Download The New Jersey Advance Directives for Mental Health Care Act

Advance Directives
For Behavioral
Health Care
Materials used with Permission From the
National Resource Center on Psychiatric Advance Directives
NJ Division of Mental Health Services
UMDNJ-University Behavioral HealthCare
June 2007
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What are Psychiatric Advance
Directives (PAD’s)?

Legal documents that allow persons when
of “sound mind”
 To
refuse or give consent to future psychiatric
treatment.
 May authorize another person to make future
decisions about mental health care on behalf
of the mentally ill person, if he/she becomes
incapacitated.
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What does it do?





Helps consumers control treatment decisions
Helps families assist their loved ones in crisis
States preferences
Provides care guidelines
Supports all concerned parties
 Consumer
 Family
and other supporters
 Treatment providers
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Goal of an Advance Directive
To ensure patients are treated according
with their wishes.
 To encourage a more informed and open
dialogue between patients and their
treatment providers.

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Why Are PAD’s Important



Patent Self-Determination Act (PSDA) of 1990
requires hospitals and clinics to assist in the use
of Medical Advance Directives (‘living wills”).
In states with PAD’s laws, the PSDA requires
hospital and clinics to assist in their use.
New Jersey has a PAD law called the “New
Jersey Advance Directives for Mental Health
Care Act”.
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Why Are PAD’s Important
Allows families to speak directly with
providers during crisis.
 Allows families help make decisions during
crisis.
 Still supports consumer autonomy and
empowerment in mental health care.
 May reduce involuntary treatment.
 May improve continuity of care.

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The Information in PAD’s
Crisis symptoms
 Medication choice
 Hospital choice
 Emergency contacts
 Relapse and protective factors
 Instructions to staff
 Other instructions

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The Potential of PAD’s

PAD’s can
 Empower
the consumer
 Enhance communications
 Facilitate timely interventions
 Reduce adversarial litigation
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Two Parts to PAD’s

Instructional Directive:
 Similar
to a living will.
 Documents wishes, consent or refusal of future care.

Health Care Power of Attorney:
 Appoints
another person to make decisions during
crisis.
 May be designed with limited or broad powers.


Not required to have either.
Can choose to have both.
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Instructional Directives

Usually permits individual to plan for,
consent to, or refuse:
 Hospital
admission
 Medications
 Electroconvulsive treatment
 Other treatments for mental illness.

Takes effect in the event individual loses
ability to make decisions (is “incapable”).
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Instructional Directives:
May include additional information
Who to contact in case of a crisis.
 What may cause a mental health crisis.
 What may help a person to avoid
hospitalization.
 How the person generally reacts to
hospitalization.
 Other instructions.

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Making an Instructional Directive
Any adult “of sound mind” can make.
 Must be in writing.
 Signed in presence of one witness:

 Not
a relative.
 Not person’s doctor, mental health provider or
other staff.
 Not staff of a health care facility which the
client is a patient.
 Present to doctor and other mental treatment
providers.
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What should the doctors or staff do
with the Instructional Directive?
Must make a part of medical record.
 Must act in accordance with instructional
directive when patient is determined to be
“lack of decision making capacity”.
 May notify all other providers to follow
instructional directive.

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What does “Lacking in Decision
Making Capacity” Mean?

…in the opinion of two responsible mental
healthcare professionals the person
currently lacks sufficient understanding or
capacity to make and communicate mental
health treatment decisions.”
14
Must clinicians always honor the
instructions?

Clinicians may disregard instructions:
 Not
consistent with “generally accepted
community practice standards.”
 When treatment requests are not feasible or
unavailable.
 When treatment requests would interfere with
treating an emergency.
 Instructions may be over-ridden by involuntary
inpatient commitment.
 Conflicts with other law.
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If one instruction is not followed,
what happens to other instructions?
Generally:
 If one part of the instructions cannot be
carried out, the remaining instructions
must still be followed.
 If not followed, reason for not following
instruction must be communicated and
documented.
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Can the instructions be changed?

Generally: These documents can be
changed or revoked at any time by
notifying the physician or treatment team,
revising the document, or by destroying
the document.
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Health Care Power of Attorney
(HCPA)

Allows a person to appoint someone to
make treatment decisions when it has
been determined that the consumer lacks
decision making capacity. Can be
combined with instructional directive.
 But

may be two different forms.
Any capable adult may execute.
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Health Care Power of Attorney
Someone the consumer trust…
 Someone to negotiate consumer care…
 When consumer cannot.

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Who can serve as the health care
power of attorney?
Any competent adult 18 or older.
 Person usually cannot be providing health
care to consumer.
 Consumer can name several people to
serve if one unavailable.

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When does health care power of
attorney take effect?
When consumer is found to be lacking in
decision making capacity and continues
during period of incapacity.
 Determined by two mental health
professionals.
 Must document decision of lacking
decision making capacity.

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What powers does the health care
power of attorney have?

Can make whatever treatment decisions
the consumer could usually make;
 Unless
the consumer limits the authority of
the health care power of attorney.
 Consumer can instruct health care power of
attorney on decision about medications, ECT,
hospital admission, other.
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What should the health care power
of attorney do?
Must make decisions consistent with any
statements in instructional directive, if one
exists.
 Can discuss and review treatment
information.
 Can usually consent/refuse admission to
hospital.
 Can usually consent/refuse medication
and ETC.

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Examples of Use of PADs
Advance informed consent to future
hospitalization in the event of
incapacitating mental health crisis.
 Request or refuse future treatment with
medications or other interventions.
 Authorize health care power of attorney to
make future decisions about psychiatric
treatment in patient’s best interest.

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Why don’t more consumers have
PADs?
Families have not realized they should
encourage them!
 Fewer than half of states have these laws.
 Some states allow pads under medical
advance directives.
 Advance directives may be difficult to
complete for some consumers.
 Help in completing advance directives may
not always be available.

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Where can I get more information
about PADs?




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New Jersey Division of Mental Health Services
www.state.nj.us/humanservices/dmhs/index.html
National Resource Center on Psychiatric Advance Directives
www.nrc-pad.org
Bazelon Center
www.bazelon.org
NAMI
www.nami.org
National Mental Health Association
www.nmha.org
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