Registry: In California, a PAD can be filed voluntarily with the Secretary of State’s Advance Health Care Directive Registry. If a PAD is filed, the individual will receive a wallet card indicating that they have registered with instructions on how to access it. The information is made available upon request to the registrant's health care provider, public guardian, or legal representative. A request for information must state the need for the information.
    • Shared Decision Making: The process in which clients and care providers collaborate on health care decision-making based on the best information and options available and the client's preferences and values. 
    • Supported Decision Making: The process in which persons with disabilities are able to make decisions about their health care and lives with the support of a team of individuals. The supported decision-making process may be useful for clients who lack some decision-making ability on a regular basis, but who are still able to express their preferences for care and services.
       
  3. MEASURES
    1. How do you determine if a client is open to a PAD?
      1. Explain what it is and ask if they might be interested.
        1. Frame the PAD as a way to gain some control when the mental illness makes decisions challenging.
        2. Explain what the PAD can and cannot do to provide a realistic impression and not a panacea.
        3. Use the least restrictive alternatives.
      2. Provide pamphlets for reading additional information about PAD.
      3. Expect the client to take more than one session to consider the use of PAD.
    2. Treatment decisions for future care can be created post-hospitalization.
      1. Is the client unhappy with the care they received at the hospital?
      2. Has the client filed with the Patient's Rights Office to obtain a Patient Advocate?
    3. Explain that treatment decisions can include:
      1. Medication management
      2. Preference for placement within options of illness seriousness
      3. Appointment of a proxy for decisions
         
  4. TREATMENT STRATEGY
    1. Introduce the concept of PAD to clients when they are well.
      1. Elaborate on the benefit.
      2. Elaborate on the cost.
    2. Explain PAD as a self-determination mechanism for psychiatric clients when they are well.
    3. Provide clear examples.
    4. Ask if assistance is needed in writing the PAD.
    5. Emphasize that informed treatment decisions only apply when the client is unable to make those decisions.
    6. Use Supported Decision-Making.
    7. Use of PAD during conservatorship may not be honored by the court or conservatorship depending on clinical treatment recommendations.
       
  5. PROVISION OF SERVICE
    1. Provide PAD template
    2. Provide assistance with PAD
    3. Apply for Registry
    4. Inform the client that the PAD must be distributed to health care providers and significant supports.
      1. The document is only effective if health care practitioners and families know a PAD exists, even if it is registered.
         
  6. OUTCOMES AND MONITORING
    1. Consider adding the PAD to the treatment plan. 
    2. Provide mental health staff with a copy of the PAD.
    3. Update or review the PAD annually or at crisis points.
       
  7. STAFF TRAINING
    1. Training on:
      1. Psychiatric Advance Directives and how to use them.
        1. How a PAD is used as a tool for self-empowerment in mental health treatment
        2. Use of Supportive Decision Making
        3. Notary and Legal Requirements for a PAD
        4. Limits of treatment staff in using a PAD
           
  8. SUPERVISION AND CONSULTATION
    1. Use of PAD registry and workflow
  9. RESOURCES
    1. State Legislation & Statutes:
      1. California Health Care Decision Law
      2. Secretary of State Advance Health Care Directive Registry
      3. Disability Rights California
    2. National Organizations
      1. Substance Abuse and Mental Health Services Administration: A Practical Guide to Psychiatric Advance Directives.