Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 570
  • Home
  • Print this page
  • Email this page

 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 3  |  Page : 181-184

Choose your own adventure: Psychiatric advanced directives coming soon to an ED near you

1 Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
2 College of Osteopathic Medicine, William Carey University, Brooksville, FL, USA

Date of Submission18-Feb-2021
Date of Acceptance08-Mar-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Dr. Veronica Theresa Tucci
College of Osteopathic Medicine, William Carey University, Oak Hill Emergency Medicine Residency Program, 11375 Cortez Blvd, Brooksville 34613, FL
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_22_21

Rights and Permissions

Psychiatric advanced directives (PADs) are utilized by mental health patients to direct their psychiatric care including assigning surrogates for medical decision-making, listing preferred inpatient psychiatric/treating facilities, preferred medication regimens to stabilize acute psychiatric condition and to facilitate the patient's overall interaction with the mental health system. This article reviews the rationale behind PADs, how they can be utilized to reduce the need for de-escalation techniques, restraints and chemical anxiolysis by partnering with patients in the delivery of their care. This paper will also briefly address some of the practical limitations that Emergency Physicians and allied health care providers might face in attempting to honor PADs including the inability to admit to preferred facilities due to staff shortages or other issues associated with the global COVID-19 pandemic.
The following core competencies are addressed in this article: Patient care, Interpersonal and communication skills, and Systems-based practice.

Keywords: Mental health directive, mental health proxy, psychiatric advanced directive, psychiatric care instructions

How to cite this article:
Moukaddam N, Tucci VT. Choose your own adventure: Psychiatric advanced directives coming soon to an ED near you. Int J Acad Med 2021;7:181-4

How to cite this URL:
Moukaddam N, Tucci VT. Choose your own adventure: Psychiatric advanced directives coming soon to an ED near you. Int J Acad Med [serial online] 2021 [cited 2021 Dec 2];7:181-4. Available from: https://www.ijam-web.org/text.asp?2021/7/3/181/326815

It is 3 a.m. and Emergency Medical Services (EMS) comes rolling in with a 40-year-old woman under an emergency detention order (EDO), this may be labeled differently in different locations for suicidal ideation. Before you can even introduce yourself, the patient spouts “I have an executed advanced directive for my care and you must follow it, don't pull any shenanigans, I know my rights!” EMS produces the advanced directive document along with the patient's EDO. You and the rest of the Emergency Department (ED) team look around waiting for Ashton Kutcher to pop out of the woodwork and for you all to be starring in a reboot of the show, Punk'd. Your triage nurse even says to the patient, “honey, that's just crazy! We are in the middle of a global pandemic and you are going to tell us how to treat you and where to send you?” Before you have chance to answer, EMS produces said document along with the patient's EDO. Perusing what appears to be a legal document, a stream of profanity goes through your mind. We don't have time for that!! Is risk management even on call at this hour?

In December 2018, the New York Times published a personal biopic of a patient in Charlotte, North Carolina, describing the concept and use of the psychiatric advance directive (PAD)[1] PADs are not new, but are gaining more momentum as more patients are encouraged to participate in a supported decision-making model. Beginning in the 1960s, the concept of advance directives began to take hold, giving patients the right to control decisions about their medical care, usually in the situation of terminal or serious illness. Emergency personnel encounter and execute the terms of Advanced Medical Directives, Living Wills and Do Not Resuscitate orders routinely for patients with medical illnesses including end-stage cancer or chronic obstructive pulmonary disease, but the advance directive concept is still a relative novelty for patients with mental illness. The PAD is a tool increasingly utilized by mental health patients to provide direction for their psychiatric care, and in some cases, to assign a surrogate to facilitate interaction with the mental health system. Indeed, the Law Professors Blog indicated that Centers for Medicare and Medicaid Services (CMS) now requires health-care providers to inquire about PADs along with general advance directives for care.[2],[3]

In the simplest parlance, a PAD is a legal record of the patient's treatment preferences and/or may include names of his/her surrogate decision-makers should the patient be unable to make decisions. It is executed by a patient who lives with a mental illness but is competent at the time of its execution. PADs, also referred to as mental health directives, come in two main varieties: (1) Instructive-the patient lists specific instructions about their care should they experience a psychiatric crisis and (2) Proxy-the patient names a health care proxy/agent to make treatment decisions on their behalf when they are unable to do so. However, a surrogate agent cannot make the decisions of hospitalizations, and thus involuntary commitment rules will govern if a patient is not able to agree to treatment.

  The Legal Background of a Psychiatric Advance Directive Top

The Federal Patient Self-Determination Act, enacted by congress in 1990, applies to health-care institutions, not individual physicians. The act has included medical and psychiatric directives since its inception, but several states have enacted specific laws regarding PADs as well, to encourage use. As of this writing, at least 25 states currently have PAD laws (for an excellent state-by state summary visit the National Resource Center for PAD at https://www.nrc-pad.org/) that vary widely in terms of immunity and liability if a PAD is not followed. Patients living in states that do not have specific statutes on PADs are being encouraged by the National Alliance on Mental Illness and other groups to use the broader health-care directives and living wills to achieve their goals of managing their condition with minimum coercion. For mental illness, PADs are extremely important because patients often lose capacity when they become psychotic, severely, manic, catatonic, or altered for other reasons, such as drug use.

Advance directives, whether psychiatric or medical, are meant to anticipate a state during which a patient is not competent to make decisions about their care, and prewritten, notarized directive then take effect (this is referred to as the competence model). The competence model (backed by the United National Human Rights Convention) assumes that the patient can understand risks, benefits of available options, and the range of options available for their treatment at the time the document is executed. At the other end of the spectrum is supported decision-making, when a person with mental illness or disability makes their own decisions all the time, with the support of a trusted group of individuals. Briefly, while beyond the scope of the article, supported decision-making places patients with mental illness at risk of undue influence and is a heavily debated topic in medical ethics, but the other option, guardianship, is seen as too harsh, and stripping individuals of too many of their rights.[4]

The potential elements composing a PAD are state-dependent and summarized in [Table 1]. On the surface, PADs are the equivalent of making advance informed consent before decompensation of the mental illness in question, in anticipation of such decompensation. PADs allow patients to express preference for treatment measures, but it does not, in any way, equate refusal of care. A major difference between psychiatric and medical PAD is the degree of denial some patients have regarding their mental illness such as psychotic disorders, bipolar disorders in manic phases, or substance use disorders in a relapse state. Acute exacerbations of said mental health conditions simply exacerbate the denial or lack of insight. In the ED, a PAD should never take precedence over safety concerns, but the presence of a PAD should help improve the patient experience.
Table 1: Potential components of a psychiatric advance directive

Click here to view

  The Rationale for Psychiatric Advance Directives Top

Many patients report that mental health-related ED visits or inpatient experiences are traumatic;[5],[6] However, as patients gain more insight into their illness, and as they realize psychotropic medications can be helpful, their attitudes change as well, often towards more appreciation of the work staff does.[5] An improvement in therapeutic alliance helps decrease the sense of coercion; PAD use goes along this direction. Physical restraints, involuntary emergency IM medications, one-to-one sitters, seclusion, and locked units, are just some examples of measures that may be necessary but uncomfortable, embarrassing, and coercive for patients.

In general, patients feel accepting of safety measures if they perceive a benefit out of it, if they feel invested in the decision-making process, and if they understand the rationale behind it.[5],[7] So, when an ED team attempts de-escalation, negotiating with patients, explaining and offering choices, providing food/snacks/blanket or other commodities, the team is involving the patient in decision-making.

  Who Uses a Psychiatric Advance Directive? Top

Most mental illness is chronic and has not cure. Patients usually have repeated encounters with the system at multiple levels. Developing a PAD can help get faster, better or ore customized access to care, especially if the patient and treating team already know what works for the patient. Patients were more likely to complete a PAD if they've has past adverse experiences with the system, if they reached independent living status, when they had a history of problematic substance use, and the length of time they have been served by the home or assertive community outreach programs (e g., assertive community treatment team).[8] Having a PAD usually helps patients get their preferred medications and have a better alliance with their treatment teams, as well as feeling less coerced. Interestingly, in that study, patients were more likely to complete a PAD if they had no perceived unmet need for hospitalization when in crisis. In other words, when they felt the system worked for the, they wanted to make it better. This differs from our case, above, attempting to use the PAD potentially to control treatment.

  Can the Psychiatric Advance Directive Help Improve Emergency Care? Top

We recommend thinking of PAD-associated issues as linked to acute care (what happens in the ED) versus disposition (where does the patient go, and do they get their first choice).

Safety of the patient and the staff supersedes all measures and therefore, when patients exhibit behaviors which constitute harm to themselves or others, more restrictive measures may be needed, over-riding PAD. It is essential for the ED team to understand that a PAD does not eliminate behaviors associated with secondary gain, for example, medication seeking and does not replace sound medical decision-making. In the context of ED boarding, extended lengths of stay and abrupt decompensation, some elements of the PAD may not be defensible or practical. Patient requests for facilities that may not accept their insurance have no bed capacity, or do not provide the required treatment, may not hold. However, a PAD can be a roadmap to a less traumatic ED stay for both the ED physician and the patient. Common situations when a PAD can be extremely helpful include paradoxical reactions to pharmacological agents with, e g., the patient with intellectual disability who gets further disinhibition with lorazepam, the patient with psychosis who gets more agitated after ketamine, or the patient who becomes scared and defensive after being placed in seclusion.

Finally, accessing a patient's PAD can present its own challenges. In a study involving more than 400 patients, Walker et al. determined that finding a PAD (medical or psychiatric) in the chart was challenging, especially when patients' wishes would have changed,[9] so the document followed does not reflect the patient's most recent wishes. Clinicians may have obstacles to PAD access in the ED.

  Practical Considerations and Summary Top

It is crucial to know your state's laws specifically. The federal requirements for advance directives apply to institutions, not individuals, but the individual physician or provider should still make a reasonable effort to accommodate the patient's preferences. PADs cover only what is specifically written in the document. Hence, the ED physician should start with basics, namely, safety and stability and consider the elements of the PAD as guidance to a better treatment experience. In the highlighted case, self-harm and agitation will be the primary focus of the assessment, and the patient may not be able to alter or influence the treatment plan unless the elements are specifically covered in her directives. In the case of a chronic mental illness, the PAD may actually be helpful in getting the patient better faster and saving the ED physician much trial and error. The PAD limitations cover only what the document includes. For mental health patients, this includes the choice of medications, type of seclusion versus restraints, whether a male or female administers the medication, and refusing hospitalization, and other setting-specific choices. However, these are all superseded by involuntary commitment. Electro-convulsive therapy can also be covered by a PAD but are not trumped by involuntary commitment. Patients may select or discharge health-care providers and institutions alternatives to hospitalization, care and temporary custody of my children or pets, and an individual under guardianship cannot execute a PAD.

Given that the need for mental health resources has exploded during the worldwide pandemic, many outpatient and community programs have been stepping up and offering more clinic times, remote access to mental health providers to decompress the need for ED stabilization and management, especially for patients with known chronic mental illness. However, even EDs presently being overwhelmed with COVID-19 patients are still seeing psychiatric patients who have acutely decompensated and need emergent stabilization and management. The risk of potential spread in locked facilities has prompted mandatory COVID-19 testing in most jurisdictions. It has already delayed inpatient psychiatric placement for countless patients and will likely impact the interpretation of what is a reasonable effort when addressing the patient's PAD.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

There was no patient information used in the preparation of this manuscript.

  References Top

Belluck P. Having Their Say: More Psychiatric Patients Are Turning ToAdvance Directives. New York Times; December 8, 2018.  Back to cited text no. 1
Morgan R. Psychiatric Advanced Directives Gain Prominence, available at: https://lawprofessors.typepad.com/elder_law/2018/12/psychiatric-advance-directives-gain-prominence.html, [Last accessed on 2021 Mar 23].  Back to cited text no. 2
Advanced Directive for Behavioral Health. SAMSA, available at: https://www.samhsa.gov/section-223/governance-oversight/directives-behavioral-health, Updated 4/22/2020, [Last accessed on 2021 Mar 23].  Back to cited text no. 3
A Practical Guide to Psychiatric Advanced Directives. SAMSA. https://www.samhsa.gov/sites/default/files/a_practical_guide_to_psychiatric_advance_directives.pdf [Last accessed on 2021 Mar 23].  Back to cited text no. 4
Mielau J, Altunbay J, Lehmann A, Bermpohl F, Heinz A, Montag C. The influence of coercive measures on patients' stances towards psychiatric institutions. Int J Psychiatry Clin Pract 2018;22:115-22.  Back to cited text no. 5
O'Donoghue B, Roche E, Lyne J, Madigan K, Feeney L. Service users' perspective of their admission: A report of study findings. Irish J Psychol Med 2017;34:251-60.  Back to cited text no. 6
Verbeke E, Vanheule S, Cauwe J, Truijens F, Froyen B. Coercion and power in psychiatry: A qualitative study with ex-patients. Soc Sci Med 2019;223:89-96.  Back to cited text no. 7
Easter MM, Swanson JW, Robertson AG, Moser LL, Swartz MS. Facilitation of psychiatric advance directives by peers and clinicians on assertive community treatment teams. Psychiatr Serv 2017;68:717-23.  Back to cited text no. 8
Walker E, McMahan R, Barnes D, Katen M, Lamas D, Sudore R. Advance care planning documentation practices and accessibility in the electronic health record: Implications for patient safety. J Pain Symptom Manage 2018;55:256-64.  Back to cited text no. 9


  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
The Legal Backgr...
The Rationale fo...
Who Uses a Psych...
Can the Psychiat...
Practical Consid...
Article Tables

 Article Access Statistics
    PDF Downloaded13    
    Comments [Add]    

Recommend this journal