- Why Should Providers be Interested in Advance Directives?
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| The commitment process is almost as difficult for providers as it for people with a mental illness or family members of such
persons. Difficulties are far less personal for providers. They include the effort needed to initiate and process a commitment and the
potential of damaging a therapeutic relationship. |
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| When a consumer of mental health services has an advance directive, commitment procedures may not be necessary. The
implementation of an advance directive may make it unnecessary to initiate commitment procedures, since treatment is provided during a
crisis. The treatment is determined and planned by the consumer. |
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| Advance directives are an extension of a consumer's informed choice of treatment. They describe circumstances that the consumer
identifies as crisis points. They offer ways in which a consumer desires crises to be treated. They suggest treatment(s) which a
consumer believes have not been helpful in the past--or which have had adverse affects on the consumer. |
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| Treatment plans can include advance directives. They can serve as a crisis intervention plan. They can enable implementation of
crisis intervention early in a crisis--at a time when the consumer believes a crisis has started, rather than when the crisis requires
involuntary treatment. |
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- What is my Role as a Provider in Developing an Advance Directive?
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| Providers should inform consumers of their right to develop and sign an advance psychiatric directive. This can be done
following a crisis, when the consumer's illness has been stabilized and he or she is thinking about the treatment(s) provided during
the previous crisis. |
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| Informing consumers that advance directives can be developed and implemented can also be a part of the treatment planning
process. Creating a "crisis plan" can be a first step in developing an advance directive. Providing this information and creating the
plan is a part of "best practices" in establishing a process of informed choice. All alternatives should be explored--with a
discussion of what is possible and what is not, what has seemed to work for the consumer in the past and what has not, and the
consumer's preferences. |
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| A provider cannot be responsible for developing the advance directive. If requested, the provider (therapist or case manager)
can offer suggestions for the content of an advance directive. It is important for the provider to enable the consumer to develop his
or her own document. It is likely that an advance directive written by anyone other than the consumer will be rejected at the time of
a crisis. |
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- What if the Consumer is in Crisis but Rejects the Advance Directive?
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| Any advance directive can be rejected verbally or in writing anytime after it is signed. A consumer in crisis should be reminded
of the advance directive and the thinking that went into creating it. Alternatives to implementing the advance directive should be
offered. |
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| If the crisis persists and the consumer appears to be exhibiting behaviors that are possibly dangerous to self or others,
commitment proceedings should be instituted. The advance directive can be utilized in considering alternatives during the commitment
process. That is, even when the advance directive itself is rejected, the selected treatment(s) may be ordered as a part of the
involuntary treatment. |
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| If a person is hospitalized as a result of a probable cause commitment or a final commitment, the provider should inform the
treating physician of the content of the advance directive. Often, physicians have a range of treatment choices. The rational
preferences of the consumer may guide the physician in selecting treatment(s) the consumer believes will be most helpful. This will
assist the physician and will usually result in improved cooperation from the consumer--and more rapid recovery. |
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- What Other Factors Should be Considered in Recommending an Advance Directive?
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| The existence and implementation of an advance directive can prevent the need for filing an application for commitment,
conducting an evaluation, and providing the testimony at a hearing. There is a cost savings for the provider, law enforcement charged
with the responsibility of detaining an individual for an evaluation, and for the Court. |
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| The advance directive also enables treatment at the time of a crisis to begin earlier in the crisis, typically resulting in more
rapid stabilization of the symptoms of a mental illness. Other intensive services--sometimes not wanted by the client or not resulting
in crisis resolution--can be replaced by the treatment(s) described in the advance directive. There is a cost savings as well as more
involvement in treatment and treatment planning. Treatments which have a negative effect on the consumer are not applied, also saving
time and costs in crisis resolution. |
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| Most providers believe in consumer empowerment. Consideration, writing, and signing an advance psychiatric directive is
implementation of that empowerment. The consumer becomes a true participant in the treatment; a true director of his or her treatment.
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- PROVIDER CONSIDERATIONS:
- Advance directives can describe treatment(s) a consumer wants in the event of a crisis
- An Advance directive can be rejected, even verbally, at any time. Rejection of the advance directive must be respected
to the same extent that the provider must respect the directive itself
- Involuntary treatment may be requested -- or imposed in an emergency -- even when there is an advance directive. Efforts
to require involuntary treatment should be made only when the treatment(s) preferred in the advance directives are not achieving
stabilization of the symptoms or when the consumer is deemed to be dangerous to self or others
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