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Psychiatric advance directives

What is a psychiatric advance directive?

A psychiatric advance directive is a document that you fill out while you are well that tells others what kind of treatments you prefer should mental health services be needed In the psychiatric advance directive document, you can list things such as what hospital you would want go to in case you got sick again, what types of medicine you like, and which ones you do not like You can also list things such as which doctors you want to be treated by, which family members or friends you want to have notified in the event that you are hospitalized You can write anything you want about what you do and do not want in the document.

Will a psychiatric advance directive be legally binding?

In Pennsylvania, and in most states, psychiatric advance directives are not legally binding However, they can be very helpful in making it known what treatments you want, and do not want, should you be hospitalized again.

Why should I have a psychiatric advance directive?

A psychiatric advance directive can give you control over what treatment you receive should you become too sick to make the best decisions With this document, you can make sure your family and mental health workers know what type of treatments you do and do not want Making it known what treatments you do and do not want can help to stop disagreements with mental health workers, may prevent forced treatment, and can shorten your hospital stay

How do I make a psychiatric advance directive?

Below is an example of what a psychiatric advance directive might look like Remember, you might want to have more information in yours than what is listed below in the example You could use something like this, or you can create your own.


Advance Directive of ____________________________for Mental Health Care

 (your name) Decisionmaking

STATEMENT OF MY DESIRES, INSTRUCTIONS, SPECIAL PROVISIONS AND LIMITATIONS REGARDING MY MENTAL HEALTH TREATMENT AND CARE

In this part, you state how you wish to be treated, such as which hospital you wish to be taken to or which medications you prefer, if you become incapacitated or unable to express your own wishes If you want a paragraph to apply, put your initials after the paragraph letter If you do not want the paragraph to apply to you, leave the line blank.

1.   My Choice of Treatment Facility and Preferences for Alternatives to Hospitalization If 24-Hour Care Is Deemed Medically Necessary for My Safety and Well-Being

A. _____ In the event my psychiatric condition is serious enough to require 24-hour care and I have no physical conditions that require immediate access to emergency medical care, I would prefer to receive this care in programs/facilities designed as alternatives to psychiatric hospitalizations.

A1. _____ I would prefer to receive 24-hour
care at the following programs/facilities:

 ____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

B._____ In the event I am to be admitted to a hospital for 24-hour care, I would prefer to receive care at the following hospitals:

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

C. _____ I do not wish to be committed to the following hospitals or programs/facilities for psychiatric care for the reasons I have listed:

Facility's Name:__________________________________________________________

Reason: _________________________________________________________________

Facility's Name: _________________________________________________________

Reason:_________________________________________________________________

Facility's Name: _________________________________________________________

Reason:_________________________________________________________________

 

 

2. My Preferences Regarding Emergency Interventions

If, during an admission or commitment to a mental health treatment facility, it is determined that I am engaging in behavior that requires an emergency intervention (e.g., seclusion and/or physical restraint and/or medication), my wishes regarding which form of emergency interventions should be made are as follows. I prefer these interventions in the following order:

 

Fill in numbers, giving 1 to your first choice, 2 to your second, and so on until each has a number. If an intervention you prefer is not listed, write it in after "other" and give it a number as well.

 

_____ seclusion

_____ physical restraints

_____ seclusion and physical restraints (combined)

_____ medication by injection

_____ medication in pill form

_____ liquid medication

_____ other:________________________

 ________________________

________________________

Reasons for my preferences:

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

 

Initial this paragraph if you agree; leave blank if you do not agree.

 

__________ In the event that my attending physician decides to use medication for rapid tranquilization in response to an emergency situation after due consideration of my preferences for emergency treatments stated above, I expect the choice of medication to reflect any preferences I have expressed in this section and in Section 3. The preferences I express in this section regarding medication in emergency situations do not constitute consent to use of the medication for non-emergency treatment.

 

3. My Preferences About the Physicians Who Will Treat Me if I Am Hospitalized.

Put your initials after the letter and complete if you wish either or both paragraphs to apply.

 


A. ______My choice of treating physician is:

Dr.______________________________

Phone number_____________________

OR

Dr.______________________________

Phone number ____________________

OR

Dr. _____________________________

Phone number ___________________


B. ______I do not wish to be treated by the following, for the reasons stated:

Dr. ______________________________________

Reason: __________________________________

_________________________________________

_________________________________________

Dr. ______________________________________

Reason:___________________________________

_________________________________________

_________________________________________

 

4. My Preferences Regarding Medications for Psychiatric Treatment

In this section, you may choose any of the paragraphs A-G that you wish to apply. Be sure to initial those you choose.

 

If it is determined that I am not legally competent to consent to or to refuse medications relating to my mental health treatment, my wishes are as follows:

 

 A. _____ I consent to the medications agreed to by my agent, after consultation with my treating physician and any other individuals my agent may think appropriate, with the reservations, if any, described in (D) below.

 

 B._____ I consent to and authorize my agent to consent to the administration of:

Medication Name

 

__________________

__________________

__________________

__________________

Not to exceed the

following dosage:

_________________

_________________

_________________

_________________

OR

In such dosage(s) as determined by

 

Dr.___________________________

Dr.___________________________

Dr.___________________________

Dr.___________________________

 

 

C._____ I consent to the medications deemed appropriate by Dr._________________________,

whose address and phone number are: ______________________________________________________________________________________________________________________________________________

 

D. _____ I specifically do not consent and I do not authorize my agent to consent to the administration of the following medications or their respective brand-name, trade-name or generic equivalents:

Name of Drug

Reason for Refusal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E._____ I am willing to take the medications excluded in (D) above if my only reason for excluding them is their side effects and the dosage can be adjusted to eliminate those side effects.

 

F. ____ I am concerned about the side effects of medications and do not consent or authorize my agent to consent to any medication that has any of the side effects I have checked below at a 1% or greater level of incidence (check all that apply).

_____ Tardive dyskinesia

_____ Tremors

_____ Loss of sensation

_____ Nausea/vomiting

_____ Motor restlessness

_____ Neuroleptic Malignant Syndrome

_____ Muscle/skeletal rigidity

 

 

 

G._____ I have the following other preferences about psychiatric medications:

____________________________________________________________________

____________________________________________________________________ ___________________________________________________________________

 

5. My Preferences Regarding Electroconvulsive Therapy (ECT or Shock Treatment)

If it is determined that I am not legally capable of consenting to or refusing electroconvulsive therapy, my wishes regarding electroconvulsive therapy are as follows:

Initial A or B; if you check B, you must also initial B1, B2 or B3:

 

 A._____ I do not consent to administration of electroconvulsive therapy.

 

 B._____ I consent, and authorize my agent to consent, to the administration of electroconvulsive therapy, but only:

B1. _____with the number of treatments that the attending psychiatrist deems appropriate;

OR

B2. _____ with the number of treatments that Dr. __________________________ deems appropriate. Phone number and address of doctor:

_____________________________
__________________________________________________________
OR
B3. _____for no more than the following number of ECT treatments: __________

C. _____ Other instructions and wishes regarding the administration of electroconvulsive therapy:

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

 

6. Consent for Experimental Studies or Drug Trials

Initial one of the following paragraphs.

 

 
A. _____ I do not wish to participate in experimental drug studies or drug trials.

 


B. _____ I hereby consent to my participation in experimental drug studies or drug trials.

 

 
C. _____ I authorize my agent to consent to my participation in experimental drug studies if my agent, after consultation with my treating physician and any other individuals my agent may think appropriate, determines that the potential benefits to me outweigh the possible risks of my participation and that other, non-experimental interventions are not likely to provide effective treatment.

SIGNATURE PAGE

By signing here I indicate that I understand the purpose and effect of this document.

_______________________________________________________________________
Your Signature

__________________________________
Date

 

The directive above was signed and declared by the "Declarant," ________________(Your name)_______________ , to be his/her mental health care advance directive, in our presence who, at his/her request, have signed names below as witness. We declare that, at the time of the execution of this instrument, the Declarant, according to our best knowledge and belief, was of sound mind and under no constraint or undue influence. We further declare that none of us is: 1) a physician; 2) the Declarant's physician or an employee of the Declarant's physician; 3) an employee or a patient of any residential health care facility in which the Declarant is a patient; 4) designated as agent or alternate under this document; or 5) a beneficiary or creditor of the estate of the Declarant.

Dated at _____________________________________________ (county, state),

this ___________________ day of ___________________, 19____.

WITNESS SIGNATURES:

Witness 1:

____________________________________
Signature of Witness 1

____________________________________
Name of Witness 1 (printed)

____________________________________
Home address of Witness 1

____________________________________
City, State, Zip Code of Witness 1

Witness 2:

____________________________________
Signature of Witness 2

____________________________________
Name of Witness 2 (printed)

____________________________________
Home address of Witness 2

____________________________________
City, State, Zip Code of Witness 2

 

(for use by the notary):

STATE OF _________________, County of ___________________________

Subscribed and sworn to or affirmed before me by the Declarant,

_______________________________________________,

and (names of witnesses)

________________________________________________ and

________________________________________________,

witnesses, as the voluntary act and deed of the Declarant, this ___________ day of ___________, _____________.

My commission expires:

__________________________________________________________

__________________________________________________________
Notary Public

 


 

RECORD OF PSYCHIATRIC ADVANCE DIRECTIVE

Keep this form and give a copy to your agent, if you have appointed one.

___________________________________
My name

___________________________________
My health care agent's name

___________________________________
My address

___________________________________

_________________________________
My health care agent's address

_________________________________

_____________________________________ My date of birth

_________________________________
My health care agent's telephone number(s)

I have given copies of this form to:

_____________________________________
Name

____________________________________
Address or phone

_____________________________________
Name

____________________________________
Address or phone

_____________________________________
Name

____________________________________
Address or phone

_____________________________________
Name

____________________________________
Address or phone

_____________________________________
Name

____________________________________
Address or phone

_____________________________________
Name

____________________________________
Address or phone

_____________________________________
Name

____________________________________
Address or phone

 


 

STATEMENT OF MY PREFERENCES REGARDING NOTIFICATION OF OTHERS, VISITORS, AND CUSTODY OF MY CHILD(REN)

 

1. Who Should Be Notified Immediately of My Admission to a Psychiatric Facility

If I am incompetent, I desire staff to notify the following individuals immediately that I have been admitted to a psychiatric facility:

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

It is also my desire that this person be
permitted to visit me: Yes_____ No _____

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

It is also my desire that this person be
permitted to visit me: Yes_____ No _____

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

It is also my desire that this person be
permitted to visit me: Yes_____ No _____

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

It is also my desire that this person be
permitted to visit me: Yes_____ No _____

2. Who Should Be Prohibited from Visiting Me

I do not wish the following people to visit me while I am receiving care in a psychiatric facility:

Name

Relationship

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

 

 

       

 

3. My Preferences for Care & Temporary Custody of My Children

In the event that I am unable to care for my child(ren), I want the following person as my first choice to care for and have temporary custody of my child(ren):

Name: ______________________________Relationship:_______________

Address:________________________________________________________

City, State, Zip:__________________________________________________

Phone number: (Day) __________________ (Evening)__________________

In the event that the person named above is unable to care for and have temporary custody of my child(ren), I desire one of the following people to serve in that capacity

My Second Choice

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________

My Third Choice

Name:______________________________

Relationship: ________________________

Address: ____________________________

____________________________________

____________________________________

Phone (Day):_________________________

Phone (Eve.): ________________________