Psychiatric Advance Directives (PADs): A US Healthcare Staff Guide

A psychiatric advance directive, usually shortened to PAD, lets a person say in advance how they want to be treated if a mental health crisis later leaves them unable to decide for themselves. For staff in emergency departments, inpatient units, crisis teams and community services in the United States, a PAD is one of the clearest records of a patient's own wishes, written when they were well. It is also an area where the rules change from state to state, so knowing the basics and knowing who to ask is part of safe practice. This guide covers what a PAD is, how it works, and what staff should do when one turns up.

What a psychiatric advance directive is

The American Psychiatric Association describes a PAD as a legal document in which patients can describe the types of mental health treatment they would or would not be willing to receive. Patients can also name another person, often called an agent, to make treatment decisions for them if they lose capacity. A PAD is not a medical order and does not replace clinical judgment, but it is a structured way of making the person's voice count when they cannot speak for themselves.

What a PAD can include

According to the APA, people writing a PAD are encouraged to think about preferred treatment location, who should be notified during a crisis, preferences or alternatives to hospitalisation, medication and treatment preferences, the clinicians they would like involved, and who should act as their agent. In practice this can include things like which medicines have caused harmful side effects, which have worked, whether the person wants a particular hospital or a crisis respite service, who should look after a pet or children, and which techniques help when they are distressed.

When a PAD takes effect

A PAD comes into force when the person's health care provider finds that they lack decision-making capacity, for example during acute psychosis, mania, catatonia or delirium, as the APA explains. It is temporary: once the person regains capacity, they are back in charge of their own decisions. This means staff should not treat a PAD as a reason to stop talking to the patient. They should keep assessing capacity, keep involving the person as much as possible, and revert to the person's contemporaneous wishes when they are able to give them.

State law differs, so check

The APA states that only 25 states have laws that specifically allow PADs, although most states let people record advance mental health instructions and appoint an agent under general medical advance directive laws. Compliance rules also vary. An article in Current Psychiatry on when clinicians may disregard a PAD notes that most states give physicians options if they believe they should not comply, and gives examples such as an emergency that endangers life or poses a serious risk to physical health, or a court order that contradicts the directive. In some states, a court that commits a patient can order treatment contrary to the directive if it acknowledges the document. The article also notes that in the three states of the Second Circuit (Vermont, New York and Connecticut), powers of attorney for patients with mental illness cannot be abrogated in the way they can elsewhere. For staff, the practical point is that the answer to "do we have to follow this?" depends on the state and the facts, so involve the legal or risk team early.

Practical steps when a patient has a PAD

• Find it early. Ask at triage or admission whether the patient has a PAD, and check the chart, the patient's belongings and the agent's contact details.
• Check validity. Confirm it is signed, witnessed or notarised as your state requires and that it appears current.
• Contact the agent. If one is named, they may be able to speak to the patient's preferences in real time.
• Record your decisions. If the team departs from the PAD, document why, which provision was overridden, and which legal route was used.
• Do not ignore it silently. A directive that is not followed without explanation can damage trust and lead to complaints.

How a PAD links to other law

A PAD does not stop a clinician from using emergency powers where the law allows. For example, involuntary holds such as California's 72-hour hold are governed by separate statutes; see our guide to involuntary psychiatric holds. PADs are also personal health information, so sharing them must respect privacy rules; see our HIPAA training requirements guide. A directive can also record what has helped in past suicidal crises, which can feed into safety planning as described in our guide to suicide risk reduction.

Frequently asked questions

Is a PAD the same as a regular living will?

No. A general advance directive is usually about end-of-life or physical health care. A PAD is about mental health treatment, and its legal status depends on the state.

Can a patient cancel a PAD?

The APA notes that PADs can be drafted so that the person must have capacity to revoke them, which is intended to protect stated wishes during a mental health crisis. Check your state's rules on revocation.

Where can staff build their knowledge?

Capacity, consent and crisis law are core to behavioural health compliance. The Learnsignal CPD hub lists healthcare courses staff can use for ongoing training.

Sources: American Psychiatric Association, psychiatric advance directives information for patients and families; Current Psychiatry, "Psychiatric advance directives: May you disregard them?". This article is general information, not legal advice.