Psychiatric advance directives

A psychiatric advance directive (PAD), also known as a mental health advance directive, is a written document that describes what a person wants to happen if at some time in the future they are judged to be suffering from a mental disorder in such a way that they are deemed unable to decide for themselves or to communicate effectively.

It can inform others about what treatment they want or don't want from psychiatrists or other mental health professionals, and it can identify a person to whom they have given the authority to make decisions on their behalf. A mental health advance directive is one kind of advance health care directive.

Psychiatric advance directives are legal documents used by persons currently enjoying legal capacity to declare their preferences and instructions for future mental health treatment, or to appoint a surrogate decision maker through Health Care Power of Attorney (HCPA), in advance of being targeted by coercive mental health laws, during which they may be stripped of legal capacity to make decisions.

In the United States, although 25 states have now passed legislation in the past decade establishing authority for PADs, there is relatively little public information available to address growing interest in these legal documents. In addition in states without explicit PAD statutes, very similar mental health advance care planning can and does take place under generic HCPA statutes—expanding the audience for PADs to all 50 states (see National Resource Center on Psychiatric Advance Directives).

In addition to recognizing the potential benefits of PADs, states are beginning to recognize legal obligations under the federal Patient Self-Determination Act of 1991, which includes informing all hospital patients that they have a right to prepare advance directives and—with certain caveats—that clinicians are obliged to follow these directive. As such, federal law helps ensure that people labeled as having mental illness can use medical advance directives to specify mental health treatment preferences or assign proxy decision-makers for mental health decisions.

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