Psychiatric advance directives are written documents specifying how an individual would like to be treated if in the future they are unable to decide for themselves due to exacerbations of their underlying conditions. These documents may describe the treatments they would prefer and/or to appoint a surrogate decision-maker through a health care power of attorney. Creating a psychiatric advance directive can improve therapeutic alliance with clinicians, enhance perceived autonomy, and improve treatment decision-making capacity among people with serious mental illnesses. While most people with serious mental illness would want a psychiatric advance directive, fewer than 10% have completed one. Completing a psychiatric advanced directive should be a high priority for all of your patients with serious mental illnesses. The National Resource Center on Psychiatric Advanced Directives (NRC-PAD) provides a state by state guide to regulations and also includes appropriate PAD template forms for use in each state where PADs are legally accepted. You can find more information at https://www.nrc-pad.org.
SAMHSA has recently released A Practical Guide to Psychiatric Advance Directives in its Evidence-Based Practices Resource Center. The report provides background and practical information to those interested in promoting the use of PADs as a tool for promoting self-directed care in psychiatric treatment, making progress toward parity in mental health treatment. It also supports crisis planning and the rights of persons who live with mental illness.
The New England Mental Health Technology Transfer Center developed an Advanced Directives Systems Checklist. Integrating psychiatric advance directives into a service system requires thoughtful consideration, clear communication with staff and patients alike, and intentional planning. This checklist serves as a guide. We suggest that a team of people complete it and then review their answers together. Identify areas for improvement and then prioritize which items to target first.