Duke Health Referring Physicians


Psychiatric Advance Directives Spell Out Care During Crises

Patients with mental illness can maintain control of treatment with roadmap for their care

Person getting counseling

When people with serious psychiatric conditions have mental health crises, they can become unable to communicate their needs or advocate for themselves. Their incapacity can lead to treatment that they would not choose—such as involuntary commitment—that can be counterproductive to their condition.

But patients can maintain some control of their treatment with the new option of drawing up a psychiatric advance directive (PAD), a legal document that sets out a person’s preferences for their treatment during a mental health crisis.

This idea is an adaptation of the advance medical directives that specify end-of-life care. “A person can make a set of instructions about what they would like to have happen during a crisis when they can’t speak for themselves,” says Duke psychiatrist Marvin Swartz, MD, a leader in the movement toward PADs. “They could have instructions such as: ‘If I need to be admitted, please admit to this hospital, don’t admit me to this hospital. I would like these medications, but don’t give me these medications. These are the people I’d ask you to contact or speak with.’ There can be a whole series of instructions as well as being able to appoint a proxy called a health care agent—someone whom they trust to speak for them.”

Swartz’ research has shown that just having a PAD can actually reduce the number of mental health crises a patient has. “Patients feel closer to their providers because they feel they were given the opportunity to voice their concerns and their treatment experiences,” Swartz says.

Patients draft their PADs when they are well enough to carefully consider their preferences for future mental health treatment. One large difference between PADs and medical directives is that patients can change their medical directives if they change their minds about what kind of life support they might desire. But, in most states where PADs have been enacted, patients can’t change them during a mental health crisis.

The concept is spreading throughout the country, and North Carolina has been a leader. The state sponsors a repository, the North Carolina Advance Health Care Directive Registry,  where health care providers can access them 24/7. “We encourage people to place them in their providers’ medical records and particularly in a hospital where they might go,” Swartz says. Their inclusion in EHRs has also helped make the documents widely accessible.

Swartz and his Duke colleagues Jeffrey Swanson, PhD, and Eric B. Elbogen, PhD, created the National Resource Center on Psychiatric Advance Directives to lower the barriers to creating PADs and promote their use. Like advance medical directives, PADs can be complex to create, so the resource center is training volunteers to help potential users create them and developing a web-based tool to facilitate their completion.

More information is available at the center’s website.