My Life, My Treatment, My Plan - PowerPoint PPT Presentation


Title: My Life, My Treatment, My Plan


1
My Life, My Treatment, My Plan
  • Client Empowerment Using Psychiatric Advance
    Directives
  • SCDMH Peer Support Continuing EducationJune 28,
    2013Katherine M. Roberts, MPH
  • Director, SCDMH Office of Client Affairs

2
  • David likes the beach, his dog, to paint, read,
    fish and hang out with buddies. He also has
    schizophrenia. He knows he needs to take
    medication to help control the symptoms of his
    illness. Complying with this is hard for him, the
    meds make him feel zoned out and sleepy, give him
    dry mouth and as he puts it makes it hard to
    focus. Consequently, David sometimes
    accidentally on purpose forgets to take them.
  • His symptom's start to come back and because of
    the symptoms David often refuses to take any
    medication at all for any reason.
  • The result is always the same he usually gets
    picked up by the police - a scuffle ensues, and
    David winds up in the ER or in jail. Both
    outcomes are bad if he goes to the ER they
    shoot him up with a bunch of mind numbing drugs
    to try and control him, if he goes to jail his
    symptoms get worse, resulting in a lot fights -
    sometimes he starts them but more often he is the
    victim of another inmate.
  • Eventually he winds up receiving emergency
    psychiatric care but in the interim a lot of
    damage has been done. He knows he shouldnt do
    this
  • and that there has to be a better way to handle
    this problem.

3
  • Susan has bi-polar disorder and she takes her
    medication as prescribed faithfully everyday. She
    knows what happens if she doesnt, she
  • decompensates quickly and winds up getting
    committed to the hospital.
  • There is just one problem, sometimes the
    medications just stop working and symptoms
    re-appear quickly often resulting in a
    hospitalization. Susan has a hard time convincing
    anyone that she just isnt complying and isnt
    doing this on purpose. She understands her
    illness, wants and is willing to accept
    responsibility but dreads having people think she
    does on purpose. Sometimes she feels being
    homeless or going to jail would be better than
    being hauled off to the emergency room, given
    medications to sedate her but do little else and
    being committed against her will.
  • If people would just listen to her and let her
    explain it might be better but she rarely sees
    the same people twice and those she does see
    thinks she is just trying to cover up the fact
    she refused to take her medications. Susan
    feels that she has enough to deal with and that
    there must be a way she can try and protect
    herself.

4
  • Mary has a long history of depression and PTSD.
    She often feels that she that should just end it
    all even though she does not really want to die.
    The impulse to her harm herself often overwhelms
    her and she knows she needs a safe place to get
    help.
  • Mary does not want to go back to the hospital
    however she finds the whole process
    traumatizing. Sometimes she thinks it makes
    things worse to go back. How can she tell them
    that when people touch her she is doing her best
    not to yell or swing at them they just think
    she bad attitude had a violent temper. No one
    wants to work with her she can tell by the way
    the act towards her.
  • Then there are the medications some of the ones
    they use make her feel worse she tries to make
    them understand but when she is really depressed
    or scared or both she just cant talk right.
    Besides, whose going to believe her shes in a
    mental hospital after all they will just say
    she is trying to manipulate to process.
  • There has to be a better way to deal with this
    than this!

5
  • Some Common Ground
  • Whether you have psychiatric diagnosis or not
    most people
  • dont like being told what to do
  • object to being held against their will
  • value the right to make decisions for themselves
  • Some think of this as a freedom, a liberty or
    right, some see it as independence, but we all
    see self-determination central to our idea of
    dignity.

6
  • Background
  • Historically, PADs are a variation of medical
    advance directives (ADs), legal instruments that
    typically offer three types of self-directed
    planning of one's own health care in anticipation
    of a later time of decisional incapacity (1) a
    competent individual's informed consent to future
    treatment (2) a statement of personal values and
    general preferences to guide future health care
    decisions and (3) the entrusting of someone to
    act as a proxy decision maker for future
    treatment.
  • In 1990 the Federal Government enacted the
    Patient Self-Determination Act. The intent is to
  • Provide an opportunity for adults to express
    their desires about medical treatment in advance
  • Balance the power between patients and providers
  • Educate the entire population on advance
    directives.
  • The federal law requires hospitals and other
    providers (including psychiatric hospitals and
    other mental health providers) and health plans
    to maintain written policies and procedures with
    respect to advance directives.

7
  • What are PADs and how can they help you?
  • Psychiatric Advance Directives or PADs permit you
    to determine what treatment you will receive if
    and/or when you lose the capacity to make
    treatment decisions for yourself because of
    illness.
  • Basically it is a written statement of your
    treatment preferences and other wishes and
    instructions.
  • There are two kinds of PADs
  • Instructive PADs, in which an individual gives
    instructions about the specific mental health
    treatment desired should the individual
    experience a psychiatric crisis.
  • Proxy PADs, in which the individual names a
    health care proxy or agent to make treatment
    decisions when the individual is unable to do so.

8
  • In South Carolina, the Department of Mental
    Health gathered a group of clients together to
    help create a PAD for clients to complete that
    details your instructions and wishes for your
    mental health treatment in times when you are too
    ill to make your wishes known.
  • The combined wisdom of the clients and staff who
    participated in developing this document
    represents more than 750 years of recovery
    experience.
  • You can use a PAD to assign decision-making
    authority to another person who can act on your
    behalf during times of incapacitation.
  • This is a legal document should be respected by
    private providers inside and outside of the state
    of South Carolina.

9
  • Why Would You Want to Fill One Out If You're Not
    Sick?
  • It can help to improve communication between you
    and your doctor, you and other staff and you and
    your family members involved in your recovery.
  • Having a psychiatric advance directive may
  • Shorten a hospital stay or help you avoid one all
    together
  • Gain more control of your treatment
  • Improve the likelihood of receiving helpful,
    informed care
  • Consent to or refuse certain treatments
  • Enhance understanding and communication with your
    treatment providers and family members

10
  • Whats Usually Included in a PAD?
  • The information that may be included in a PAD
    varies by state. In general, PADs allow you to
    agree to, refuse and give your preferences about
    such as
  • Psychiatric medications
  • Hospitalization
  • Alternatives to hospitalization
  • Seclusion and restraint
  • ECT (electroconvulsive therapy)
  • One of the more important aspects of a PAD is
    that it can help to explain why you made the
    choices you did so your doctors and others will
    understand your reasoning. Its to your advantage
    for them to know the basis for your preferences.
  • For instance, you might explain that certain
    medications have given you severe side effects,
    that you prefer a certain hospital because of its
    therapeutic programs, or that certain self-care
    methods have helped you through mental health
    crises in the past.

11
  • What Specifically does the SCDMH PAD Include?
  • A statement of Intent your desires/instructions
  • Psychiatric History including
  • Diagnosis,
  • Doctors and case managers name
  • Who you want informed
  • Agents name if one was chosen
  • Your wishes, instructions, special provisions and
    limitations for your mental health treatment and
    care including
  • Choices Regarding Emergency Interventions
  • Choices about Medication(s)
  • Choices about Personal Interventions
  • Choices Regarding Release of Information about My
    Health

12
  • Are there any special rules that apply to a PAD
    in SC?
  • Yes, there are five things to remember
  • S.C. does not recognize Statements of Desires
    without appointment of an agent/surrogate under a
    Health Care Power of Attorney. Forms for a Health
    Care Power of Attorney can be found at
    http//www.state.sc.us/dmh/client_affairs/advance_
    directive.htm
  • Your case manager or other mental health worker
    cannot be your agent.
  • It is important that you understand that in an
    emergency situation, a doctor can do something
    different from what you have stated in your
    Declaration for Mental Health Treatment, but the
    doctor must go through certain steps to do this.

13
  • Five things
  • It is up to you or your agent to make sure that
    the hospital has a copy of your Declaration for
    Mental Health Treatment. You may want to have a
    copy placed in your outpatient record so that
    outpatient staff are aware of what hospital or
    crisis stabilization approaches you would prefer,
    if you are not able to express your own choices
    at the time.
  • You can substitute the Crisis Portion of your
    WRAP (Wellness Recovery Action Plan) Plan if you
    have completed one and so desire. You should
    attach a copy of your WRAP Crisis Plan to this
    form.

14
  • What is a Health Care Proxy or Agent?A Health
    Care Proxy is someone you appoint to make your
    treatment decisions when you cannot make them
    yourself. Naming a proxy may be optional some
    states require it. Some states only let you
    appoint a proxy you may not give your own
    treatment preferences. In those cases, however,
    the individual usually may give instructions
    directly to the agent.
  • Generally, a Health Care Proxy can be any
    capable, competent adult (18 years or older) who
    is not your health care provider. Often you can
    name more than one proxy, though only one can be
    active at a time.

15
  • What does a Health Care Agent/Proxy Do?If you
    become unable to make your own treatment
    decisions due to psychiatric symptoms, your
    Health Care Agent/Proxy would make them for you
    following your instructions about your desire for
    care spelled out in your PAD.
  • The Agent/Proxy should follow the instructions
    and make the same decisions you would about
    medications, hospitalization, health care
    provider, ECT and anything else you have covered
    in the PAD.
  • Remember the law in S.C. does not recognize
    Statements of Desires without appointment of an
    agent/surrogate under a Health Care Power of
    Attorney.

16
  • Who can I appoint to be my Health Care Power of
    Attorney?
  • You can appoint any capable and competent adult
    who is 18 years or older but they cannot be
    providing your health care. You can appoint more
    than one Health Care Agent. However, only one can
    serve as your Health Care Agent at a time. You
    must indicate your order preference.
  • When does my Health Care Agent make treatment
    decisions for me?
  • When your health care provider determines that
    you are incapable of making decisions, your
    health care agent will be consulted about your
    treatment. If your health care provider is not
    available, then the attending physician or
    eligible psychologist decides when to consult
    your health care agent. The decision to consult
    your health care agent must be put into writing.

17
  • If I am unable to make decisions, can I choose
    someone to speak for me?
  • Yes. This is done through a document called a
    Health Care Power of Attorney, or a Durable Power
    of Attorney for Health Care, sometimes also
    called a health care agent, surrogate, or proxy
    decision maker.
  • You can appoint any capable and competent adult
    who is 18 years or older who is not your health
    care provider.
  • What if I want to change my Agent/Proxy?
  • You can change or revoke your Agent/Proxy choice
    at any time as you are considered capable at
    the time of change.

18
  • If I am involuntarily committed will my PAD be
    followed?
  • Involuntary commitment to a treatment facility
    takes priority over what your PAD says about
    hospitalization. However, your preferences
    regarding medication and other aspects of
    treatment while hospitalized should be followed
    even while you are involuntarily committed.
  • Are there reasons my PAD might not be followed?
  • Yes, your PAD would not be followed
  • If it conflicts with generally accepted
    community practice standards.
  • If the treatments requested are not feasible or
    available.
  • If it conflicts with emergency treatment.
  • If it conflicts with applicable law.

19
  • Can a provider refuse to follow an advance
    directive?
  • Technically yes, under certain conditions
  • If permitted under state law, providers can
    refuse to implement provisions of an advance
    directive, based on conscience objections. The
    facility must make clear when instructions of an
    advance directive would not be followed due to a
    conscience objection and
  • Provide a clear and precise statement of
    limitations if the provider cannot implement the
    advance directive based on conscience
  • Clarify any differences between
    institution-wide conscience objection and those
    that may be raised by individual physicians
  • Identify the State legal authority permitting a
    conscience objection,
  • Describe the range of medical conditions or
    procedures affected by the conscience objection.

20
  • Once I have created a PAD, what do I do with the
    document?
  • You should give it to your mental health care
    provider who will make it a part of your medical
    record.
  • You should give a copy to agent.
  • You might want to consider giving a copy to a
    trusted friend or family member.
  • You should keep a copy for yourself.
  • Do I have to use the SCDMH PAD?
  • No, you may use any for you remembering that to
    enforce your directives you must have appointed
    an health care agent

21
  • Does the SCDMH have a policy on Advanced
    Directives?
  • Yes, policy 850-05 (5-100) Advance Directives
    states that while competent, individuals may
    anticipate the possibility of later incapacity
    and may prepare Advance Directives stating their
    desires regarding the provision or withholding of
    medical care in such event.
  • It is the Department's policy to encourage the
    use of advance health care directives and to
    honor Advance Directives.
  • However, no Departmental facility shall condition
    the provision of care or otherwise discriminate
    against an individual based on whether or not the
    individual has executed an advance health care
    directive.

22
  • The purpose of this directive is to implement the
    "Patient Self Determination Act" and the State's
    public policy to encourage the execution of
    advance health care directives.
  • The Patient Self Determination Act requires that
    each hospital and nursing facility receiving
    federal Medicare or Medicaid funds must provide
    information to every patient/resident, about the
    facility's policies concerning implementation of
    Advance Directives, and distribute a written
    description of State law concerning Advance
    Directives to the patient/resident.
  • It is also the declared policy of the State of
    South Carolina to promote the use of Advance
    Directives as a means of encouraging patient
    self-determination and avoiding uncertainty in a
    health care crisis.

23
  • A look at the Directive Developed for Mental
    Health Clients by Mental Health Clients in SC

24
  • My Declaration for Mental Health Treatment
    (Psychiatric Advance Directive)
  • Summary
  • If I am in crisis or in case of a psychiatric
    emergency
  • 1. My case managers name is ____________________
    ______________________
  • 2. Doctors I want notified are
  • A. _______________________________________________
    _
  • B. _______________________________________________
    _
  • C. _______________________________________________
    _
  • 3. Persons I want notified are
  • A. _______________________________________________
    _
  • B. _______________________________________________
    _
  • C. _______________________________________________
    _
  • 4. ___ I have completed a Psychiatric Advanced
    Directive and/or a WRAP Plan and wish treatment
    providers follow the instruction I have laid down
    in it to the fullest extent possible.
  • 5. ___ I have appointed an agent to make
    decisions for me in the event I am not capable of
    communicating my preferences for treatment at
    this time. That person is

25
  • These Are My Wishes, Instructions, Special
    Provisions and Limitations in My Mental Health
    Treatment and Care (__________________________
    your name)
  • I. My choice of Treatment Facility or other
    alternative to hospitalization if it is medically
    necessary for me to have 24-hour care for my
    safety and well being.
  • A. _____ If I am to go into a hospital for
    24-hour care, I choose to go to the following
    hospitals
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • B.____ If my condition requires 24 hour
    psychiatric care but it is not necessary to be in
    a hospital, I choose to have this care in
    programs and facilities that are considered
    alternatives to psychiatric hospitals listed
    below
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • C. _____I choose to receive crisis stabilization
    at the following programs/facilities
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • D._____I do not want to be committed to the
    following hospitals or programs/facilities for
    the following reasons (optional) if I need
    psychiatric care.

26
  • II. My Choices Regarding Emergency Interventions
  • If I engage in behavior that requires an
    emergency intervention (such as seclusion,
    restraint or medications), I choose the
    interventions in the order listed below.
  • Most preferred is 1, next is 2 and so on until
    there is a number by each option
  • _____seclusion _____physical restraints
  • _____seclusion physical restraints
    _____medication by injection
  • _____medication in pill form _____liquid
    medication
  • _____other________________________________________
    __________
  • Put your initials by this section if you agree
    if you dont agree, leave it blank.
  • _____If after considering the choices I have
    listed above, the doctor attending me decides to
    use medication to tranquilize me quickly (rapid
    tranquilization) in an emergency situation I
    expect the doctor to use medication that reflects
    the choices I have stated in this Declaration.
    The choices I agree to concerning emergency
    medications do not give consent for using these
    medications for non-emergency treatment.

27
  • III. My Choices about Medication(s)
  • A. I prefer medication given to me ?
    Orally ? Pill ? Liquid ? Injection
  • B. The following medications have been the most
    helpful to me in the past and I would consent to
    taking them, if appropriate
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • C. If I am hospitalized and am not considered
    able to consent or refuse medications related to
    my mental health treatment, my wishes are as
    follows
  • (I) _____I consent to and give permission to my
    agent to consent to the use of the following
    medication(s)
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • (II) _____I specifically do not consent to and I
    do not give permission for my agent to consent to
    me taking the following medications, no matter
    what their brand name or generic equivalent
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _

28
  • D. I am concerned about the side effects of
    medications. I wish to be told about the
    possible medication side effects if any of these
    side effects listed below are possible or to be
    told how these side effects can be managed.
  • _____tardive dyskinesia _____loss of sensation
  • _____motor restlessness _____seizure
  • _____blurred vision _____cognitive (thinking)
    problems
  • _____sleep problems _____aggressiveness
  • _____tremors _____nausea/vomiting/diarrhea
  • _____neuroleptic malignant syndrome _____muscle/sk
    eletal rigidity
  • _____dizziness _____mood swings
  • _____sexual dysfunction _____other
  • F. I am allergic to the following medications
    (medication and reaction if known)
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _

29
  • IV. My Choices about Personal Interventions
  • A. Others will know when I am having a
    hard/difficult time or when I am upset if I am
  • __________________________________________________
    __________________________________________________
    __________________________________
  • B. Approaches that I and others can use to help
    me when Im having a hard time or when Im
    expressing anger inappropriately (Check all that
    apply)
  • ? voluntary time out in my room ? voluntary
    time out in a quiet room
  • ? sitting by staff ? talking with a peer
  • ? talking with staff ? having my hand held
  • ? going for a walk ? punching a pillow
  • ? writing in a journal ? lying down
  • ? listening to music ? reading
  • ? watching TV ? pacing the halls
  • ? calling a friend ? talking with my therapist
  • ? pounding some clay ? exercising
  • ? deep breathing exercises ? taking a shower
  • ? praying ? meditation
  • ? singing ? getting a hug
  • ? yelling or screaming ? being silent
  • ? being outside ? calling crisis hotline

30
  • C. Special Wishes about Touch/Body Space (check
    all that apply)
  • ____I do not wish to be touched.
  • ____I wish to be asked permission before being
    touched.
  • ____I wish to be told the reason why I am being
    touched.
  • ____I wish special attention be given to allowing
    me extra personal body space.
  • ____I do not need special attention given to my
    body space.
  • ____Other________________________________________
    ________________
  • V. My Choices Regarding Release of Information
    about My Health
  • If I am hospitalized, I voluntarily give
    permission for the following information about me
    to be given by the hospital where I am currently
    admitted to the people listed below.
  • I realize that I may also have to sign a release
    of information for the hospital, but this
    Declaration for Mental Health Treatment should be
    followed concerning the limits of information
    provided to each person listed. The information
    can be given in writing or verbally.
  • 1. Name of Individual ___________________________
    ______________________
  • Address _________________________________________
    __________________ City _________________________
    ______State______________Zip__________
  • Day Phone ____________________ Night Phone
    __________________________
  • Type of information to be released
  • ___Diagnosis

31
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32
  • My Life, My Treatment, My Plan
  • Client Empowerment Using Psychiatric Advance
    Directives
  • SCDMH Peer Support Continuing EducationJune 28,
    2013Katherine M. Roberts, MPH
  • Director, SCDMH Office of Client Affairs
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My Life, My Treatment, My Plan

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Title: My Life, My Treatment, My Plan


1
My Life, My Treatment, My Plan
  • Client Empowerment Using Psychiatric Advance
    Directives
  • SCDMH Peer Support Continuing EducationJune 28,
    2013Katherine M. Roberts, MPH
  • Director, SCDMH Office of Client Affairs

2
  • David likes the beach, his dog, to paint, read,
    fish and hang out with buddies. He also has
    schizophrenia. He knows he needs to take
    medication to help control the symptoms of his
    illness. Complying with this is hard for him, the
    meds make him feel zoned out and sleepy, give him
    dry mouth and as he puts it makes it hard to
    focus. Consequently, David sometimes
    accidentally on purpose forgets to take them.
  • His symptom's start to come back and because of
    the symptoms David often refuses to take any
    medication at all for any reason.
  • The result is always the same he usually gets
    picked up by the police - a scuffle ensues, and
    David winds up in the ER or in jail. Both
    outcomes are bad if he goes to the ER they
    shoot him up with a bunch of mind numbing drugs
    to try and control him, if he goes to jail his
    symptoms get worse, resulting in a lot fights -
    sometimes he starts them but more often he is the
    victim of another inmate.
  • Eventually he winds up receiving emergency
    psychiatric care but in the interim a lot of
    damage has been done. He knows he shouldnt do
    this
  • and that there has to be a better way to handle
    this problem.

3
  • Susan has bi-polar disorder and she takes her
    medication as prescribed faithfully everyday. She
    knows what happens if she doesnt, she
  • decompensates quickly and winds up getting
    committed to the hospital.
  • There is just one problem, sometimes the
    medications just stop working and symptoms
    re-appear quickly often resulting in a
    hospitalization. Susan has a hard time convincing
    anyone that she just isnt complying and isnt
    doing this on purpose. She understands her
    illness, wants and is willing to accept
    responsibility but dreads having people think she
    does on purpose. Sometimes she feels being
    homeless or going to jail would be better than
    being hauled off to the emergency room, given
    medications to sedate her but do little else and
    being committed against her will.
  • If people would just listen to her and let her
    explain it might be better but she rarely sees
    the same people twice and those she does see
    thinks she is just trying to cover up the fact
    she refused to take her medications. Susan
    feels that she has enough to deal with and that
    there must be a way she can try and protect
    herself.

4
  • Mary has a long history of depression and PTSD.
    She often feels that she that should just end it
    all even though she does not really want to die.
    The impulse to her harm herself often overwhelms
    her and she knows she needs a safe place to get
    help.
  • Mary does not want to go back to the hospital
    however she finds the whole process
    traumatizing. Sometimes she thinks it makes
    things worse to go back. How can she tell them
    that when people touch her she is doing her best
    not to yell or swing at them they just think
    she bad attitude had a violent temper. No one
    wants to work with her she can tell by the way
    the act towards her.
  • Then there are the medications some of the ones
    they use make her feel worse she tries to make
    them understand but when she is really depressed
    or scared or both she just cant talk right.
    Besides, whose going to believe her shes in a
    mental hospital after all they will just say
    she is trying to manipulate to process.
  • There has to be a better way to deal with this
    than this!

5
  • Some Common Ground
  • Whether you have psychiatric diagnosis or not
    most people
  • dont like being told what to do
  • object to being held against their will
  • value the right to make decisions for themselves
  • Some think of this as a freedom, a liberty or
    right, some see it as independence, but we all
    see self-determination central to our idea of
    dignity.

6
  • Background
  • Historically, PADs are a variation of medical
    advance directives (ADs), legal instruments that
    typically offer three types of self-directed
    planning of one's own health care in anticipation
    of a later time of decisional incapacity (1) a
    competent individual's informed consent to future
    treatment (2) a statement of personal values and
    general preferences to guide future health care
    decisions and (3) the entrusting of someone to
    act as a proxy decision maker for future
    treatment.
  • In 1990 the Federal Government enacted the
    Patient Self-Determination Act. The intent is to
  • Provide an opportunity for adults to express
    their desires about medical treatment in advance
  • Balance the power between patients and providers
  • Educate the entire population on advance
    directives.
  • The federal law requires hospitals and other
    providers (including psychiatric hospitals and
    other mental health providers) and health plans
    to maintain written policies and procedures with
    respect to advance directives.

7
  • What are PADs and how can they help you?
  • Psychiatric Advance Directives or PADs permit you
    to determine what treatment you will receive if
    and/or when you lose the capacity to make
    treatment decisions for yourself because of
    illness.
  • Basically it is a written statement of your
    treatment preferences and other wishes and
    instructions.
  • There are two kinds of PADs
  • Instructive PADs, in which an individual gives
    instructions about the specific mental health
    treatment desired should the individual
    experience a psychiatric crisis.
  • Proxy PADs, in which the individual names a
    health care proxy or agent to make treatment
    decisions when the individual is unable to do so.

8
  • In South Carolina, the Department of Mental
    Health gathered a group of clients together to
    help create a PAD for clients to complete that
    details your instructions and wishes for your
    mental health treatment in times when you are too
    ill to make your wishes known.
  • The combined wisdom of the clients and staff who
    participated in developing this document
    represents more than 750 years of recovery
    experience.
  • You can use a PAD to assign decision-making
    authority to another person who can act on your
    behalf during times of incapacitation.
  • This is a legal document should be respected by
    private providers inside and outside of the state
    of South Carolina.

9
  • Why Would You Want to Fill One Out If You're Not
    Sick?
  • It can help to improve communication between you
    and your doctor, you and other staff and you and
    your family members involved in your recovery.
  • Having a psychiatric advance directive may
  • Shorten a hospital stay or help you avoid one all
    together
  • Gain more control of your treatment
  • Improve the likelihood of receiving helpful,
    informed care
  • Consent to or refuse certain treatments
  • Enhance understanding and communication with your
    treatment providers and family members

10
  • Whats Usually Included in a PAD?
  • The information that may be included in a PAD
    varies by state. In general, PADs allow you to
    agree to, refuse and give your preferences about
    such as
  • Psychiatric medications
  • Hospitalization
  • Alternatives to hospitalization
  • Seclusion and restraint
  • ECT (electroconvulsive therapy)
  • One of the more important aspects of a PAD is
    that it can help to explain why you made the
    choices you did so your doctors and others will
    understand your reasoning. Its to your advantage
    for them to know the basis for your preferences.
  • For instance, you might explain that certain
    medications have given you severe side effects,
    that you prefer a certain hospital because of its
    therapeutic programs, or that certain self-care
    methods have helped you through mental health
    crises in the past.

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  • What Specifically does the SCDMH PAD Include?
  • A statement of Intent your desires/instructions
  • Psychiatric History including
  • Diagnosis,
  • Doctors and case managers name
  • Who you want informed
  • Agents name if one was chosen
  • Your wishes, instructions, special provisions and
    limitations for your mental health treatment and
    care including
  • Choices Regarding Emergency Interventions
  • Choices about Medication(s)
  • Choices about Personal Interventions
  • Choices Regarding Release of Information about My
    Health

12
  • Are there any special rules that apply to a PAD
    in SC?
  • Yes, there are five things to remember
  • S.C. does not recognize Statements of Desires
    without appointment of an agent/surrogate under a
    Health Care Power of Attorney. Forms for a Health
    Care Power of Attorney can be found at
    http//www.state.sc.us/dmh/client_affairs/advance_
    directive.htm
  • Your case manager or other mental health worker
    cannot be your agent.
  • It is important that you understand that in an
    emergency situation, a doctor can do something
    different from what you have stated in your
    Declaration for Mental Health Treatment, but the
    doctor must go through certain steps to do this.

13
  • Five things
  • It is up to you or your agent to make sure that
    the hospital has a copy of your Declaration for
    Mental Health Treatment. You may want to have a
    copy placed in your outpatient record so that
    outpatient staff are aware of what hospital or
    crisis stabilization approaches you would prefer,
    if you are not able to express your own choices
    at the time.
  • You can substitute the Crisis Portion of your
    WRAP (Wellness Recovery Action Plan) Plan if you
    have completed one and so desire. You should
    attach a copy of your WRAP Crisis Plan to this
    form.

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  • What is a Health Care Proxy or Agent?A Health
    Care Proxy is someone you appoint to make your
    treatment decisions when you cannot make them
    yourself. Naming a proxy may be optional some
    states require it. Some states only let you
    appoint a proxy you may not give your own
    treatment preferences. In those cases, however,
    the individual usually may give instructions
    directly to the agent.
  • Generally, a Health Care Proxy can be any
    capable, competent adult (18 years or older) who
    is not your health care provider. Often you can
    name more than one proxy, though only one can be
    active at a time.

15
  • What does a Health Care Agent/Proxy Do?If you
    become unable to make your own treatment
    decisions due to psychiatric symptoms, your
    Health Care Agent/Proxy would make them for you
    following your instructions about your desire for
    care spelled out in your PAD.
  • The Agent/Proxy should follow the instructions
    and make the same decisions you would about
    medications, hospitalization, health care
    provider, ECT and anything else you have covered
    in the PAD.
  • Remember the law in S.C. does not recognize
    Statements of Desires without appointment of an
    agent/surrogate under a Health Care Power of
    Attorney.

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  • Who can I appoint to be my Health Care Power of
    Attorney?
  • You can appoint any capable and competent adult
    who is 18 years or older but they cannot be
    providing your health care. You can appoint more
    than one Health Care Agent. However, only one can
    serve as your Health Care Agent at a time. You
    must indicate your order preference.
  • When does my Health Care Agent make treatment
    decisions for me?
  • When your health care provider determines that
    you are incapable of making decisions, your
    health care agent will be consulted about your
    treatment. If your health care provider is not
    available, then the attending physician or
    eligible psychologist decides when to consult
    your health care agent. The decision to consult
    your health care agent must be put into writing.

17
  • If I am unable to make decisions, can I choose
    someone to speak for me?
  • Yes. This is done through a document called a
    Health Care Power of Attorney, or a Durable Power
    of Attorney for Health Care, sometimes also
    called a health care agent, surrogate, or proxy
    decision maker.
  • You can appoint any capable and competent adult
    who is 18 years or older who is not your health
    care provider.
  • What if I want to change my Agent/Proxy?
  • You can change or revoke your Agent/Proxy choice
    at any time as you are considered capable at
    the time of change.

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  • If I am involuntarily committed will my PAD be
    followed?
  • Involuntary commitment to a treatment facility
    takes priority over what your PAD says about
    hospitalization. However, your preferences
    regarding medication and other aspects of
    treatment while hospitalized should be followed
    even while you are involuntarily committed.
  • Are there reasons my PAD might not be followed?
  • Yes, your PAD would not be followed
  • If it conflicts with generally accepted
    community practice standards.
  • If the treatments requested are not feasible or
    available.
  • If it conflicts with emergency treatment.
  • If it conflicts with applicable law.

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  • Can a provider refuse to follow an advance
    directive?
  • Technically yes, under certain conditions
  • If permitted under state law, providers can
    refuse to implement provisions of an advance
    directive, based on conscience objections. The
    facility must make clear when instructions of an
    advance directive would not be followed due to a
    conscience objection and
  • Provide a clear and precise statement of
    limitations if the provider cannot implement the
    advance directive based on conscience
  • Clarify any differences between
    institution-wide conscience objection and those
    that may be raised by individual physicians
  • Identify the State legal authority permitting a
    conscience objection,
  • Describe the range of medical conditions or
    procedures affected by the conscience objection.

20
  • Once I have created a PAD, what do I do with the
    document?
  • You should give it to your mental health care
    provider who will make it a part of your medical
    record.
  • You should give a copy to agent.
  • You might want to consider giving a copy to a
    trusted friend or family member.
  • You should keep a copy for yourself.
  • Do I have to use the SCDMH PAD?
  • No, you may use any for you remembering that to
    enforce your directives you must have appointed
    an health care agent

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  • Does the SCDMH have a policy on Advanced
    Directives?
  • Yes, policy 850-05 (5-100) Advance Directives
    states that while competent, individuals may
    anticipate the possibility of later incapacity
    and may prepare Advance Directives stating their
    desires regarding the provision or withholding of
    medical care in such event.
  • It is the Department's policy to encourage the
    use of advance health care directives and to
    honor Advance Directives.
  • However, no Departmental facility shall condition
    the provision of care or otherwise discriminate
    against an individual based on whether or not the
    individual has executed an advance health care
    directive.

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  • The purpose of this directive is to implement the
    "Patient Self Determination Act" and the State's
    public policy to encourage the execution of
    advance health care directives.
  • The Patient Self Determination Act requires that
    each hospital and nursing facility receiving
    federal Medicare or Medicaid funds must provide
    information to every patient/resident, about the
    facility's policies concerning implementation of
    Advance Directives, and distribute a written
    description of State law concerning Advance
    Directives to the patient/resident.
  • It is also the declared policy of the State of
    South Carolina to promote the use of Advance
    Directives as a means of encouraging patient
    self-determination and avoiding uncertainty in a
    health care crisis.

23
  • A look at the Directive Developed for Mental
    Health Clients by Mental Health Clients in SC

24
  • My Declaration for Mental Health Treatment
    (Psychiatric Advance Directive)
  • Summary
  • If I am in crisis or in case of a psychiatric
    emergency
  • 1. My case managers name is ____________________
    ______________________
  • 2. Doctors I want notified are
  • A. _______________________________________________
    _
  • B. _______________________________________________
    _
  • C. _______________________________________________
    _
  • 3. Persons I want notified are
  • A. _______________________________________________
    _
  • B. _______________________________________________
    _
  • C. _______________________________________________
    _
  • 4. ___ I have completed a Psychiatric Advanced
    Directive and/or a WRAP Plan and wish treatment
    providers follow the instruction I have laid down
    in it to the fullest extent possible.
  • 5. ___ I have appointed an agent to make
    decisions for me in the event I am not capable of
    communicating my preferences for treatment at
    this time. That person is

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  • These Are My Wishes, Instructions, Special
    Provisions and Limitations in My Mental Health
    Treatment and Care (__________________________
    your name)
  • I. My choice of Treatment Facility or other
    alternative to hospitalization if it is medically
    necessary for me to have 24-hour care for my
    safety and well being.
  • A. _____ If I am to go into a hospital for
    24-hour care, I choose to go to the following
    hospitals
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • B.____ If my condition requires 24 hour
    psychiatric care but it is not necessary to be in
    a hospital, I choose to have this care in
    programs and facilities that are considered
    alternatives to psychiatric hospitals listed
    below
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • C. _____I choose to receive crisis stabilization
    at the following programs/facilities
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • D._____I do not want to be committed to the
    following hospitals or programs/facilities for
    the following reasons (optional) if I need
    psychiatric care.

26
  • II. My Choices Regarding Emergency Interventions
  • If I engage in behavior that requires an
    emergency intervention (such as seclusion,
    restraint or medications), I choose the
    interventions in the order listed below.
  • Most preferred is 1, next is 2 and so on until
    there is a number by each option
  • _____seclusion _____physical restraints
  • _____seclusion physical restraints
    _____medication by injection
  • _____medication in pill form _____liquid
    medication
  • _____other________________________________________
    __________
  • Put your initials by this section if you agree
    if you dont agree, leave it blank.
  • _____If after considering the choices I have
    listed above, the doctor attending me decides to
    use medication to tranquilize me quickly (rapid
    tranquilization) in an emergency situation I
    expect the doctor to use medication that reflects
    the choices I have stated in this Declaration.
    The choices I agree to concerning emergency
    medications do not give consent for using these
    medications for non-emergency treatment.

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  • III. My Choices about Medication(s)
  • A. I prefer medication given to me ?
    Orally ? Pill ? Liquid ? Injection
  • B. The following medications have been the most
    helpful to me in the past and I would consent to
    taking them, if appropriate
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • C. If I am hospitalized and am not considered
    able to consent or refuse medications related to
    my mental health treatment, my wishes are as
    follows
  • (I) _____I consent to and give permission to my
    agent to consent to the use of the following
    medication(s)
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _
  • (II) _____I specifically do not consent to and I
    do not give permission for my agent to consent to
    me taking the following medications, no matter
    what their brand name or generic equivalent
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _

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  • D. I am concerned about the side effects of
    medications. I wish to be told about the
    possible medication side effects if any of these
    side effects listed below are possible or to be
    told how these side effects can be managed.
  • _____tardive dyskinesia _____loss of sensation
  • _____motor restlessness _____seizure
  • _____blurred vision _____cognitive (thinking)
    problems
  • _____sleep problems _____aggressiveness
  • _____tremors _____nausea/vomiting/diarrhea
  • _____neuroleptic malignant syndrome _____muscle/sk
    eletal rigidity
  • _____dizziness _____mood swings
  • _____sexual dysfunction _____other
  • F. I am allergic to the following medications
    (medication and reaction if known)
  • 1. _______________________________________________
    _
  • 2. _______________________________________________
    _
  • 3. _______________________________________________
    _

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  • IV. My Choices about Personal Interventions
  • A. Others will know when I am having a
    hard/difficult time or when I am upset if I am
  • __________________________________________________
    __________________________________________________
    __________________________________
  • B. Approaches that I and others can use to help
    me when Im having a hard time or when Im
    expressing anger inappropriately (Check all that
    apply)
  • ? voluntary time out in my room ? voluntary
    time out in a quiet room
  • ? sitting by staff ? talking with a peer
  • ? talking with staff ? having my hand held
  • ? going for a walk ? punching a pillow
  • ? writing in a journal ? lying down
  • ? listening to music ? reading
  • ? watching TV ? pacing the halls
  • ? calling a friend ? talking with my therapist
  • ? pounding some clay ? exercising
  • ? deep breathing exercises ? taking a shower
  • ? praying ? meditation
  • ? singing ? getting a hug
  • ? yelling or screaming ? being silent
  • ? being outside ? calling crisis hotline

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  • C. Special Wishes about Touch/Body Space (check
    all that apply)
  • ____I do not wish to be touched.
  • ____I wish to be asked permission before being
    touched.
  • ____I wish to be told the reason why I am being
    touched.
  • ____I wish special attention be given to allowing
    me extra personal body space.
  • ____I do not need special attention given to my
    body space.
  • ____Other________________________________________
    ________________
  • V. My Choices Regarding Release of Information
    about My Health
  • If I am hospitalized, I voluntarily give
    permission for the following information about me
    to be given by the hospital where I am currently
    admitted to the people listed below.
  • I realize that I may also have to sign a release
    of information for the hospital, but this
    Declaration for Mental Health Treatment should be
    followed concerning the limits of information
    provided to each person listed. The information
    can be given in writing or verbally.
  • 1. Name of Individual ___________________________
    ______________________
  • Address _________________________________________
    __________________ City _________________________
    ______State______________Zip__________
  • Day Phone ____________________ Night Phone
    __________________________
  • Type of information to be released
  • ___Diagnosis

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32
  • My Life, My Treatment, My Plan
  • Client Empowerment Using Psychiatric Advance
    Directives
  • SCDMH Peer Support Continuing EducationJune 28,
    2013Katherine M. Roberts, MPH
  • Director, SCDMH Office of Client Affairs
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