Provider Utilization of Advance Directives in the Psychiatric Setting: PAD's Yad M. Jabbarpour, MD, DFAPA Chief of Staff Catawba Hospital Clinical Assistant.

Provider Utilization of Provider Utilization of Advance Directives in the Advance Directives in the Psychiatric Setting: PAD'sPsychiatric Setting: PAD's

Yad M. Jabbarpour, MD, DFAPAYad M. Jabbarpour, MD, DFAPAChief of StaffChief of Staff

Catawba HospitalCatawba HospitalClinical Assistant Professor of Psychiatric MedicineClinical Assistant Professor of Psychiatric Medicine

University of Virginia School of MedicineUniversity of Virginia School of Medicine

ADVANCE DIRECTIVES TRAININGNovember 5, 2009Richmond, Virginia

Do we have Psychiatric Advanced Do we have Psychiatric Advanced Directive’s in Virginia?Directive’s in Virginia?

Legally:Legally: Advance Directives (AD): Advance Directives (AD): Yes (Yes (§ 54.1-2981 et § 54.1-2981 et seq)seq)

““PPsychiatric”sychiatric” AD (PAD): AD (PAD): NoNo

Clinically & for the Consumer:Clinically & for the Consumer: Yes, one can look at the Yes, one can look at the PAD in Virginia as an advance directive for mental health PAD in Virginia as an advance directive for mental health carecare

Virginia: AD’s are not disease-specificVirginia: AD’s are not disease-specific A person is free to draft an advance directive that only A person is free to draft an advance directive that only

addresses one particular type of health situation if he/she addresses one particular type of health situation if he/she chooseschooses

AD law allows instruction & proxy directives across the AD law allows instruction & proxy directives across the continuum of one’s lifecontinuum of one’s life

What is a PAD,What is a PAD,Psychiatric Advance Directive?Psychiatric Advance Directive?

… … a relatively new legal instruments that may a relatively new legal instruments that may be used to document a competent person’s be used to document a competent person’s specific instructions or preferences specific instructions or preferences regarding future mental health treatment, in regarding future mental health treatment, in preparation for the possibility that the person preparation for the possibility that the person may lose capacity to give or withhold may lose capacity to give or withhold informed consent to treatment during acute informed consent to treatment during acute episodes of psychiatric illness.episodes of psychiatric illness.

http://pad.duhs.duke.edu/ obtained 8/13/07http://pad.duhs.duke.edu/ obtained 8/13/07

What does a (Psychiatric) Advance What does a (Psychiatric) Advance Directive direct?Directive direct?

I. Instructional DirectiveI. Instructional Directive Medications, specific treatment; ways to handle Medications, specific treatment; ways to handle

emergencies; restraint/seclusion, release information; emergencies; restraint/seclusion, release information; visit list; preferences, persons to take care of pets, visit list; preferences, persons to take care of pets, house, child care; medical carehouse, child care; medical care

e.g., living wille.g., living will Drawback: difficult to predict future situationsDrawback: difficult to predict future situations

II. Proxy DirectivesII. Proxy Directives ““health care power of attorney”health care power of attorney”

III. Both: Proxy + Instruction (2 in 1)III. Both: Proxy + Instruction (2 in 1)

What does The Joint What does The Joint Commission say about AD’s?Commission say about AD’s?

Definition:Definition: A document or documentation allowing a person to A document or documentation allowing a person to

give directions about future medical care or to give directions about future medical care or to designate another person(s) to make medical designate another person(s) to make medical decisions if the individual loses decision-making decisions if the individual loses decision-making capacity. capacity.

AdvanceAdvance directivedirectives may include living wills, durable s may include living wills, durable powers of attorney, do-not-resuscitate orders powers of attorney, do-not-resuscitate orders (DNRs), right to die, or similar documents listed in (DNRs), right to die, or similar documents listed in the Patient Self-Determination Act which express the the Patient Self-Determination Act which express the patient's preferences. patient's preferences.

The Joint Commission ManualThe Joint Commission Manual, July 1, 2009, July 1, 2009

What does The Joint What does The Joint Commission say about PAD’s?Commission say about PAD’s?

““The hospital determines if the patient has The hospital determines if the patient has a behavioral health advance directive and a behavioral health advance directive and informs the licensed independent informs the licensed independent practitioner and staff who participate in practitioner and staff who participate in the use of restraint and seclusion of the the use of restraint and seclusion of the directive and its content.”directive and its content.”

PC.03.03.09, Element of Performance 5, PC.03.03.09, Element of Performance 5, The Joint Commission ManualThe Joint Commission Manual, July 1, 2009, July 1, 2009

What medical ethical principles apply?What medical ethical principles apply?

I.I. Respect for AutonomyRespect for Autonomy

II.II. Non-maleficience Non-maleficience “Do No Harm”“Do No Harm”

III.III. Beneficience Beneficience ““Do Good” Do Good” Moral application: “Right to Treatment”Moral application: “Right to Treatment”

IV.IV. ConfidentialityConfidentiality

V.V. JusticeJustice Safety of OthersSafety of Others

What are some of the possible What are some of the possible ethical challenges?ethical challenges?

Person lacks capacity to prepare a PADPerson lacks capacity to prepare a PAD Lack of resourcesLack of resources Discrepancy between what PAD says & Discrepancy between what PAD says &

Standard of TreatmentStandard of Treatment MH Clinician doesn’t agree with PADMH Clinician doesn’t agree with PAD Assessment of person’s capacity to make Assessment of person’s capacity to make

informed consent decisionsinformed consent decisions Person with PAD admitted to hospital, lacks Person with PAD admitted to hospital, lacks

capacity & refuses their own PAD instructioncapacity & refuses their own PAD instruction Disagreement between patient & power of Disagreement between patient & power of

attorneyattorney Accessibility of PAD while also maintaining Accessibility of PAD while also maintaining

confidentialityconfidentiality

Case Practice: Case Practice: Develop a PAD for yourselfDevelop a PAD for yourself

… in case of acute psychoses… in case of acute psychoses

Do you think it appropriate to develop a PAD for Do you think it appropriate to develop a PAD for yourself?yourself?

What treatment would you agree to?What treatment would you agree to? What treatment, if any, would you refuse?What treatment, if any, would you refuse? Would you want an agent to make healthcare Would you want an agent to make healthcare

decisions? If so, who?decisions? If so, who? Preferred HospitalsPreferred Hospitals Hospitals to AvoidHospitals to Avoid Methods to de-escalate crisis to prevent restraintMethods to de-escalate crisis to prevent restraint Would you want a directive and/or agent that was Would you want a directive and/or agent that was

irrevocable by yourself during periods of incapacity?irrevocable by yourself during periods of incapacity? With whom would you share your PAD?With whom would you share your PAD?

How would clinicians write their How would clinicians write their own PAD’s?own PAD’s?

Amering M, et al, Soc Psychiatry Psychiatr Epidemiol, Amering M, et al, Soc Psychiatry Psychiatr Epidemiol, 19991999

Universität Wien, AustriaN=101 psych nurses & psychiatristsAsked to anonymously draft PAD’s for

themselves “in case of acute psychoses”

Who is likely to be interested in & complete a PAD?Who is likely to be interested in & complete a PAD?

Swanson J, Swartz M, et al; J Am Acad Psychiatry Law, Swanson J, Swartz M, et al; J Am Acad Psychiatry Law, 20062006

Survey, N=1,011 5 U.S. Cities4-13% had completed PAD4-13% had completed PAD66-77% interested in completing PAD if given 66-77% interested in completing PAD if given

assistanceassistanceHigher demand in participants who were ♀, Higher demand in participants who were ♀,

non-white; had h/o self-harm, arrest, ↓ non-white; had h/o self-harm, arrest, ↓ personal autonomy; felt pressured to take Rxpersonal autonomy; felt pressured to take Rx

Completion: ↑ insight, leverage from a payee, Completion: ↑ insight, leverage from a payee, external pressure to keep MH outpt appt’sexternal pressure to keep MH outpt appt’s

What do patients put in their PAD’s? What do patients put in their PAD’s? Srebnik DS, et al; Srebnik DS, et al; Psych ServPsych Serv 2005 2005

Srebnik D; Psych Serv, 2005N=106 MH Center outpt with 2

hospitalizations or ED visits within 2 yrsDx: Schizophrenia (44%); Bipolar (27%);

Major Depression (22%)


Listed preferred medsListed preferred meds Listed meds you would refuseListed meds you would refuse No one rejected all medicationsNo one rejected all medications Most preferredMost preferred

AntidepressantsAntidepressants 22ndnd Generation Antipsychotics Generation Antipsychotics Medications for Medical ConditionsMedications for Medical Conditions

Medications refusedMedications refused 11stst Generation Antipsychotics Generation Antipsychotics Mood stabilizersMood stabilizers AntidepressantsAntidepressants

Reasons for Refused MedicationsReasons for Refused Medications Side-effectsSide-effects Feeling “doped up & foggy”Feeling “doped up & foggy” Medications "don’t help”Medications "don’t help”

81%81% 64%64%

54%54% 53%53% 19%19%

35%35% 15%15% 15%15%

45%45% 32%32% 29%29%


Listed preferred medsListed preferred meds Listed meds you would refuseListed meds you would refuse

Preference between hospitals & alternativesPreference between hospitals & alternatives Chose hospital alternatives over hospitalChose hospital alternatives over hospital Preferred hospitalsPreferred hospitals

Preferred Hospital AlternativePreferred Hospital Alternative See prescriber to help with medicationsSee prescriber to help with medications Have someone I could callHave someone I could call Stay overnight in crisis bed or respite bedStay overnight in crisis bed or respite bed Have MH provider visit meHave MH provider visit me Have someone who would call meHave someone who would call me

Preferred HospitalsPreferred Hospitals Specific preferred hospital listedSpecific preferred hospital listed Specific hospital to avoidSpecific hospital to avoid

Reasons for hospitals to avoidReasons for hospitals to avoid Poor quality of carePoor quality of care Staff not treating clients with respectStaff not treating clients with respect Problems with patient being hurt or abusedProblems with patient being hurt or abused Inconvenient location for family and friends to visitInconvenient location for family and friends to visit

81%81% 64%64%

68%68% 25%25%

47%47% 42%42% 42%42% 39%39% 38%38%

80%80% 48%48%

29%29% 21%21% 16%16% 8%8%


Listed preferred medsListed preferred meds Listed meds you would refuseListed meds you would refuse Chose hospital alternatives over hospitalChose hospital alternatives over hospital Specify methods to de-escalate crisesSpecify methods to de-escalate crises Refuse ECTRefuse ECT Surrogate decision makerSurrogate decision maker Directive that was irrevocable during Directive that was irrevocable during

periods of incapacityperiods of incapacity How many of the PAD’s were rated as How many of the PAD’s were rated as

feasible, useful and consistent with feasible, useful and consistent with practice standards?practice standards?

81%81% 64%64% 68%68% 89%89% 72%72% 46%46% 57%57%

______

What is the clinical utility of what people put in their PAD’s?What is the clinical utility of what people put in their PAD’s?Srebnik DS, et al; Psych Serv 2005

InstructionInstruction Preferred MedicationsPreferred Medications Meds refusedMeds refused Willingness to try meds not listed in Willingness to try meds not listed in

directivedirective Preferred hospital alternativesPreferred hospital alternatives Hospital preferencesHospital preferences ECTECT Deescalation methodsDeescalation methods seclusion, restraint, sedating medsseclusion, restraint, sedating meds Person to care for dependentsPerson to care for dependents Person to care for petsPerson to care for pets Person to care for financesPerson to care for finances Designation of surrogate decision Designation of surrogate decision

makermaker

Consistent Feasible (%)Consistent Feasible (%) Useful Useful (%)(%)

with standard with standard

of care (%)of care (%)

9494 9999 9797

9696 9696 9696

5757 5959 5959

100100 100100 100100

100100 100100 100100

100100 100100 100100

100100 100100 100100

9999 100100 100100

9898 9999 100100

100100 100100 100100

100100 100100 100100

100100 100100 100100

9696 9696 9696

If a person comes with a PAD, what If a person comes with a PAD, what do I do next?do I do next?

If a person is determined to lack capacity to If a person is determined to lack capacity to make his/her own decisions about treatment, the make his/her own decisions about treatment, the health care provider must generally follow the health care provider must generally follow the treatment instructions that are written in your treatment instructions that are written in your PAD or given by your health care agent. Your PAD or given by your health care agent. Your health care provider may notify all other health care provider may notify all other providers of the instructions in your PAD. providers of the instructions in your PAD.

However, the health care provider is not required However, the health care provider is not required to follow your PAD instructions if they conflict to follow your PAD instructions if they conflict with accepted standards of medical care or are with accepted standards of medical care or are contrary to the patient’s needs during an contrary to the patient’s needs during an emergency. emergency.

Are there times when a PAD would Are there times when a PAD would not be followed?not be followed?

Yes, A PAD would not be followedYes, A PAD would not be followed If it conflicts with generally accepted community If it conflicts with generally accepted community

practice standards.practice standards. If the treatments requested are not feasible or If the treatments requested are not feasible or

available.available. If it conflicts with emergency treatment.If it conflicts with emergency treatment. If it conflicts with applicable law. If it conflicts with applicable law.

http://www.nrc-pad.org/content/view/32/25/ obtained on 10/12/2009

http://www.nrc-pad.org/content/view/32/25/

What happens if a part of my PAD What happens if a part of my PAD cannot be followed? cannot be followed?

If PAD instructions are not followed, the mental If PAD instructions are not followed, the mental health care provider must notify the patient or the health care provider must notify the patient or the person’s health care agent,person’s health care agent,

then document this notification in the medical record then document this notification in the medical record with the reason for not following your PAD.with the reason for not following your PAD.

If the conflict remains unresolved, the physician must If the conflict remains unresolved, the physician must make reasonable efforts to transfer the patient to make reasonable efforts to transfer the patient to another physician who is willing to comply with the another physician who is willing to comply with the PAD.PAD.



If a part of a PAD can't be followed, If a part of a PAD can't be followed, does that mean all of it should be does that mean all of it should be

ignored? ignored?

No. The PAD will be followed as closely as No. The PAD will be followed as closely as circumstances and the law allow. circumstances and the law allow.

Does the PAD apply if Does the PAD apply if the person is involuntarily committed to the person is involuntarily committed to

a hospital?a hospital?

Involuntary commitment to a treatment facility takes Involuntary commitment to a treatment facility takes priority over what your PAD says about priority over what your PAD says about hospitalization. hospitalization.

However, your preferences regarding medication and However, your preferences regarding medication and other aspects of treatment while hospitalized should other aspects of treatment while hospitalized should be followed even while you are involuntarily be followed even while you are involuntarily committed unless other provisions of law apply committed unless other provisions of law apply – e.g., preferences may be overridden in an emergency.



Can a person change his mind Can a person change his mind and either change or end his and either change or end his

PAD?PAD?

Yes Yes

& No& No

Can a person change his mind and Can a person change his mind and either change or end his PAD?either change or end his PAD?

YesYes … … if a person is capable of understanding the nature and if a person is capable of understanding the nature and consequences of his actions,consequences of his actions,

An advance directive may be revoked at any time by An advance directive may be revoked at any time by the declarant by a signed, dated writing;the declarant by a signed, dated writing;

OROR By physical cancellation or destruction of the By physical cancellation or destruction of the

advance directive by the declarant or another in his advance directive by the declarant or another in his presence and at his direction; presence and at his direction;

OROR By oral expression of intent to revoke.By oral expression of intent to revoke.


Ulysses ClauseUlysses Clause

Ulysses and the Sirens Ulysses and the Sirens by John William Waterhouseby John William Waterhouse

Can a PAD be revoked in Virginia?Can a PAD be revoked in Virginia? Ulysses ClauseUlysses Clause

NoNo if a person is incapable of understanding the nature if a person is incapable of understanding the nature and consequences of his actionsand consequences of his actions

Ulysses Clause is legally supported if the patient made it Ulysses Clause is legally supported if the patient made it

explicit in the AD to i) support the agent even over later explicit in the AD to i) support the agent even over later protestprotest

Ulysses Clause is legally supported if the patient made it Ulysses Clause is legally supported if the patient made it explicit in the AD to i) support the agent & ii) the AD explicit in the AD to i) support the agent & ii) the AD instructions (including for admission) even over later protest & instructions (including for admission) even over later protest & iii) have a doctor/LCP sign off on language specifically iii) have a doctor/LCP sign off on language specifically supporting the TREATMENT over later protest. supporting the TREATMENT over later protest.

If the patient is now incapacitated and didn’t choose and If the patient is now incapacitated and didn’t choose and agent, or removed a particular agent, but he has a signed agent, or removed a particular agent, but he has a signed Ulysses clause regarding specific treatment, then whoever Ulysses clause regarding specific treatment, then whoever the statutorily appointed agent is (by default) could authorize the statutorily appointed agent is (by default) could authorize the treatment over protest instead. the treatment over protest instead.


Generally, the answer is yes, you may Generally, the answer is yes, you may change or end your PAD at any time you change or end your PAD at any time you are considered “capable.” For more are considered “capable.” For more detailed information about how to revoke detailed information about how to revoke or modify your PAD, you should click on or modify your PAD, you should click on your state and refer to either the statute or your state and refer to either the statute or the frequently asked questions for that the frequently asked questions for that state. state.

Why don’t more consumers have PAD’s?Why don’t more consumers have PAD’s?

Families and consumer’s don’t know the Families and consumer’s don’t know the benefitsbenefits

Some hospitals don’t request and/or Some hospitals don’t request and/or implement PAD’simplement PAD’s

Only about ½ of states have PAD lawsOnly about ½ of states have PAD lawsPAD’s may be difficult to completePAD’s may be difficult to completeHelp to complete PAD’s is not always Help to complete PAD’s is not always

availableavailable

What about PAD’s for persons of other What about PAD’s for persons of other cultures? cultures? Van Dorn, et al; Psych Serv, Oct 2009

N=85 Latinos with mental illnessN=25 family membersN=30 their clinicians

92% wanted either a healthcare agent or 92% wanted either a healthcare agent or agent + advance instructionagent + advance instruction

Strong preference for prescriptive functionStrong preference for prescriptive function 89% thought bilingual document would improve 89% thought bilingual document would improve

communication between families & clinicianscommunication between families & clinicians 93% of clinicians thought PAD could convey 93% of clinicians thought PAD could convey

cultural preferencescultural preferences

What are clinician’s attitudes regarding the What are clinician’s attitudes regarding the barriers to implementations of PAD’s?barriers to implementations of PAD’s?

Van Dorn RA, Swartz MS, et al, Adm Policy Ment Health, 2006Van Dorn RA, Swartz MS, et al, Adm Policy Ment Health, 2006

N=591 psychiatrists, psychologists, SW’s Operational Barriers Operational Barriers > > Clinical BarriersClinical Barriers

work environmentwork environment inappropriate treatment requestsinappropriate treatment requestslack of communication among stafflack of communication among staff consumers’ desire to change their mindconsumers’ desire to change their mindlack of access to documentlack of access to document about treatment during about treatment during crisescrises

↑ ↑ Perceived Barriers: psychiatrists, legal Perceived Barriers: psychiatrists, legal defensiveness, public sector employment, belief that defensiveness, public sector employment, belief that risk of Tx refusals > benefit of PAD’srisk of Tx refusals > benefit of PAD’s

↓ ↓ Perceived Barriers: age, positive perception of Perceived Barriers: age, positive perception of PAD’sPAD’s

How do docs view PAD’s developed How do docs view PAD’s developed with facilitated sessions?with facilitated sessions?

and more…and more…

Swanson, Swartz, et al, AJP, 2006Swanson, Swartz, et al, AJP, 2006

““Psychiatrists rated the advance directives as highly Psychiatrists rated the advance directives as highly consistent with standards of community practice. consistent with standards of community practice.

““Most participants used the PAD to refuse some Most participants used the PAD to refuse some medications & to express preferences for admission medications & to express preferences for admission to specific hospitals and not others, although none to specific hospitals and not others, although none used an advance directive to refuse all treatmentused an advance directive to refuse all treatment

““A 1-month f/u, participants in facilitated sessions had a had a greater working alliancegreater working alliance with their clinicians with their clinicians

and and were were more likelymore likely than those in the control group than those in the control group to to

report receiving the MH services they believed report receiving the MH services they believed they neededthey needed.”.”

How can a person share a PAD? & How can a person share a PAD? & How can a clinician find a patient’s PAD?How can a clinician find a patient’s PAD?

Medical RecordMedical Record

Health System Electronic RegistryHealth System Electronic Registry Meaningful Use term to be associated with increased reimbursement by CMS if

AD registry kept (up for public comment)

VDH: Advance Health Care Directive RegistryVDH: Advance Health Care Directive Registry Early 2010 “go live”Early 2010 “go live” freefree

U.S. Living Will DirectoryU.S. Living Will Directory Free if there is a partnerFree if there is a partner $59 one time fee$59 one time fee

http://www.uslivingwillregistry.com/default.asphttp://www.uslivingwillregistry.com/default.asp

What is WRAPWhat is WRAP ((WWellnessellness RRecoveryecovery AActionction PPlanlan)?)?

http://mentalhealth.samhsa.gov/publications/allpubs/SMA-3720/crisis.asp obtained on 3/19/07

Developing a Wellness ToolboxDeveloping a Wellness Toolbox Daily Maintenance PlanDaily Maintenance Plan TriggersTriggers Early Warning SignsEarly Warning Signs When Things Are Breaking Down orWhen Things Are Breaking Down or Getting WorseGetting Worse

Crisis PlanningCrisis Planning Using Your Action PlansUsing Your Action Plans

http://mentalhealth.samhsa.gov/publications/allpubs/SMA-3720/crisis.asp

How can I make How can I make a WRAP also a PAD?a WRAP also a PAD?

A A writtenwritten advance directive shall be advance directive shall be signed by the declarant in the presence of signed by the declarant in the presence of twotwo subscribing witnesses subscribing witnesses

An An oraloral advance directive shall be made in advance directive shall be made in the presence of the the presence of the attending physicianattending physician and and twotwo witnesses. witnesses.

How consistent is Crisis Care with PAD’s?How consistent is Crisis Care with PAD’s?Srebnik DS, Russo J; Psych Serv, 2007

N=90 crisis events in which advance directive N=90 crisis events in which advance directive accessedaccessed

Average rate of care consistent Average rate of care consistent with PAD:with PAD:

How consistent is Crisis Care with PAD’s?How consistent is Crisis Care with PAD’s?Srebnik DS, Russo J; Psych Serv, 2007

Treatment InstructionsTreatment Instructions ECTECT 100%100% Rx agreed toRx agreed to 90%90% Rx refusedRx refused 89%89% Hospital AlternativesHospital Alternatives 81%81% Hospitals to AvoidHospitals to Avoid 68%68% Emergency Service: seclusion & restraintsEmergency Service: seclusion & restraints 50%50%

NonTreatment Personal Care InstructionsNonTreatment Personal Care Instructions Care for dependentsCare for dependents 100%100% People not authorized to visitPeople not authorized to visit 100%100% Surrogate Decision MakerSurrogate Decision Maker 60%60%

Why have a PAD?Why have a PAD?

Advantages:Advantages: Alternative to coercion, forced treatment or no Alternative to coercion, forced treatment or no

treatmenttreatment You pick the agent you want, instead of defaulting You pick the agent you want, instead of defaulting

to the statutory hierarchyto the statutory hierarchy Agent must take your preferences into considerationAgent must take your preferences into consideration Agent under an advance directive/POA trumps Agent under an advance directive/POA trumps

other LARs that may be appointed by a provider other LARs that may be appointed by a provider under the human rights regulationsunder the human rights regulations

Why have a PAD? Why have a PAD? Adapted from Srebnik & La Fond, 1999

More Advantages:More Advantages:↑ ↑ consumer empowerment, self-determination & consumer empowerment, self-determination &

choicechoice↑ ↑ functioningfunctioning↑ ↑ Communication among patients, family members Communication among patients, family members

and providersand providers↑ ↑ support for autonomy and recovery at the support for autonomy and recovery at the

organizational level organizational level ↑ ↑ relapse preventionrelapse prevention↓ ↓ use of hospital services and judicial proceedingsuse of hospital services and judicial proceedings

How can a PAD be best implemented?How can a PAD be best implemented?

Involve Service ProvidersInvolve Service ProvidersNot too vague but not overly restrictiveNot too vague but not overly restrictiveDesignate a Proxy/Surrogate Healthcare Designate a Proxy/Surrogate Healthcare

Decision MakerDecision MakerDisseminationDisseminationSupport system strategies to facilitate Support system strategies to facilitate

development & implementation of PAD’sdevelopment & implementation of PAD’s

How can a system support PAD’s?How can a system support PAD’s?

Swanson, Swartz, et al, AJP, 2006Swanson, Swartz, et al, AJP, 2006 N=469 pt’s with SMI randomly assigned

Facilitated PAD Session Control Group: written info, referral to resources in public MH system

Completion rate with PADControl Group 3 %Facilitated sessions 61 %

“Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the PAD to refuse some medications & to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment”

“A 1-month f/u, participants in facilitated sessions had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the MH services they believed they needed.

Take-Home Message: System-Level Policies and Programs “to embed facilitation of these instruments” may help us “achieve the promise”

What are some PAD Resources?What are some PAD Resources? The National Resource Center on Psychiatric The National Resource Center on Psychiatric

Advanced Directives:Advanced Directives: http://www.nrc-pad.org/index.phphttp://www.nrc-pad.org/index.php The Duke Program on Psychiatric Advanced The Duke Program on Psychiatric Advanced

Directives:Directives: http://pad.duhs.duke.edu/http://pad.duhs.duke.edu/ Bazelon Center:Bazelon Center:

http://www.bazelon.org/issues/advancedirectives/index.htmhttp://www.bazelon.org/issues/advancedirectives/index.htm

NAMI:NAMI: http://www.nami.org/Template.cfm?http://www.nami.org/Template.cfm?

Section=Issue_Spotlights&Template=/TaggedPage/Section=Issue_Spotlights&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=5&ContentID=8217TaggedPageDisplay.cfm&TPLID=5&ContentID=8217

WRAPWRAP http://www.mentalhealthrecovery.com/art_wrap.phphttp://www.mentalhealthrecovery.com/art_wrap.php

Provider Utilization of Advance Directives in the Psychiatric Setting: PAD's Yad M. Jabbarpour, MD, DFAPA Chief of Staff Catawba Hospital Clinical Assistant.

Documents

advance directives ad

pad instructiondisagreement

future medical care

instruction proxy directives

psychiatric setting

joint commission manual

future mental health

et seqpsychiatric ad