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What is an Advance Directive?
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An advance directive is a written and
signed document which expresses acts
or actions you want taken in the event
you become incapacitated or are unable
to express your wishes or take action
on your own. An advance directive may
describe under what conditions someone
may assume control over your financial
affairs--and who should have that power.
It may provide information on who may
assume control over decisions about life
support--or simply describe what you want
done in the event life supports are
believed to be necessary.
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An advance directive can also be written to describe what you want done in the
event you are in a crisis as a result of a mental illness. This document must be
written during a time when your illness is not severe enough to impair your
judgment. It can be a powerful tool to prevent involuntary treatment or
commitment. Even if it is determined that commitment is necessary, an advance
directive can be used to identify treatment(s) that are and/or are not desired
by you.
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You may write an advance directive to specify your choices for treatment or you
may designate a power of attorney for medical decisions. An advance directive
may also be written with both provisions: treatment choices and a proxy for
medical decisions. Neither the desired treatments nor the medical power of
attorney would be utilized unless you were experiencing impaired decisional
capacity. You would describe the circumstances under which you could be judged
to have impaired decisional capacity.
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In short, an advance psychiatric directive helps you maintain choice and control
in your treatment. It decreases the possibility of involuntary treatment and all
that goes with it: being taken into custody, facing a commitment hearing, being
taken to a hospital against your will. It increases the possibility that your
treatment will be continuous, providing recognition that the illness may need to
be treated more intensively on occasion--but limiting the intensity, type, and
place of the treatment to what you recognize works best for you.
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What Should be Included in an Advance Directive?
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If there is someone you trust--a family
member, another consumer, a mental health professional, a friend, anyone--you
may want to write a document that includes reference to that person as having
medical power of attorney for you in choosing treatment for you in the event of
a psychiatric crisis. Prior to writing such a document you would want to:
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Discuss your treatment choices with the individual;
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Obtain the person's agreement that he or she will comply with/request your treatment choices;
You should assure yourself that the person you have chosen agrees with your
treatment choices and will advocate for the use of those treatments. You and
that individual should also agree that your medical power of attorney will
advocate against treatments you do not want--treatments that have had bad
effects on you or that, from your experience, delay the resolution of the
crisis.
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You and the person you designate as your medical power of attorney should
delineate in writing the conditions under which the power can be used. You
should carefully describe behaviors, fears, concerns, or actions which would be
evident in your life for the medical power of attorney to be exercised.
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You may also write an advance directive which describes the treatment you desire:
- Medicine(s) which you want prescribed or do not want prescribed;
- Place(s) you want treatment to be provided or place(s) you do not want to go for treatment;
- Preferences about electroconvulsive treatment;
- Your wishes about seclusion and/or restraint;
- Instructions about care of your children, if you have any;
- Preferences for aspects of medical care (life sustaining treatments, "do not resuscitate orders," organ donation, etc.);
- Preferences for length-of-stay and alternative places to stay during a crisis (for example: a short hospital stay followed by a longer residential treatment program, if available...or a stay in crisis residential unit, if available, followed by short-term supports in your residence);
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Your advance directive could be anecdotal, describing your past experiences
during crisis: what seemed to work best, and what treatment(s) seemed to set off
negative reactions, worsening the crisis.
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An advance directive can include both a medical power of attorney
provision and a list of preferred treatments and/or treatments you do not want
utilized.
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What are the Procedures for Making an Advance Directive Official?
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Consider under what circumstances you would want special treatment(s) to
be instituted. These circumstances may include thoughts, actions, behaviors, or
fears. During these circumstances, you may want a different treatment than you
typically receive: more intense, in a different setting, with people other those
with whom you normally associate.
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Describe, in as much detail as possible, what those circumstances are. Any
person--especially the person you may designate as having your medical power of
attorney--should be able to recognize these circumstances and differentiate
between them and other life events. If you do not choose to have a medical power
of attorney, people who are close to you--family, friends, a case manager, a
therapist--should be able to recognize the circumstances you describe as
requiring special or different treatment.
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Write about those circumstances from your experience. Use as much information as
possible. Information you provide should be comfortable to you. A story format
is okay.
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Describe in detail what you want to happen when these circumstances occur. You
may be more comfortable in a crisis residential unit than in a hospital--or in
one hospital than another one. You may want to see and talk with some people,
and not with others. You may have had an adverse reaction to one kind of
medication during a previous crisis, but have benefited from another. Describe
that. Again, a story format is okay.
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What you write about the treatment you want in a crisis is important. It should
have much detail as you feel comfortable providing. Anyone reading your
description of desired treatment should be able to understand what you want and
where you want it provided.
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Do not be unreasonable in describing the treatment you desire. That is, do not
request services or treatment that do not exist. It may be important to discuss
treatment possibilities with family, friends, and mental health professionals.
Other consumers can provide considerable information and insight into treatment
possibilities. Some of your friends and peers, in particular, can describe to
you how you responded in previous crises. Use that information in creating your
plan for services during the circumstances you have previously described.
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Carefully write the information you decided to include:
- Circumstances under which the advance directive is to take effect;
- Types of desired treatment under these circumstances;
- Where you want treatment to be provided;
- Who should be notified about the commencement of the treatment you are going to receive;
- Who, if anyone, is authorized to act on your behalf in making medical decisions (your medical power of attorney);
Sign the document and have another individual witness your signature. If you
choose a medical power of attorney, that person should not sign the document as
your witness. You may want several people--family, friends, mental health
professionals treating you--to also sign the document indicating that they agree
with the procedures you have outlined. This is not necessary, but may be an
additional assurance of compliance with your wishes.
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Share your document with people you care about and people you believe should know it exists.
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Ask your case manager about signing up with MedAlert or similar service. It may
be possible for you to have your advance directive registered so that any
medical professional may access the information on the basis of identification
you carry.
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You should share the document with your case manager, therapist, psychiatrist
and other physicians treating you, and any family members or friends you want to
provide information to. The document should be in your treatment record.
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Is it Possible for me to Change my Mind About my Advance Directive?
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You may vacate an advance directive at
any time after you write and sign it. That is, any time after you write, sign,
and share an advance directive, you may decide this is not the treatment you
desire. At that time, you would inform persons providing treatment that you no
longer desire that treatment. This may be a verbal expression: it does not have
to be written.
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For example, you may have written that you wanted to be admitted to a crisis
residential unit under certain circumstances. At some point after your
admission, you may decide that you no longer want that treatment. You may state
your wishes. You must be discharged, even if treatment personnel or others
believe it is not in your best interests. You may decide to keep the written
advance directive for other circumstances later--or you may request that it be
destroyed or replaced with another advance directive.
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Can Treatment Still be Provided Against my Will?
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An advance directive is an excellent instrument to describe preferred treatments
and circumstances that must exist for those treatments to be used. Treating
personnel, family members, friends, and the Court must usually abide by those wishes.
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There may be situations in which your advance psychiatric directive--or your
decision to void the advance directive--may be replaced with an order for
involuntary treatment. You have several rights to protect you in these
situations.
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If dangerousness is involved--if you are a danger to yourself or to others
because of your mental illness--an application for commitment may be filed. The
results of a hearing may be to require involuntary treatment. But the advance
directive may play an important role in the hearing:
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Be certain the attorney representing you in the hearing has a copy of your advance
directive (request a continuance if it is not immediately available);
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Request that family, friends, or mental health professionals who have helped
you develop your advance directive (if you have had assistance) be allowed to
testify as to using the advance directive instead of involuntary treatment;
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If the Court decides involuntary treatment is necessary, request that the
treatment and location of treatment be utilized as outlined in your advance
directive.
An attorney can help you in making these requests. Even if involuntary treatment
is ordered, your advance directive can be helpful in describing situations or
treatments which you believe have not been helpful in the past. You, your
medical power of attorney (if you have provided that designation), and others
can advocate against treatment(s) which have not been helpful or have produced
effects you do not desire.
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Involuntary treatment of another type may also be provided. If you are committed
for probable cause or final commitment, you may refuse medications or other
treatment. If it is determined that a specific treatment is necessary for your
safety or the safety of others in the hospital, two physicians may determine
that emergency treatment is necessary. You have rights in these situations and
should request that an advocate represent you when these decisions are
considered.
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Here, too, your advance directive will help. If you have described medications
or other treatments which have not been helpful (or that you believe have been
harmful) in the past, treating personnel and your advocate will consider this
information. Consideration will also be given to information you have provided
to indicate treatment(s) that have been helpful in the past.
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IT IS IMPORTANT TO REMEMBER:
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An advance directive
specifies treatments and
places for treatment and/
or who can make treatment
decisions for you.
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An Advance directive can
be canceled by you at any
time; it can be canceled
in writing or through
expressing your wishes
verbally.
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A due process hearing and/
or decision for emergency
treatment can be used to
override your advance
directive.
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Your advance directive
will help your attorney
and/or your advocate and
treating personnel make
decisions about commitment
or emergency treatment.
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