Implementing psychiatric advance directives: Service provider issues and answers

Psychiatric advance directives (PADs) are an emerging method for adults with serious and persistent mental illness to document treatment preferences in advance of periods of incapacity. This article presents and responds to issues most frequently raised by service providers when planning for implementation of PADs. Issues discussed include access to PADs; competency to execute PADs; the relationship of PADs to standards of care, resource availability, and involuntary treatment; roles of service providers and others in execution of PADs; timeliness and redundancy of PAD information; consumer expectations of PADs; complexity of PADs; revocation and “activation”; legal enforceability of PADs; the role and powers of agents; liability for honoring and not honoring PADs; and use of PADs to consent for release of health care information. Recommendations are made for training staff and consumers, consideration of statute development, and methods to reduce logistical, attitudinal, and system barriers to effective use of PADs.