Directions for Using the Advance Psychiatric Directive Forms
If you are reading this online, print or download the sections you plan
to use.
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I. How to Fill Out the Forms
- Read each section carefully.
- Choose which sections you wish to use. Sections I and VI are required.
If you aren't sure whether or not you want to use section II, appointing
an agent, find out if your state's law requires an agent for mental
health decisionmaking. Your state protection
and advocacy agency may be able to tell you. Sections III, IV and
V are optional and cover the substance of your instructions.
- If you decide to appoint an agent, make sure he or she understands
your wishes and is willing to take the responsibility. Your agent and
alternate agent(s) should sign the form to show acceptance of the responsibility.
- Talk over your choices with your treating providers and your case
manager.
- Fill in only the choices you want in sections III, IV and V. Your
advance directive should be valid for whatever part(s) you fill in,
as long as it's properly signed. You may cross out and/or write in words
or sentences (or rewrite, if you are editing the document on a computer).
- To indicate which choices you want, put your initials in the blank
at the beginning of a statement. If you do not want a statement to be
true, leave the blank empty
- Add any special instructions in the spaces provided. Be sure you also
put your initials in the blank at the beginning of that segment to make
your choices valid. You can write additional instructions or comments
on a separate sheet of paper, but be sure to write on the form that
there are additional pages.
- Complete the checklist attached to section I to show at a glance what
your advance directive covers.
- Assemble the completed sections, renumber the pages and sign section
VI before two witnesses (see the list on the signature page of people
who cannot be your witness). Some states may require a notary's signature
as well; if you are not sure, it's best to have the document notarized.
- Have copies made and give them to your doctor(s), the individual(s)
you have appointed to make mental health care decisions for you, your
family and anyone else who might be involved in your care. Explain your
choices to each of them
II. Frequently Asked Questions
Can I change my mind?
You can revise your advance directive at any time unless you have been
declared legally incompetent. However, state laws vary about whether you
may revoke your advance directive or overrule your own agent after becoming
incapacitated. Part V spells out some options describing when you want
to be able to revoke, suspend or end this advance directive. A lawyer
can explain your state's law in this regard. (Note that only a few states
have any specific law on this. As of 1997, Alaska, Hawaii, Illinois, Maine,
Minnesota, North Carolina, Oklahoma, Oregon, South Dakota, Utah and West
Virginia do.)
Should I see a mental health professional before signing an advance
directive?
For your advance directive to be valid, you must be legally competent
when you sign it. To protect yourself against any claim that you were
not competent when you signed your advance directive, you can ask a mental
health professional to conduct a mental status exam and note in your medical
record file that you were of sound mind at the time. Ask for a signed
copy of this note, and attach it to your advance directive. This is not
absolutely necessary, but it can head off future challenges.
What to do when you are finished
You want your advance directive to be an active part of your medical
record. It is a good idea to discuss your choices with your case manager
and treating providers. Your advance directive is more likely to be remembered
and followed if you have told them about it and explained to them the
choices you made, and why.
When will my advance directive take effect?
Your advance directive will become active, under most states' laws, when
a doctor, usually your treating physician, determines that you are not
capable of making health care decisions on your own behalf.
Who should have copies?
Your treating professionals should have copies of your advance directive.
Your agent, if you appoint one, and each alternate agent you name should
have a copy. Also consider giving copies to family members, close friends,
the hospitals or programs where you might be taken in an emergency, your
managed care firm (if you have one) and your other service providers.
If you make changes, be sure to let everyone who has a copy know. For
this reason, you'll want to keep track of who has copies; a form for doing
this is attached to the signature page.
If you travel, be sure to take a copy with you. And keep the original
in an easily accessible place.
How will anyone know I have an advance directive?
A form that advises physicians and others of your advance directive appears
below. It is designed to fit in your wallet. Complete the information
on the form, cut it out, fold it in half and keep it in your wallet.
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PHYSICIANS AND OTHERS PLEASE NOTE:
I have an advance directive for mental health
decisionmaking, a legal document stating my preferences as to
psychiatric hospitalization and treatment. A copy may be found
at:
_______________________________________________
_______________________________________________
If I am incapacitated, please obtain this document
and respect the choices I have registered in it.
My name: ______________________________________
My SS#: _______________________________________
I have appointed as my agent for mental health
decisionmaking _________________________________
who can be reached at __________________(day)
or
________________ (evening). This person is authorized
to make all decisions about my psychiatric treatment in the event
that I am incapable of making such decisions.
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