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How to write a psychiatric advance directive

A psychiatric advance directive (PAD) is a legal document in which a person, while well, records how they want to be treated during a future mental health crisis and, if they wish, names someone to speak for them when they cannot.[1] This page is a practical guide to writing one. It covers what a PAD may do, the important limits on what it cannot do, what the research shows, how to draft each section, how to choose an agent, how to make the document findable in a crisis, and how the law works in one example state. It is written for people who have been through a crisis before, for people who support them, and for students of psychiatry, law, and medical ethics.

Important notice.

  • This is general educational information, not legal or medical advice.
  • Laws vary by state and change over time.
  • A psychiatric advance directive may be overridden and does not guarantee protection against involuntary commitment or forced treatment.
  • Consult a lawyer or a legal advocacy organization (such as the state protection and advocacy agency) before relying on one.

The problem a psychiatric advance directive solves

During a severe crisis, a person may be judged unable to make treatment decisions. At that point, other people decide which hospital, which medication, which dose, and who gets told. Those decisions are often made quickly by staff who have never met the person and do not know their history: which drug caused a bad reaction, which approach calms them down, who should feed the cat, or which relative should not be called.

A PAD moves some of that knowledge and some of that choice back to the person. It is written in a calm period, when the person can think through their own history, and it is used later, when they may not be able to explain it. For readers interested in problems in living and the critique of involuntary treatment, a PAD is one of the few tools available inside the current system today, although, as the limits section below explains, it offers only partial and conditional protection. Psychiatrist Thomas Szasz proposed a related idea in 1982, which he called a psychiatric will, as a way for a person to refuse in advance psychiatric interventions they did not want.[2] See Szaszian studies for more on his work.

What the research shows

Demand is high and completion is low. In a survey of 1,011 outpatients in public mental health systems in five United States cities, only 4 to 13 percent had completed a PAD, but 66 to 77 percent said they would want one if someone helped them.[3]

Help with writing makes a large difference. In a randomized trial with 469 participants, 61 percent of people who had a structured facilitation session completed a PAD or named a proxy, compared with 3 percent of people who only received written information. Psychiatrists rated the facilitated documents as consistent with community standards of practice, most participants used them to refuse some medications and to choose some hospitals over others, and none used a PAD to refuse all treatment.[4]

Planning ahead is linked to fewer compulsory admissions. A 2019 meta-analysis of five randomized trials of crisis planning, including advance statements and joint crisis plans, found a 25 percent reduction in compulsory admissions compared with usual care, with no clear effect on voluntary admissions.[5] In a 2022 trial in seven French mental health facilities, people who wrote a PAD with help from a trained peer worker had a compulsory admission rate of 27.0 percent over 12 months, compared with 39.9 percent in the control group. They also reported greater empowerment and higher recovery scores.[6]

Stated preferences can shape ordinary care too. In a study of 123 people who listed medication preferences in a PAD, prescriptions moved toward the medications they had requested, and people who were prescribed at least one requested medication were much more likely to keep taking it at 12 months.[7]

These studies show associations and average effects in specific settings. They do not show that a PAD will prevent compulsory treatment for any individual person. The practical lesson is to write it with someone, and to write it so a clinician can use it.

Limits: what a psychiatric advance directive cannot do

A PAD records a person's wishes, but in many situations the law allows those wishes to be set aside. Readers should understand these limits before relying on one.

  • Civil commitment, emergencies, and court-ordered treatment. The National Resource Center on Psychiatric Advance Directives explains that state PAD laws commonly list circumstances in which clinicians may decline to follow a directive, and its state pages describe each state's rules.[8] In Oregon, for example, the statute allows treatment contrary to a declaration if the person is civilly committed and treatment is authorized under the commitment law, if the person is committed or transferred to a state hospital or similar facility under certain criminal or fitness to proceed provisions, or in an emergency endangering life or health.[9]
  • A PAD does not block commitment itself. Oregon law states that a declaration does not limit any authority under the civil commitment statutes (ORS 426.005 to 426.390) to take a person into custody, or to admit, retain, or treat a person in a health care facility.[9]
  • Professional judgment and withdrawal. In Oregon, a provider acting under a declaration must follow it "to the fullest extent possible, consistent with reasonable medical practice, the availability of treatments requested and applicable law," and a provider who is unwilling to follow it may withdraw from providing treatment.[10] The national resource center's summary also notes that a provider may refuse to follow a declaration that is inconsistent with professional judgment.[11]
  • Uneven use in practice. A directive helps only if someone finds and reads it. In a two-year study of 106 outpatients who had completed directives, researchers examined 90 crisis events in which a directive was accessed. In those events, care was consistent with the directive's instructions in an average of 67 percent of relevant areas. Instructions about hospital choice, seclusion and restraint, and contacting a surrogate were followed less consistently, and the most common reason given for overriding instructions was clinical need.[12]

For these reasons, a PAD is best understood as a way to communicate and document preferences, not as a guarantee against involuntary commitment or forced treatment.

Types of advance statements

  • Instructional directive. Written instructions about treatment: medications, hospitals, approaches to calming down, and people to contact.
  • Proxy directive. Names an agent, sometimes called a health care representative or attorney-in-fact, who makes decisions when the person cannot.
  • Combined directive. Both instructions and an agent. This is usually the strongest choice, because the agent can apply the instructions to situations the document did not foresee.
  • Joint crisis plan. A plan written together with the treatment team, often with a neutral facilitator. It is usually a clinical agreement rather than a legal document.
  • Self-binding directive. A statement that asks for treatment even if the person refuses it during a future crisis. It is the most debated type, and its legal status varies from place to place.[13]

Step 1: Find the rules and forms for your state

Almost all states allow some kind of health care advance directive that can cover at least some psychiatric treatment, and the National Resource Center on Psychiatric Advance Directives reports that 25 states have adopted laws specific to PADs.[8] Its state pages list each state's forms, witness rules, and the situations in which clinicians may decline to follow a directive. Start there, download the official form if your state has one, and read the override rules before you write anything. Those rules tell you which parts of your document are most likely to carry weight, and in which situations the document may be set aside.

Step 2: Describe your own crisis pattern

Clinicians read a PAD in a hurry. Give them context first, in a few short lines:

  • Early warning signs that others usually notice before you do.
  • What tends to trigger a crisis, such as lost sleep, a medication change, or a specific kind of stress.
  • What has helped in the past, and what has made things worse.
  • How you act when frightened, so staff do not mistake fear for aggression.

Step 3: Write specific treatment preferences with reasons

A preference with a reason is more persuasive than a bare refusal. Compare two lines. One says no antipsychotics. The other names a specific drug and the reaction it caused during a stated year, and then names a drug that worked with fewer side effects. The second version gives a clinician something to act on.

Cover these areas:

  • Medications. List drugs you accept, drugs you refuse, and the reasons. Include dose limits and known allergies.
  • Hospitals and programs. Name facilities you prefer and facilities you want to avoid. Include alternatives you would accept, such as a crisis respite program or an outpatient plan.
  • Calming approaches. Describe what helps: a quiet room, a specific person, time to talk, music, or walking.
  • Seclusion and restraint. State your preferences and any history of trauma that makes these more dangerous for you.
  • Other treatments. Address any treatments you have strong views about, such as electroconvulsive therapy, and check whether your state requires separate consent for them.

Step 4: Cover your life outside the hospital

A crisis can cost a person their housing, job, or pet. List who should be told and who should not, who looks after children or animals, how rent and bills get paid, whom to call at work, and where spare keys are. Practical instructions like these may help prevent a short hospital stay from turning into a lasting financial setback.

Step 5: Choose your agent carefully

An agent should be someone who will follow your wishes even when they disagree, who stays calm under pressure, who can be reached quickly, and who is willing to advocate firmly with staff. Talk through the whole document with them before you sign. Name an alternate in case the first agent cannot be reached. Some states, including Oregon, bar treating clinicians and facility staff from serving as an agent unless they are related to you, so check the rules on your state's page.

Step 6: Sign it correctly

Follow your state's signing rules exactly: the number of witnesses, who may not witness, and whether a notary is required. A document that fails a formal requirement may be ignored at the moment it matters most.

Step 7: Make it findable in a crisis

A PAD that sits in a drawer helps no one. Give copies to your agent, your alternate, your prescriber, your therapist, and your primary care provider. Ask each clinic to scan it into your record and confirm that they did. Carry a wallet card that says you have a PAD and gives your agent's phone number. Keep a photo of the signed pages on your phone. Review the document every year and after any major crisis, and renew it before it expires.

Worked example: Oregon

Oregon calls its PAD a Declaration for Mental Health Treatment, governed by ORS 127.700 to 127.737.[14] According to the national resource center's summary of the statute:[11]

  • A person can write instructions, appoint an agent, or both, and the declaration may cover medications and hospitalization, including refusals.
  • A person can give advance consent to admission to a facility for mental health treatment for 17 days or less.
  • Two adult witnesses who know the person must sign and certify that the person appeared of sound mind and was not under pressure. The agent, relatives, and employees of the person's health care provider cannot serve as witnesses.
  • The declaration takes effect when two physicians find the person unable to make mental health decisions; no court order is needed.
  • Providers may decline to follow it if the person is civilly committed, in certain criminal or fitness proceedings, in an emergency, or when it conflicts with their professional judgment. The statute also states that a declaration does not limit the authority to take a person into custody or to admit, retain, or treat a person under the civil commitment laws.[9]
  • It is valid for three years, and stays in effect past that date if the person is incapable at the time it would expire.

The statute also requires health and mental health care organizations to give adults receiving mental health treatment written information about their right to make a declaration.[14] Readers in other states will find different rules, which is why Step 1 comes first.

Limits to keep in mind

A PAD is a request, not a guarantee. See the limits section above for details. Most states allow clinicians to set it aside in emergencies or during involuntary commitment, and some allow them to decline on grounds of professional judgment. A document that refuses everything is the easiest to set aside. A document that offers reasoned alternatives may be easier for staff to follow, although no wording ensures that it will be followed. A PAD also does not replace a good working relationship with a prescriber, and it should be updated when your preferences change.

Getting help writing one

The research points to help, not willpower, as the deciding factor. Options include a peer support worker, a clinician you trust, a legal aid or disability rights organization, or a friend who has written one. Bring your state's form, a list of past medications and reactions, and the names and phone numbers of your agents. Plan for two sessions: one to draft and one, a few days later, to revise with fresh eyes.

  • In what situations can a psychiatric advance directive be overridden in your state, and what does that suggest about its limits?
  • Why might a facilitated session raise completion rates from 3 percent to 61 percent, and what does that suggest about how other legal tools are designed?
  • Write an essay comparing a psychiatric advance directive with Thomas Szasz's proposed psychiatric will.
  • Should self-binding directives be legally enforceable? Argue both sides.
  • How could peer workers be trained and paid to help people write advance directives at scale?
  • What makes a treatment preference persuasive to a busy clinician?
  • AI prompt idea: Ask an AI assistant to turn a list of your past medications and reactions into a clear, specific medication section for a psychiatric advance directive, then check every line yourself.
  • AI prompt idea: Ask an AI assistant to summarize your state's psychiatric advance directive rules from the official statute and to list each point with the section number so you can verify it.
  • AI prompt idea: Ask an AI assistant to role-play an emergency room clinician reading your draft and to point out which instructions are vague or hard to follow.

See also

References

  1. ↑ National Resource Center on Psychiatric Advance Directives, home page
  2. ↑ Szasz, T. S. (1982). The psychiatric will: A new mechanism for protecting persons against psychosis and psychiatry. American Psychologist, 37(7), 762 to 770. doi:10.1037/0003-066X.37.7.762
  3. ↑ Swanson, J., et al. (2006). Psychiatric advance directives among public mental health consumers in five U.S. cities: prevalence, demand, and correlates. Journal of the American Academy of Psychiatry and the Law, 34(1), 43 to 57.
  4. ↑ Swanson, J. W., et al. (2006). Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. American Journal of Psychiatry, 163(11), 1943 to 1951.
  5. ↑ Molyneaux, E., et al. (2019). Crisis-planning interventions for people with psychotic illness or bipolar disorder: systematic review and meta-analyses. BJPsych Open, 5(4), e53.
  6. ↑ Tinland, A., et al. (2022). Effect of psychiatric advance directives facilitated by peer workers on compulsory admission among people with mental illness: a randomized clinical trial. JAMA Psychiatry, 79(8), 752 to 759.
  7. ↑ Wilder, C. M., et al. (2010). Medication preferences and adherence among individuals with severe mental illness and psychiatric advance directives. Psychiatric Services, 61(4), 380 to 385.
  8. ↑ 8.0 8.1 National Resource Center on Psychiatric Advance Directives, State by state information
  9. ↑ 9.0 9.1 9.2 Oregon Revised Statutes 127.720, Circumstances in which physician or provider may disregard declaration
  10. ↑ Oregon Revised Statutes 127.717, Declaration to be made part of medical record; physician or provider to comply with declaration
  11. ↑ 11.0 11.1 National Resource Center on Psychiatric Advance Directives, Oregon questions and answers
  12. ↑ Srebnik, D. S., and Russo, J. (2007). Consistency of psychiatric crisis care with advance directive instructions. Psychiatric Services, 58(9), 1157 to 1163.
  13. ↑ Lasalvia, A., et al. (2023). Advance statements in mental healthcare: time to close the evidence to practice gap. Epidemiology and Psychiatric Sciences, 32, e68.
  14. ↑ 14.0 14.1 Oregon Revised Statutes, Chapter 127
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