Writing Your Mental Health Advance Directive. A Practical Guide

Transcription

1 Writing Your Mental Health Advance Directive A Practical Guide

2 Disability Rights Washington 315 Fifth Avenue South, Suite 850 Seattle WA voice Made possible with a grant from King County Bar Association Elder Law Section Permission to reprint this publication is granted by the author, Disability Rights Washington, provided that the publication is distributed free of charge and with attribution. This booklet is available in alternative formats upon request. DRW is a member of the National Disability Rights Network A substantial portion of the DRW budget is federally funded.

3 Writing Your Mental Health Advance Directive A Practical Guide 3

4 Important Notice This guide is not intended to substitute for legal advice. The guide discusses some common problems and questions that people have about mental health advance directives. This includes some legal information, and is offered to help you understand mental health advance directives. However, if you have a legal question about mental health advance directives, please consult with a lawyer. 4

5 Table of Contents Section One: Is a Mental Health Advance Directive Right for You? 7 What is a mental health advance directive? 8 Are there other kinds of advance directives? 8 Who can write a mental health advance directive? 9 Why make an advance directive? 9 Some reasons you might not want to write an advance directive. 11 Who will look at my advance directive? 11 Do doctors and others have to follow an advance directive? 12 What are some things you can t do with an advance directive? 12 Is a mental health advance directive right for you? 13 Section Two: Do You Need an Agent? 14 What is the Agent s job? 15 Choose an agent who will do the job 17 Agents: some advantages and disadvantages 19 Information for your agent 20 Section Three: Writing Your Mental Health Advance Directive 22 Thinking it through 23 Involving others 23 Section Four: Mental Health Advance Directive Form with Explanatory Notes 29 Section Five: Putting Your Advance Directive to Work 61 Make sure people know you have an advance directive 62 Keep a list of those who have your advance directive 62 Review your advance directive regularly 63 Section Six: Appendix 65 A. Glossary, Abbreviations & Resources 66 B. Sample Wallet MHAD card 72 5

6 How to Use this Guide In 2002, Washington State passed a law about mental health advance directives. A mental health advance directive is a written document that says what mental health treatment you want and don t want for the future. It is used when your mental health symptoms make you unable to say what you want or you are not able to make decisions. The law includes a form to be used by people who want to make a mental health advance directive. You can fill out this form and give instructions about what medications and treatment you consent to, who you want to be involved in your treatment, and other matters. The purpose of this guide is to give you information you can use in filling out your own mental health advance directive. 1. Before you write your mental health advance directive, read Section One, Is a Mental Health Advance Directive is Right for You. 2. Read Section Two, Do You Need an Agent? 3. Next, read Section Three, Writing Your Mental Health Advance Directive. 4. In Section Four, refer to the Mental Health Advance Directive Form with Explanatory Notes while you fill out your blank form. 5. Finally, to understand how you can get the most out of your directive, read Section Five, Putting Your Mental Health Advance Directive to Work. There is also information in the Appendix that you may find useful. The Appendix has a glossary of terms used in an advance directive and some resources for more information. This guide will use the term advance directive to refer to a mental health advance directive. 6

7 Section One Is a Mental Health Advance Directive Right for You? 7

8 What is a Mental Health Advance Directive? A mental health advance directive is a written document that says what mental health treatment you want and don t want for the future. It is used when your mental health symptoms make you unable to say what you want or you are not able to make decisions. With a mental health advance directive, you can also give another person, an agent, the power to make your decisions for you when you aren t able to make them. Your mental health advance directive states your choices about how you want to be treated in a crisis. Are there other kinds of advance directives? You can make better decisions NOW, about what you want to happen later, when you are in crisis. Yes. For many years, people have used advance directives to say what treatment they want at the end of life. These directives can be used when a person is in a coma or otherwise not able to say what he or she wants to happen. This kind of advance directive is called a living will. You can talk to a lawyer to find out more about living wills. Also, there is information and a form that you can fill out to make a living will at the website for Northwest Justice Project (see Appendix). 8

9 Who Can Write a Mental Health Advance Directive? Any person who has the capacity to make his or her own decisions can write an advance directive. You can write an advance directive even if you are in jail or if you have been involuntarily committed as long as you have capacity. All adults are presumed under the law to have capacity. However, there are specific exceptions: 1. A guardian has been appointed to make your health care decisions; 2. You can t understand the possible risks and benefits of the treatment suggested for you by professionals. Why Make an Advance Directive? A mental health advance directive is a plan a plan that you make for how you want to be treated when you are in a crisis. You can plan who you want to help you through the crisis and what sort of treatment you want and don t want. Here are some of the benefits of planning ahead for a crisis, with an advance directive: 1. You can make better decisions NOW about what you want to happen later, when you are in crisis. When you are in crisis, it could be much harder to decide what 9

10 kind of treatment you want and to weigh all the risks and benefits. 2. Your choices will be considered. Although hospital staff are not required to do everything you ask for in your advance directive, they must know and consider what is in your advance directive. 3. You take responsibility for planning your own treatment. Making a plan and creating an advance directive is a way to be more in control of this part of your life. 4. You communicate your preferences and choices. You will help others understand how they can help you when you are in a crisis. 5. You can appoint an agent who will advocate for you. If you decide to appoint an agent, your agent can make decisions for you when you are unable to make them. 6. You can give alternatives to hospitalization. In your advance directive, you can state who will take care of you and what can be done instead of going to the hospital. 7. You can arrange for care of your money, home, pets, children, and other matters. 8. You can say what medication and treatment you want and don t want while you are in the hospital. You can say what works, doesn t work, and what harms you. (NOTE: Some of your choices 10

11 can still be overridden under some circumstances but your wishes must be considered.) 9. Your advance directive may shorten the time you are in crisis. By providing information about what works for you, you may be able to reduce the time you stay in the hospital and recover more quickly. You Might Not Want to Write an Advance Directive. If you aren t sure what you want, and there is no one you trust who you want to make your decisions for you, you may not have a good reason to write an advance directive. Don t write an advance directive just to please someone else. If you are pressured into writing an advance directive that you don t want revoke it. Who Will Look at My Advance Directive? When you are in a mental health crisis, other people will look at your advance directive to find out what decisions you made about your treatment. This includes your family and friends, if you have asked them to do things for you. It also includes mental health professionals, case managers, hospital staff, doctors, psychiatrists, and nurses. When you are 11

12 hospitalized, professionals must look at your advance directive and consider your choices when treating you. Do Doctors and Others have to Follow an Advance Directive? The law says that your mental health advance directive should be followed to the fullest extent possible. However, the hospital or your mental health provider can object to some parts of your directive at the time you are admitted for treatment. There are also some limitations on what you can do with your directive. What are Some Things You Can t Do with an Advance Directive? You cannot: Give another person the power to make you stay in a hospital or otherwise hold you against your will Force a hospital to admit you if they decide not to Force a doctor or other health care worker to respond in an emergency in a way that would endanger your life or health 12

13 Force a doctor or other health care worker to give you a treatment you ask for, if they decide it would violate their standard of care Force a doctor or other health care worker to give you a treatment that is not available or that is against the law Is a Mental Health Advance Directive Right for You? An advance directive is a way to plan for your treatment in a crisis. Not everyone wants or needs a mental health advance directive. You will need to decide for yourself if writing a mental health advance directive is a good idea for you. 13

14 Section Two Do You Need An Agent? 14

15 You may want to give another person the power to help make sure your advance directive is followed. That person is called an agent. In order to make someone your agent, you have to fill out Part VI of the Mental Health Advance Directive form. What is the Agent s Job? An agent is a person you choose to make mental health care decisions for you if you aren t able to make the decisions yourself. There are legal terms used when an agent is appointed. * You are called the principal when you appoint an agent to help carry out your mental health advance directive. * The person you appoint is called an agent. There are other terms for this person, too. An agent is also called attorney-in-fact or proxy. * The document where you appoint an agent is called a durable power of attorney. This can be part of your mental health advance directive. 15

16 Do You Have to Have an Agent? You do not have to choose an agent. When you fill out the form to make a mental health advance directive, you may decide that you want to choose an agent. If you want someone else to make mental health care decisions for you if you aren t able to make the decisions yourself, then you will want to choose an agent. The Agent s Role is to Advocate The agent s role is to be your advocate. The agent should advocate for what you want for mental health treatment. Things an Agent Can Do Your agent can do the following: 1. Give consent for mental health treatment you have included in your advance directive 2. Refuse mental health treatments you rejected in your advance directive 3. Look at your mental health records and decide to let other people look at them 4. Talk to your doctors and other mental health providers about your treatment 16

17 Things an Agent Cannot Do There are some powers that an agent does not have under Washington State law. An agent cannot: 1. Involuntarily commit you to a hospital. Involuntary commitment is a process that requires a court hearing. Your agent cannot physically restrain you or force you to go to a hospital or other place you do not want to go. 2. Consent to restraint. The agent cannot consent to restrain you except as requested it in your mental health advance directive. 3. Consent to anti-psychotic drugs. The agent cannot consent to anti-psychotic drugs except as requested in your mental health advance directive. 4. Consent to shock treatment. The agent cannot consent to shock treatments (such as E.C.T.) except as requested in your mental health advance directive. 5. Consent to lobotomy. The agent cannot consent to psychosurgery or other brain surgeries. 6. Advocate against what you ask for. The agent must advocate for what you say you want. You should be very clear about what power you are giving your agent before you sign your advance directive. 17

18 Choose an Agent Who Will Do the Job You want an agent who will do what you ask for in your advance directive. The agent must be able to get things done. This requires some specific skills and a special attitude. It may be a mistake to pick an agent who is the person you like or love the most. This person may not be willing to do what you ask for in your advance directive. Or, that person may not have good judgment in a crisis or may become too upset in a crisis to be effective as an advocate. You may have specific ideas about what you want to happen when you have a crisis. In that case, you will want an agent who will closely follow the directions you give in your mental health advance directive. However, even if you give careful directions, there are times when your agent may have to exercise good judgment on your behalf without knowing exactly what you would want. It is often very hard to find someone who will accept the responsibility to be an agent. Even so, you do not want to settle for an agent who you don t trust or won t get the job done. 18

19 Some People Can t Be Your Agent The law says you should not appoint as an agent any professional who gives you health or mental health services of any kind. This includes doctors, psychiatrists, nurses, psychologists, case managers, and others who work in the mental health system with you. You can listen to these people for advice on mental health decisions. However, none of them should be your agent. What if I Want to Remove My Agent? You, as principal, have the authority to revoke the agent s power. This is called revocation. Ordinarily, a principal can fire the agent at any time, for any reason. Sometimes a principal may want to limit his or her authority to fire the agent. The principal may worry about firing the agent when feeling paranoid or otherwise not thinking straight. The Mental Health Advance Directive form allows a principal to limit his or her own ability to revoke the directive or fire the agent. The principal can decide to fire the agent only when she or he has capacity. Agents: Some Advantages and Disadvantages By appointing an agent, you make it much more likely that people will pay attention to your mental 19

20 health advance directive. This is because the agent has the authority that you give him or her to advocate for what you say in your directive. An agent can talk to the professionals and make sure they are paying attention to what you have said you want. In this way, your agent may be able to get you good treatment that fits with your plan. Unfortunately, sometimes an agent doesn t do a good job of advocating. Agents sometimes don t do what the directive says, but instead do what they want. It can be very difficult to find someone who you will trust to do a good job, and will agree to do it. Information for your Agent Discuss the following duties of an effective agent with the person you have chosen or are considering choosing to be your agent. How to be an Effective Agent 1. Know your responsibilities and authority * Obtain information on how to be an agent (See resources: Northwest Justice Project, Washington Protection and Advocacy System) 2. Know what the principal wants * Talk to the principal about what s/he wants before you agree to be an agent. 20

21 3. Consult with the professionals * get medical records * ask questions * identify all the options 4. Consult with the principal * Consult the principal, even after the advance directive is in effect. However, during incapacity, some people prefer to have the agent make the decisions without consultation. Find out what the principal wants and follow his or her wishes. 5. Be an advocate * An advocate is a problem solver. An advocate is assertive, but not unreasonable. An advocate always follows the wishes of the principal. 21

22 Section Three Writing Your Advance Directive 22

23 Thinking It Through Writing an advance directive takes time and thought. Take time to think through what you want in your advance directive. You may want to involve other people in the process of writing your advance directive. Even if you decide to write your directive on your own, consider having someone read it over to make sure your wishes are clearly stated and you have included everything. An advance directive is a plan that gives direction to other people when you are in crisis. It makes sense to talk to those people now, before a crisis occurs, to make sure they understand what you want and agree to do what you ask. Your advance directive is more likely to be carried out if it is clearly written, your wishes are easy to understand, you have talked with every person you want involved and they have agreed to their part in the plan, and it follows the law. Involving Others Writing or reviewing your directive. For help with writing your advance directive, you need someone who listens well, and whose judgment you trust. Consider asking a trusted friend, family member, case manager, or other person to help you with your advance directive. People who know you well can help you weigh the pros and cons of decisions you want to make, read your directive for clarity 23

24 and provide support as you work your way through the process of writing your directive. Involve others who will support you in writing an advance directive that reflects your choices for treatment in a crisis. Although others will have their own opinions about your choices, they should be able to withhold their opinions, while assisting you in choosing treatment. They should offer information and opinion when you ask them. The people you involve should understand your right to make your treatment choices, even if they disagree with your choices. You are not required to hire a lawyer to assist you with writing your advance directive. In this guide, there is a form designed to be filled out by a person without the help of a lawyer. The form, when you have filled it out and signed it, will be your advance directive. On the other hand, you may also want to consider hiring a lawyer to help you. If you have complex legal issues or a great deal of property, it makes sense to have a lawyer help you. If you wish to consult a lawyer, look for one who knows about mental health advance directives. Finding the Right Person to Help You Write Your Advance Directive Look for these things when choosing people to help you with your advance directive. Does the person or persons helping you: 24

25 1. Listen to what you have to say about your treatment choices and ask questions to make sure they understand? 2. Ask questions that will help you clarify what you want to have happen? 3. Support your right to make a choice, even if they disagree? The person helping you should offer opinions in a respectful manner, when asked or when appropriate. 4. Make sure you understand what your advance directive says and what you are agreeing to? 5. Take the time needed to complete the advance directive? It may take several meetings to complete the job. People who help you should not try to rush you. The person who helps you should match your pace and take breaks when needed. 6. Help you identify others who could play a role in your advance directive? Anyone who has a role in carrying out your wishes should know what is expected of him or her and should agree to do it. 7. Help you gather information? In order to make choices about your treatment in a crisis, you will need information about the available medications and treatments. The person helping you can help you get accurate, current information, including information regarding the 25

26 risks and benefits of treatment you are considering. 8. Ask you questions about why you made a choice? They may ask: Why do you want/not want to take that medication? Why do you want/not want a visit from that person while you are in the hospital? This information can be very helpful to the people who are referring to the advance directive when you are in crisis. 9. Help you identify pros and cons of each important choice. 10. Help you know and understand your rights? The person helping you cannot give you legal advice, but he or she can help you find out more information. 11. Be careful about conflict of interest. A mental health provider cannot be an agent, and certain family members and providers cannot be witnesses to an advance directive. 26

27 Is the person who is helping you with your advance directive supporting you or making your decisions for you? If the person helping you answers your questions, suggests ideas, but lets you make the decisions, makes sure you understand everything in your advance directive, listens to what you want, then that person is supporting you. If the person helping you fills out the directive for you, argues with you about what you should put in your directive, includes things in the directive you don t understand, dominates your conversations about the directive, then that person is making your decisions for you. 27

28 Look for Advice When Making Your Decisions It can be useful to talk to people who know how the mental health system and mental health treatments work. A mental health case manager can help you figure out what services will be available to you before, during, and after hospitalization. The case manager may also be able to help you figure out how to get your advance directive in the hands of the people who need to see it. You can decide to have the advance directive placed in your medical record. Your physician or psychiatrist can help you make sure that the information you want in your advance directive regarding your health is accurate. Also, health care professionals can give you information that will help you decide which treatments to choose and which to avoid. Make Sure that the People You Name in Your Advance Directive Actually Agree to Do What You Write Down In your advance directive, you may want other people to do things for you. For example, you may ask a friend to take care of your pet. Or, you may ask the hospital to contact your community psychiatrist. There are many tasks that you may want others to do for you. Each person you ask to do something for you should have a copy of your advance directive and you should be sure that they agree to whatever you have asked of them. 28

29 Section Four A Mental Health Advance Directive Form (with notes explaining each section) 29

30 This section contains a copy of the Mental Health Advance Directive Form with added explanations. The information alongside the text explains the sections of the form. You may want to use this form with the shaded boxes as a guide while you fill out your Mental Health Advance Directive. As you are filling out your form, you can refer to the explanatory notes included in shaded boxes. As you are filling out your form, notice that some sections must be filled out in order to have a valid Mental Health Advance Directive. Other sections do not have to be filled out. The notes and the form tell you which sections must be filled out. 30

31 Note: This section explains the purpose of the MHAD and your rights. Ask questions if you don t understand what any of it means. Do not sign the MHAD until you are sure you know what this section says. MENTAL HEALTH ADVANCE DIRECTIVES FORM NOTICE TO PERSONS CREATING A MENTAL HEALTH ADVANCE DIRECTIVE: This is an important legal document. It creates an advance directive for mental health treatment. Before signing this document you should know these important facts: (1) This document is called an advance directive and allows you to make decisions in advance about your mental health treatment, including medications, short-term admission to inpatient treatment and electroconvulsive therapy. YOU DO NOT HAVE TO FILL OUT OR SIGN THIS FORM. IF YOU DO NOT SIGN THIS FORM, IT WILL NOT TAKE EFFECT. If you choose to complete and sign this document, you may still decide to leave some items blank. (2) You have the right to appoint a person as your agent to make treatment decisions for you. You must notify your agent that you have appointed him or her as an agent. The person you appoint has a duty to act consistently with your wishes made known by you. If your agent does not know what your wishes are, he or she has a duty to act in your best interest. Your agent has the right to withdraw from the appointment at any time. (3) The instructions you include with this advance directive and the authority you give your agent to act will only become effective under the conditions you select in this document. You may choose to limit this directive and your agent s authority to times when you are incapacitated or to times when you 33

32 are exhibiting symptoms or behavior that you specify. You may also make this directive effective immediately. No matter when you choose to make this directive effective, you treatment providers must still seek your informed consent at all times that you have capacity to give informed consent. (4) You have the right to revoke this document in writing at any time you have capacity. YOU MAY NOT REVOKE THIS DIRECTIVE WHEN YOU HAVE BEEN FOUND TO BE INCAPACITATED UNLESS YOU HAVE SPECIFICALLY STATED IN THIS DIRECTIVE THAT YOU WANT IT TO BE REVOCABLE WHEN YOU ARE INCAPACITATED. (5) This directive will stay in effect until you revoke it unless you specify an expiration date. If you specify an expiration date and you are incapacitated at the time it expires, it will remain in effect until you have capacity to make treatment decisions again unless you chose to be able to revoke it while you are incapacitated and you revoke the directive. (6) You cannot use your advance directive to consent to civil commitment. The procedures that apply to your advance directive are different than those provided for in the Involuntary Treatment Act. Involuntary treatment is a different process. (7) If there is anything in this directive that you do not understand, you should ask a lawyer to explain it to you. (8) You should be aware that there are some circumstances where your provider may not have to follow your directive. (9) You should discuss any treatment decisions in your directive with your provider. (10) You may ask the court to rule on the validity of your directive. PART I. STATEMENT OF INTENT TO CREATE A MENTAL HEALTH ADVANCE DIRECTIVE I, being a person with capacity, willfully and voluntarily execute this mental health advance directive so that my choices 33

33 regarding my mental health care will be carried out in circumstances when I am unable to express my instructions and preferences regarding my mental health care. Note: If you are given a guardian sometime in the future, that guardian must consider what you want before making decisions. A benefit of creating a MHAD is to give a guardian specific, written information about what you want. If a guardian is appointed by a court to make mental health decisions for me, I intend this document to take precedence over all other means of ascertaining my intent. Note: This first sentence give your agent the power to make decisions for you in any sections that you have not completed. The fact that I may have left blanks in this directive does not affect its validity in any way. I intend that all completed sections be followed. If I have not expressed a choice, my agent should make the decision that he or she determines is in my best interest. Note: Sometimes a person may make more than one directive. By stating that this directive takes precedence makes it clear that this is the directive that should be followed instead of previous directives (where they say different things). I intend this directive to take precedence over any other directives I have previously executed, to the extent that they are inconsistent with this document, or unless I expressly state otherwise in either document. 33

34 Notes: Usually, you can cancel your directive whenever you want. You can fire the agent you have appointed, or change your mind about some of the choices you have made. There are exceptions. You may not be able to change your MHAD if you lose the ability to make rational decisions. See Part IV of the MHAD Form for more explanation. I understand that I may revoke this directive in whole or in part if I am a person with capacity. I understand that I cannot revoke this directive if a court, two health care providers, or one mental health professional and one health care provider find that I am an incapacitated person, unless, when I executed this directive, I chose to be able to revoke this directive while incapacitated. I understand that, except as otherwise provided in law, revocation must be in writing. Notes: You should not be threatened or forced to have any treatment as a result of this MHAD. I understand that nothing in this directive, or in my refusal of treatment to which I consent in this directive, authorizes any health care provider, professional person, health care facility, or agent appointed in this directive to use or threaten to use abuse, neglect, financial exploitation, or abandonment to carry out my directive. 34

35 You may not get all of the treatments you ask for in this directive. Examples of limitations are provided in the following sections of the form. Also, you may be forced to go to the hospital and have some treatments you do not agree to if involuntarily committed. However, your statements in this MHAD about what treatment you want in the hospital must be considered before treatment is given. I understand that there are some circumstances where my provider may not have to follow my directive. Notes: You must complete the following section, Part II, or NONE of the MHAD will be followed by professionals. PART II. WHEN THIS DIRECTIVE IS EFFECTIVE YOU MUST COMPLETE THIS PART FOR YOUR DIRECTIVE TO BE VALID. 35

36 Note: There are three boxes. You must pick one. Which one? There are several things to think about in making this decision. It can make a big difference which box you select if you have chosen an agent. In the following pages, there are some things to consider in making your decision. I intend that this directive become effective (YOU MUST CHOOSE ONLY ONE): Immediately upon my signing of this directive. If I become incapacitated. When the following circumstances, symptoms, or behaviors occur: Note: If you check the first box, your MHAD is effective immediately. Advantages of choosing first box: No one will have any doubt about when it becomes effective. It is effective now. If you have appointed an agent, you have the immediate benefit of advocacy from an agent. Your agent may be able to help you while you are decompensating or having symptoms of mental illness, but not yet incapacitated. Disadvantages of choosing first box: Some professionals may not understand that even though there is an agent, the professional must still consult you in making decisions. You may not really need the help of an agent at this time, and professionals may wrongly think that they must go to the agent for all decisions. 36

37 Note: If you check the second box, your MHAD does not becomes effective until you are incapacitated. Advantages of choosing second box: It is clear that professionals don t have to consult with the agent until you are incapacitated. There can be a finding of incapacity by a court or by professionals, so it can be clear when the MHAD is in effect. Disadvantages of choosing second box: You don t get one of the benefits mentioned for the first box your agent can t get involved with your mental health decision making until you are clearly incapacitated. Most people could benefit from the help of an advocate before they have become incapacitated. It may delay getting help from the agent until a court of a mental health professional decides you are incapacitated. 37

38 Note: If you choose the third box, your MHAD becomes effective when certain things happen that you identify. Advantages of choosing the third box: You can tailor your MHAD to fit your particular symptoms. For example; you may want to have the MHAD become effective when you start acting in a particular way, such as the way you do when you are beginning to show symptoms. This could be when you start refusing your medications, or when you isolate yourself in your home. Disadvantages of choosing the third box: It may be hard to describe exactly what needs to happen to make the MHAD go into effect. For example, if you decide that the MHAD will go into effect when you isolate yourself in your home, not everyone will have the same idea about what isolating means. Note: You must complete this section, Part III, or none of your MHAD will be followed by professionals. PART III. DURATION OF THIS DIRECTIVE YOU MUST COMPLETE THIS PART FOR YOUR DIRECTIVE TO BE VALID. I want this directive to (YOU MUST CHOOSE ONLY ONE): 38 Remain valid and in effect for an indefinite period of time. Automatically expire years from the date it was created.

39 If you decide to check the first box, your MHAD will be valid until you die or you cancel (revoke) it. If you decide to do this, you don t have to worry about forgetting to renew your directive. The second box allows you to put an expiration date on the MHAD. You may want to have the directive expire. That way, if you forget about it and your situation changes in a way that you no longer agree with your directive, you don t have to worry; the directive is no longer valid. Note: You must complete this section, Part IV, or none of your MHAD will be followed by professionals. PART IV. WHEN I MAY REVOKE THIS DIRECTIVE YOU MUST COMPLETE THIS PART FOR THIS DIRECTIVE TO BE VALID. I intend that I be able to revoke this directive (YOU MUST CHOOSE ONLY ONE): Only when I have capacity. I understand that choosing this option means I may only revoke this directive if I have capacity. I further understand that if I choose this option and become incapacitated while this directive is in effect, I may receive treatment that I specify in this directive, even if I object at the time. Even if I am incapacitated. I understand that choosing this option means that I may revoke this directive even if I am incapacitated. I further understand that if I choose this option and revoke this directive while I am incapacitated I may not receive treatment that I specify in this directive, even if I want the treatment. 39

40 Notes: You must either check box 1 or box 2. If you do not check either box, your directive will not be valid. If you check box 1, you will not be able to cancel your directive if you are incapacitated. What does incapacitated mean? If you are incapacitated, you have been found to be unable to understand your choices and make decisions. The law says that a court or a group of professionals might find you to be incapacitated. If you check box 1, during the period that you are incapacitated you will not be able to cancel your directive or fire your agent. Advantages of box 1 option: It can protect you from making a bad decision when you are incapacitated. For example, a person might put in the directive that when she has certain symptoms, she gives consent to hospitalization. However, when the symptoms happen, the person might feel anxious about the decision and not want to agree to stay at the hospital. By checking box 1, the person has given consent to the hospital treatment and can be hospitalized even if the person doesn t want hospitalization at the time. However even in this case, checking box 1 does not mean that you can be forced to go to the hospital, and you cannot be forced to stay if you demand to leave. The only way to force you to stay when you want to leave is through involuntary commitment. 40

41 Notes: (continued) Disadvantages of box 1 option: If you check box 1, during the time you are incapacitated you won t be able to change your mind about your treatment. During that time, whatever you say in this directive will be your choice even if you say something different at the time. If you want to be able to change your directive or cancel the whole directive even when you are incapacitated you can do so by checking box 2. Choosing box 2 has this advantage: *If you check box 2, you can revoke the directive any time you want or make any change you want even if you are found to be incapacitated. For example, let s say in this directive that you consent to ECT (shock treatment), and then you become incapacitated. Even though you are incapacitated, you can change your mind and say no. If you have checked box 2, you won t have the ECT unless a court decides that you need it. Choosing box 2 has this disadvantage: * If you choose box 2 and you become incapacitated, you can make a bad decision that is different from what you would decide normally. For example, you might decide to revoke your MHAD while incapacitated, and lose the benefit of it. 41

42 Notes: Many people want to continue to have their regular community doctor involved in their treatment when they are in a crisis or at a hospital. If you go to a hospital, the hospital will not always know who your doctor is, what medication you are taking and what works for you and what doesn t, unless you tell them your doctor s name. Also, you may know a hospital doctor who you think does a good job. You can use this section to say that you would prefer to have a specific doctor involved in your treatment. You can also say that you don t want to be treated by a doctor who you don t like. The hospital does not have to do what you say, but they must at least consider your request. PART V. PREFERENCES AND INSTRUCTIONS ABOUT TREATMENT, FACILITIES, AND PHYSICIANS A. Preferences and Instructions About Physician(s) to be Involved in My Treatment I would like the physician(s) named below to be involved in my treatment decisions: Dr. Contact information: Dr. Contact information: 42 I do not wish to be treated by Dr.

43 B. Preferences and Instructions About Other Providers I am receiving other treatment or care from providers who I feel have an impact on my mental health care. I would like the following treatment provider(s) to be contacted when this directive is effective: Name Profession Contact information: Name Profession Contact information: Note: Often, medications will be changed while a person is in crisis. You may know some medications that work well for you and some that are not helpful. By filling out this section, you can give valuable information about what has worked in the past and not worked, as well as what allergies you have. TIP: You may want to have your doctor or psychiatrist review or help you complete this section. If your doctor agrees with what you put down here, it is more likely that the doctors in the hospital will take it seriously and do what you ask. C. Preferences and Instructions About Medications for Psychiatric Treatment (initial and complete all that apply) I consent, and authorize my agent (if appointed) to consent, to the following medications:

44 _ I do not consent, and I do not authorize my agent (if appointed) to consent, to the administration of the following medications: I am willing to take the medications excluded above if my only reason for excluding them is the side effects which include: and these side effects can be eliminated by dosage adjustment or other means. I am willing to try any other medication the hospital doctor recommends. I am willing to try any other medications my outpatient doctor recommends. I do not want to try any other medications. Medication Allergies I have allergies to, or severe side effects from, the following: Other Medication Preferences or Instructions: I have the following other preferences or instructions about medications:

45 Note: When you have a mental health crisis, you might end up in the hospital because no one knows of any safe alternative. Fill out this section if you have some ideas for how you can avoid going to the hospital when in a crisis. TIP: Be sure to talk to anyone you identify in this section so they understand that you want their help and they also understand what you want them to do. D. Preferences and Instructions About Hospitalization and Alternatives (initial all that apply and, if desired, rank 1 for first choice, 2 for second choice, and so on) 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 prefer to receive this care in programs/ facilities designed as alternatives to psychiatric hospitalizations. I would also like the interventions below to be tried before hospitalization is considered: Calling someone or having someone call me when needed: Name: Telephone: Staying overnight with someone: Name: Telephone: 45

46 Having a mental health service provider come to see me Going to a crisis triage center or emergency room Staying overnight at a crisis respite (temporary) bed Seeing a service provider for help with psychiatric medications Other, specify: Note: You may want to give another person an agent the right to consent to admitting you to a hospital. You may want to agree to future hospital treatment in case you have a mental health crisis. The next section allows you to do this, so that you do not have to go through the involuntary treatment process when you need hospital treatment, but don t have the capacity to consent. If you decide to fill out the section, you must pick one of the three choices. By choosing the first option, you are agreeing to let your agent consent to hospital treatment, with the agreement of a doctor. The hospital must also agree to admit you for treatment. With the second choice, you are agreeing that you can be hospitalized if you are behaving in a certain way. You can decide which symptoms you think are a sign that you need to be in the hospital. The hospital does not have to admit you when you show these symptoms. By choosing choice the third choice in this section, you have decided not to consent to hospital treatment in advance and you have also decided not to give your agent the power to consent for you. 46

47 Authority to Consent to Inpatient Treatment I consent, and authorize my agent (if appointed) to consent, to voluntary admission to inpatient mental health treatment for days (not to exceed 14 days) (Sign one): If deemed appropriate by my agent (if appointed) and treating physician. (Signature) or Under the following circumstances (specify symptoms, behaviors, or circumstances that indicate the need for hospitalization): (Signature) or I do not consent, or authorize my agent (if appointed) to consent, to inpatient treatment. (Signature) 47

48 Note: This section gives you a chance to say which hospital you prefer but in an emergency or if there is limited space available, you will not necessarily be taken to the hospital you choose. Hospital Preferences and Instructions If hospitalization is required, I prefer the following hospitals: I do not consent to be admitted to the following hospitals: E. Preferences and Instructions About Pre-emergency I would like the interventions below to be tried before use of seclusion or restraint is considered (initial all that apply): Talk me down one-on-one More medication Time out/privacy Show of authority/force Shift my attention to something else Set firm limits on my behavior Help me to discuss/vent feelings Decrease stimulation 48

49 Offer to have neutral person settle dispute Other, specify: Note: Restraint and seclusion can sometimes be avoided if the hospital staff know what works to calm a person down. The hospital is not required to follow your wishes in this or the next section on restraint and seclusion preferences. However, hospital staff are required to read your directive and consider your choices. F. Preferences and Instructions About Seclusion, Restraint, and Emergency Medications If it is determined that I am engaging in behavior that requires seclusion, physical restraint, and/or emergency use of medication, I prefer these interventions in the order I have chosen (choose 1 for first choice, 2 for second choice, and so on): Seclusion Seclusion and physical restraint (combined) Medication by injection Medication in pill or liquid form In the event that my attending physician decides to use medication in response to an emergency situation after due consideration of my preferences and instructions for emergency treatments stated above, I expect the choice of medication to reflect any preferences and instructions I have expressed in Part III C of this form. The preferences and instructions I express in this section regarding medication in emergency situations do not constitute consent to use of the medication for nonemergency treatment. 49

50 Note: How much do you know about electroconvulsive therapy, (ECT or shock treatment)? Before you agree to ECT or decide to refuse ECT you might want to find out about it. To find out more, talk to your physician or other professional. There is information available on the internet and elsewhere. There are disagreements about ECT, though. Discuss what you find out with others to make sure the information you get is accurate. G. Preferences and Instructions About Electroconvulsive Therapy (ECT or Shock Therapy) My wishes regarding electroconvulsive therapy are (sign one): I do not consent, nor authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy (Signature) I consent, and authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy (Signature) I consent, and authorize my agent (if appointed) to consent, to the administration of electroconvulsive therapy, but only under the following conditions: (Signature)

51 H. Preferences and Instructions About Who is Permitted to Visit If I have been admitted to a mental health treatment facility, the following people are not permitted to visit me there: Name: Name: Name: I understand that persons not listed above may be permitted to visit me. I. Additional Instructions About My Mental Health Care Other instructions about my mental health care: In case of emergency, please contact: Name: Address: Work telephone: Home telephone: Physician: Address: Telephone: The following may help me to avoid a hospitalization: I generally react to being hospitalized as follows: Staff of the hospital or crisis unit can help me by doing the following: 51

52 Note: Remember that if you refuse to consent to any treatment, you may still be treated if you are hospitalized under the Involuntary Treatment Act, or if there is an emergency. J. Refusal of Treatment I do not consent to any mental health treatment. Signature Note: Please see Section Two of this manual for more information about what an agent does. An agent can help make sure that your MHAD is followed. PART VI. DURABLE POWER OF ATTORNEY (APPOINTMENT OF MY AGENT) (Fill out this part only if you wish to appoint an agent or nominate a guardian.) I authorize an agent to make mental health treatment decisions on my behalf. The authority granted to my agent includes the right to consent, refuse consent, or withdraw consent to any mental health care, treatment, service, or procedure, consistent with any instructions and/or limitations I have set forth in this directive. I intend that those decisions should be made in accordance with my expressed wishes as set forth in this document. If I have not expressed a choice in this document and my agent does not otherwise know my wishes, I authorize my agent to make the decision that my agent determines is in my

53 best interest. This agency shall not be affected by my incapacity. Unless I state otherwise in this durable power of attorney, I may revoke it unless prohibited by other state law. A. Designation of an Agent I appoint the following person as my agent to make mental health treatment decisions for me as authorized in this document and request that this person be notified immediately when this directive becomes effective: Name: Address: Work telephone: Home telephone: Relationship: B. Designation of Alternate Agent If the person named above is unavailable, unable, or refuses to serve as my agent, or I revoke that person s authority to serve as my agent, I hereby appoint the following person as my alternate agent and request that this person be notified immediately when this directive becomes effective or when my original agent is no longer my agent: Name: Address: Work telephone: Home telephone: Relationship: 53

54 C. When My Spouse is My Agent (initial if desired) If my spouse is my agent, that person shall remain my agent even if we become legally separated or our marriage is dissolved, unless there is a court order to the contrary or I have remarried. D. Limitations on My Agent s Authority I do not grant my agent the authority to consent on my behalf to the following: E. Limitations on My Ability to Revoke this Durable Power of Attorney I choose to limit my ability to revoke this durable power of attorney as follows: Note: You can use the following section to say who you want to be your guardian, if a court ever decides to give you a guardian. By filling out this section you are not agreeing to have a guardian. You will have a guardian only if a court appoints one for you. If you fill out this section and a court decides you need a guardian, the court will appoint your choice unless there is good cause for not doing so. So, if you are worried that someone you don t like might be appointed to be your guardian, you can use this section to try to stop that. TIP: If you nominate someone to be a guardian, make sure they would be willing to do it if called upon. 54