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Explain why you need their help and what you are asking them to do. 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.

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 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.

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Advances in Psychiatry Second

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

It's important that people know you have completed an advance directive and know where to find it.


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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. In spite of widespread perceptions that the mere presence of severe mental illness compromises decision-making abilities, the evidence clearly shows that for the majority of such persons, this is not the case 5. In this context, the psychiatric advance directive is often described as a significant advance that can empower persons with mental disorders to have a say in treatment decisions; in turn, this can help decrease coercion, increase treatment collaboration, motivation and adherence, and help avoid conflict over treatment and medical issues 6 , 7.

The psychiatric advance directive is interesting since it engages in a challenging conceptual interface — the need to maintain the autonomy of the person with the need for appropriate treatment, in situations where there is disagreement between the parties involved. With the knowledge that many severe mental illnesses may be characterised by fluctuating mental capacity and loss of competence, the advance directive is an attempt to help the individual cope with the latter, without losing sight of the former.

In the wake of the Patient Self Determination Act, in the United States, mental health advocates appropriated some of the ideals of advance directives, and applied them to the context of patients of mental illness, who were seen to be particularly vulnerable to loss of autonomy and at risk of receiving unwanted interventions. These advocates hoped that the advance directive would give persons with severe mental illness greater autonomy and control over their own lives; it would do so directly, during times of crisis, and perhaps indirectly, by improving continuity of care and improving the working alliance with mental health professionals, thus decreasing the need for involuntary treatment.

It was also hoped that this would lead to a reduction of adversarial court proceedings 8 , A spectrum of advance statements has emerged in many developed countries Apart from specific psychiatric advance directives, the spectrum has included. These vary in their goals, the level of involvement of the care provider, the role of the third party, the determination of competency, the nature of the advance agreement, and the degree to which they are legally binding Common features of these agreements are: requests for treatment in a particular hospital or ward; requests for treatments that were helpful in the past, or directives about those that should not be used; preferences for staff gender and emergency measures forced medication versus physical restraint ; nomination of the person to be consulted on decisions about treatment; and arrangements for dependents during hospital treatment.

However, there have been various differences across countries. These differences are in: the definition of advance directives, variations in terminology, determination of competence to make such a directive, mechanisms for making a directive, the legal status of such directives, whether the wishes of the person being treated at the time of admission override any earlier advance directive made by the same person, and the time validity of the advance directive.

In the new statutes in some US states, clinicians are not required to follow directives that conflict with community practice standards, or with the need for emergency care, or that are unfeasible, or if the patient meets involuntary commitment criteria Similarly, advance statements can also be overridden in the UK. In Australia, the utility of advance directives has been questioned; it is felt that they have failed to guide clinical decision making.

Currently in Australia, mental health legislation can override an advance directive One self acts on the urging of short-term impulse, mood or emotion, as evidenced by the manic episode in bipolar disorder, where the individual may start manifesting unusual assertiveness, grandiosity, irritability, impulsivity, and risk taking behaviour.

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Thus, by providing, in advance, consent to treatment and waiving the right to refusal, the Ulysses contract puts in place a process that introduces concepts of pre-commitment, self binding and self paternalism In operational terms, when it becomes legislated policy, the state, which becomes the enforcing party, then has to determine when the party to be restrained has lost the power of self-control, and has to predict the consequences of such loss. Furthermore, the power of the state must be invoked to enforce the legally binding agreement While in many ways, the rationale for the advance directive seems self-evident, when we delve deeper, a number of issues emerge.

The use of Ulysses contracts raises a number of ethical concerns, including the questions of moral authority, personal identity, revocation during crisis and the risk of misuse and abuse. It is unclear as to how the process ensures that using advance directives is a process not enforced upon the patient. An example cited is whether a patient who does not sign a contract can be refused treatment Elaborating on these concerns, Widdershoven and Berghmans stress the need for looking at the advance directive as an ongoing communication between the patient and the doctor in a narrative context.

It goes beyond merely recording instructions to the treating team; it becomes a record of the ongoing, informed discussion regarding treatment modalities between the patient and the doctor. It is then to be viewed as a tool, not to replace discussion, but to facilitate ongoing communication.

Feinberg argues that the voluntariness of a decision is the decisive criterion. Typical examples are an alcoholic who is considering quitting drinking and a patient suffering from bipolar disorder. However, despite the fact that advance directives have been in place for some time, the evidence of their effectiveness is very limited. There has, actually, been little in the way of research into the effects of advance directives in promoting the objectives of informed choice and consensual treatment during episodes of acute care.

There is more data on their effects on health service use, but even here the results have been equivocal 20 , Some of the disparities in results may be due to differences in the sample including selection bias, or in the type of intervention More intense interventions, including a lengthy interview with patients and their carers 21 , appear to be more effective than providing patients with a booklet for completion The main opposition to advance psychiatric directives has been that they are undesirable and unworkable in practice; giving mentally ill persons the right to consent to or refuse mental health treatment before the onset of any psychiatric illness does not actually promote or protect their best interests, since future decisions cannot be made about potentially unforeseen circumstances Others view it as leading to legal and ethical problems, and being unworkable 24 , Other concerns about advance directives include situations where patients may agree to some treatments in their advance directives, but not others, even when they may be more appropriate for the patient One solution is to involve third parties in the agreement Although this may be associated with better outcomes in terms of health service use, it may add to their complexity and undermine the very autonomy that advance directives are designed to protect For example, feelings of hopelessness secondary to depression may lead individuals to underestimate the effectiveness of available treatments.

The issue of the use of advance directives in psychiatry has not received much attention in academic or social fora in India till date.

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The question of the applicability and effectiveness of psychiatric advance directives in India is certainly relevant, especially since the current evidence for both effectiveness and usage seems, somewhat surprisingly, to be marginal in countries where this has been implemented. The diversity of the various forms of psychiatric advance directives is an indicator of the critical influence of the particular social, political and service delivery contexts where they have been operationalised, as also the fact that different societies are trying to negotiate differently with this complex concept.

All of these are very different in India, especially the service context. Advance directives implicitly work within an accessible, well defined and predictable service delivery context. The relatively unorganised nature of services in India, and the limited access to them, makes the use of advance directives particularly challenging. The other concern that has been raised is of the possibility of abuse and misuse of this tool. In countries and societies where monitoring and regulatory controls tend to be either lax or non-existent, the possibility of the misuse of this tool is very real.

Again, in the Indian context, the involvement of family members in determining the type and requirements for acute care is critical.

Critical psychiatry

Any plans for the introduction of advance directives needs to take into account the views and preferences of key caregivers as well. Otherwise, it runs the risk of alienating users, families and care providers, rather than encouraging collaboration between the parties. Another issue of concern is the requirement for dedicated resources like competent legal aid services for the implementation of advance directives in an accessible and affordable manner.

In addition, local complaints and dispute redressal agencies to manage conflict arising out of the implementation of the advance directive, and an ombudsman-like agency at each district level, will be needed. This is an issue of concern in India where such resources are sparse in rural settings and for a large proportion of vulnerable population groups. Otherwise, there is a possibility of the use of advance directives being restricted to urban elites who have access to services, information and resources to execute them.

Finally, effective monitoring systems, that will capture the process, uptake and utility of advance directives in the acute care context, are needed. This is a significant challenge that requires considerable financial and human resources which is a potential barrier in India. We believe that, given these challenges, the adaptation of advance directives in the Indian context needs to be researched in detail around the issues of feasibility, acceptability to a range of primary and secondary stakeholders, and effectiveness in implementation.

This process will allow for the identification of the logistical, ethical, legal and operational barriers that need to be addressed before legal adoption can be advocated. The advance directive is a mechanism for involving and empowering persons with mental illnesses in taking charge of their lives and participating in clinical decision making.

The authors are of the opinion that the use of the advance directive as a clinical tool, embedded in the nature of the clinical narrative, is certainly something which should help in both facilitating and nurturing dialogue. It can thus potentially serve as a clinical tool for collaborative decision-making.

However, the utility of such a directive as a legal tool seems fraught with complexities in conceptualisation, operationalisation and application. At present, it is not supported by adequate evidence of its utility. Further debate and discussion are needed before the advance directive can be incorporated into the legal provisions that will govern the care of persons with mental illnesses in India in the near future.

The contribution of all the participants is gratefully acknowledged. Toggle navigation Indian Journal of Medical Ethics. Article Tools PDF. Print this article. Indexing metadata. How to cite item. Finding References. Email this article. Email the author. Post a Comment. Rationale for psychiatric advance directives In spite of widespread perceptions that the mere presence of severe mental illness compromises decision-making abilities, the evidence clearly shows that for the majority of such persons, this is not the case 5.

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History and international experience In the wake of the Patient Self Determination Act, in the United States, mental health advocates appropriated some of the ideals of advance directives, and applied them to the context of patients of mental illness, who were seen to be particularly vulnerable to loss of autonomy and at risk of receiving unwanted interventions. Apart from specific psychiatric advance directives, the spectrum has included facilitated advance directives, joint crisis plans, crisis cards, treatment plans, and wellness recovery action plans.

Effectiveness, feasibility and uptake However, despite the fact that advance directives have been in place for some time, the evidence of their effectiveness is very limited. Informing the discourse in India The issue of the use of advance directives in psychiatry has not received much attention in academic or social fora in India till date. Challenges related to service delivery methods: The diversity of the various forms of psychiatric advance directives is an indicator of the critical influence of the particular social, political and service delivery contexts where they have been operationalised, as also the fact that different societies are trying to negotiate differently with this complex concept.

Abuse and decision making related challenges: The other concern that has been raised is of the possibility of abuse and misuse of this tool. Challenges related to the creation of supporting agencies: Another issue of concern is the requirement for dedicated resources like competent legal aid services for the implementation of advance directives in an accessible and affordable manner.

Conclusions The advance directive is a mechanism for involving and empowering persons with mental illnesses in taking charge of their lives and participating in clinical decision making. Advance treatment directives for people with severe mental illness. Cochrane Database Syst Rev. Rand Corporation.

Literature review on advance directives. End-of-life decisions and advance directives in palliative care: A cross-cultural survey of patients and health-care professionals. J Pain Symptom Manage. United Nations Convention on the rights of persons with disabilities: an advocacy initiative for its implementation in India [Internet]. MacArthur treatment competence study. J Am Psychiatr Nurses Assoc. Using a hypothetical scenario to inform psychiatric advance directives. Psychiatr Serv. Advance statements in adult mental health. Adv Psychiatr Treat. Appelbaum PS. Advance directives for psychiatric treatment.

Hosp Community Psychiatry. Backlar P. Community Ment Health J.