Quick Safety 53: Improving care with psychiatric advance directives

Issue:

Patient-centered quality care provided to individuals suffering from mental illness — especially when in crisis — can be significantly enhanced by completing and using a psychiatric advance directive (PAD), also called a mental health advance directive. A PAD specifies an individual’s preferences regarding future mental health treatment.

The PAD evolved from the medical advance directive, though PADs have yet to garner the same attention as other medical advance directives, such as palliative care or end-of-life care advance directives.¹ PADs offer patients an opportunity to address issues specific to mental health care and treatment, such as medication preferences for psychiatric treatment, inpatient treatment considerations, conditions for seclusion and restraints, and selection of psychiatrists or treatment facilities.^2,3 Any adult who is competent to make medical decisions can create a PAD. If a patient does not have a PAD, the process for creating a PAD can be initiated during hospitalization. A PAD takes effect in a crisis situation if a patient is deemed incompetent to make decisions, and it offers information to treatment providers about the patient’s treatment preferences and contacts.⁴

While state laws regarding PADs vary, a PAD generally has two parts:

• An advance instruction that can detail treatment and medication preferences, as well as provide consent for admission or contact.
• A health care power of attorney, allowing the person to appoint a trusted individual to make decisions during times when their decision-making capacity is impaired.
• A patient who wishes to develop a PAD may use either or both parts, subject to state requirements.

Benefits of PADs

PADs have the potential to benefit many patients living with mental illness, especially a population of adults living with serious mental illness.⁵ The most recent data available from the National

Institute of Mental Health (NIMH) found that nearly 11.2 million adults aged 18 or older in the United States – or 4.5% – had serious mental illness in 2017.⁵ 

Early advocacy for PADs speculated that PADs could support patient autonomy, enhance patient-provider relationships and communication, and promote treatment adherence.⁶ Research over the last 15 years has corroborated these advantages.6 Studies have shown that compared to patients without PADs, patients who utilized PADs were more likely to report feelings of autonomy, self-determination, and empowerment; less likely to require coercive interventions during mental health crises; and, among those who specified particular medications in their PADs, more likely to adhere to prescribed medications following discharge.⁶

Despite likely benefits from PADs and evidence of interest among patients educated about PADs, the rate of PAD completion remains low. Studies have found a PAD usage rate of 4% to 13% among outpatients receiving public-sector mental health treatment.^7,8 Yet studies also suggest that about two-thirds of patients with serious mental illness would complete a PAD if provided with the option and the necessary assistance.⁷

The Substance Abuse and Mental Health Services Administration (SAMHSA) has prioritized expanding the use of PADs and promotes PADs as a tool to advance self-directed care in psychiatric treatment, achieve progress toward mental health parity, and support crisis planning and the rights of patients living with mental illness.⁴

Barriers to using PADs

Low utilization of PADs may be attributable to both operational features of work environments and clinical barriers.⁹ Operational barriers may include a lack of access to the document, insufficient clinician education about legal implications of PADs, or a lack of communication between staff.^9,10 Access to existing PADs can pose a challenge for facilities if a system is not in place to ensure a PAD is accessible in urgent or emergency situations.⁶ SAMHSA recognizes that the lack of a single place to store PADs can create issues around retrieval and communication to treatment providers regarding a PAD’s existence.⁴ SAMHSA also suggests “the mental health and emergency response workforce may benefit from trainings on the utility and practical application of PADs, along with the principles of shared decision-making, supported decision-making and decision support aids.”⁴

Clinical barriers may include provider concerns about inappropriate treatment requests or patients’ desires to alter their treatment preferences during crises.⁹ Much of the concern about the risk of limiting available treatment options or adversely impacting care remains largely theoretical and has not been substantiated by evidence.⁶ PADs that designate a psychiatric health care proxy may help alleviate concerns that providers often raise about limited treatment options due to the specificity of PADs.⁶ Additionally, most PAD statutes allow for health care providers to petition a court to override a patient’s PAD if it runs contrary to the patient’s best interest.⁶

Despite some of the challenges and concerns around PADs, a 2017 study found clinicians can play a crucial role in increasing the prevalence of PADs, which could help improve the implementation of PADs in mental health care.¹¹

Regulatory framework and Joint Commission requirements

The Centers for Medicare and Medicaid Services’ (CMS) Patient Rights Condition of Participation for hospitals requires that a “patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives.”¹² In addition, the National Resource Center on Psychiatric Advance Directives (www.nrc-pad.org) offers summaries of federal and state policies, state-specific PAD forms, educational videos, and other resources.

The Joint Commission’s Behavioral Health Care Accreditation program includes a Care, Treatment, and Services standard — CTS.01.04.01 — that requires accredited behavioral health care organizations that serve adults with serious mental illness to document whether the adult has a PAD and share resources on formulating PADs when requested. It also specifies that if an adult has an advance directive, clinical staff who are involved in the care, treatment, or services provided to the adult must be aware that the PAD exists and know how to access it. Additional Joint Commission standards in other accreditation programs broadly support the use of advance directives, including the following:

Include information on any advance directives in clinical records (Record of Care, Treatment, and Services standard RC.02.01.01 for the hospital [including psychiatric hospitals], critical access hospital, behavioral health care, home care, and office-based surgery programs).

• Maintain and communicate to patients written policies on honoring advance directives (Rights and Responsibilities of the Individual standard RI.01.05.01 for the hospital [including psychiatric hospitals] and behavioral health care programs).
• Offer resources on completing advance directives (RI.01.05.01 for the hospital [including psychiatric hospitals], critical access hospital, behavioral health care, and home care programs).
• Include advance directive information in hospital transfer and discharge materials (Provision of Care, Treatment, and Services standard PC.04.02.01 and RC.02.04.01 for the critical access hospital program and Joint Commission-accredited hospitals [including psychiatric hospitals] that use accreditation for deemed status purposes).
• Communicate and use any advance directives in care coordination (PC.01.03.01 and PC.02.02.01 for the home care and nursing care center programs).
• Respect the rights of patients or surrogate decision-makers to refuse care in accordance with advance directives (RI.01.02.01 for the nursing care center program). 

Safety actions to consider:

PADs can serve as beneficial tools for patients with mental illness, allowing them to exercise more autonomy over their mental health treatment and provide a forum for collaborative, coordinated treatment planning. Health care organizations that provide psychiatric care and services can improve the safety and quality of care provided to their patients by:

• Providing education for patients and providers. Both patients and providers demonstrate gaps in knowledge in developing and using PADs. Improved awareness efforts would likely increase PAD usage and engage patients and providers in greater shared decision-marking.^7,10 Additionally, patients and providers should be aware of state-specific laws regarding PADs.

• Using the Facilitated PAD (FPAD) developed by researchers at Duke University Medical Center. The FPAD is a 2-hour structured interview that guides patients through the process of completing a PAD. A randomized controlled trial of over 450 patients found that 61% of patients who underwent the FPAD process completed a PAD, compared to 3% of patients who were simply provided resources to complete a PAD on their own.⁸

Providers pressed for time or resources may consider delegating PAD discussions to other members of the health care team to increase efficiency.¹¹ A second study on the FPAD found that patients with serious mental illness showed similar rates of PAD completion and document quality when guided by either clinicians or peer support specialists.

• Partner with community organizations to increase awareness of PADs. Several community organizations have collaborated with health care facilities and public agencies to increase PAD awareness.⁴ Facilities limited in their ability to provide PAD services may refer patients to other organizations’ resources.

Resources:

1. Sofer D. Psychiatric Advance Directives. The American Journal of Nursing, 2019;119(5):16-17.
2. National Alliance on Mental Illness (NAMI). Psychiatric Advance Directives (PAD) webpage
3. >Bazelon Center for Mental Health Law. Psychiatric Advance Directives Template.
4. >U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services. A Practical Guide to Psychiatric Advance Directives. Rockville, MD: SAMHSA; 2019.
5. National Institute of Mental Health. Mental Illness webpage, updated February 2019. 
6. Murray H & Wortzel HS. Psychiatric Advance Directives: Origins, Benefits, Challenges, and Future Directions. Journal of Psychiatric Practice, 2019;25(4):303-07.
7. Swanson JW, et al. Psychiatric Advance Directives Among Public Mental Health Consumers in Five U.S. Cities: Prevalence, Demand, and Correlates. Journal of the American Academy of Psychiatry and the Law, 2006;34:43-57.
8. Swanson JW, et al. Facilitated Psychiatric Advance Directives: A Randomized Trial of an Intervention to Foster Advance Treatment Planning Among Persons with Severe Mental Illness. The Journal of American Psychiatry, 2006;163(11):1943-51. 
9. Van Dorn RA, et al. Clinicians’ Attitudes Regarding Barriers to the Implementation of Psychiatric Advance Directives. Administration and Policy in Mental Health, 2006;33(4):449-60. 
10. Elbogen EB, et al. Clinical Decision Making and Views About Psychiatric Advance Directives. Psychiatry Services, 2006;57(3):350-55. 
11. Easter MM, et al. Facilitation of Psychiatric Advance Directives by Peers and Clinicians on Assertive Community Treatment Teams. Psychiatry Online, 2017;68(7):717-23.
12. Condition of Participation: Patient’s Rights, 42 C.F.R. §482.13, 2019. 

Note: This is not an all-inclusive list.

Additional resources:

1. National Resource Center on Psychiatric Advance Directives (NRC-PAD): A partnership between patients, providers, and organizations interested in PADs. Educational resources include toolkits with step-by-step instructions on PAD completion, live and archived webcasts, and links to all U.S. statutes on medical and psychiatric advance directives. 
2. National Alliance on Mental Illness: Navigating a mental health crisis: A NAMI resource guide for those experiencing a mental health emergency. Developed to support people experiencing mental health crises, along with their friends and families, this guide outlines what can contribute to a crisis, warning signs that a crisis is emerging, strategies to help de-escalate a crisis, and resources that may be available for those affected. The guide also includes information about advocating for a person in crisis along with a sample crisis plan. Includes a crisis planning form and a relapse plan form. 
3. Mental Health America: The website provides a brief overview of the steps to creating a psychiatric advance directive. 
4. American Psychiatric Association: Psychiatric Advance Directives: Planning for Mental Health Care. The American Psychiatric Association describes the purpose and process of creating a PAD.