By Daniel Waters
The patient faces yet another emotional crisis. He feels that he just cannot hold it together. The acting out intensifies once again, and once again, a psychotic breakdown is imminent. The patient arrives in the hospital emergency department in psychiatric rather than medical crisis, although the two are so often intertwined. This patient’s psychosis manifests with a severe paranoia, and the usual medication regime is now highly suspect, as are these strangers in the emergency department. This patient, who under “normal” circumstances is compliant with all medications, is spinning out of control while refusing to take even blood pressure medication.
For such a patient, the psychiatric advance directive is a relatively new legal document that allows an individual with mental health issues to document his or her wishes for future mental health treatment, and it allows for a proxy to make those decisions during a crisis. Normally in the above scenario, a court order might be required to administer medication by force. With the PAD, the decision to override the patient’s refusal is accomplished with the psychiatric healthcare profession in consultation with the proxy.
The document is drafted when the patient is well enough to execute it, as determined by their mental healthcare professional. A patient hospitalized due to a mental health crisis cannot execute the directive. This is not a document that a chaplain can take to an inpatient room to have a conversation.
This type of directive can include not only a name of proxy, but depending on the state, many or all of the following: a yes or no list of medications; yes or no to electro-convulsive treatment; yes or no to inpatient admission to a facility and for how long; an area to spell out a wellness recovery plan; a yes or no list of physicians; names of facilities to be or not be admitted to; a list of family/friends who can or cannot visit; a place to name someone to care for pets or home.
There are 25 states with psychiatric advance directive, although specifics can vary. The legal definition of capacity is not the same in each state, hence in some a designated physician can make the decision while others still require a judge to decide capacity. The document should be shared with a case manager, the proxy, primary physician, specialists, and family members.
A chaplain in any setting dealing with patients with mental health issues should be aware of these directives for their state. As an integrated member of a care team, it would be important to know whether an individual patient has a PAD. The focus of the PAD is to treat an individual with the dignity that they request when they are well. A chaplain can help to keep the focus on the dignity and value of everyone, especially when it is hard to care about patients who does not seem to care about themselves. Directive 23 in the Ethical and Religious Directives for Catholic Healthcare Services states that the inherent dignity of the human person must be respected regardless of health problem or social status. A PAD helps to extend the healing ministry of Jesus in a challenging area of healthcare.
Daniel Waters, BCC, is Spiritual Care Coordinator at Mercy Health in Oregon, OH.