psychiatric-advance-directive

# Psychiatric Advance Directive (PAD)

A PAD preserves autonomous psychiatric treatment choices across a capacity gap. It captures medication preferences, agent authority, de-escalation instructions, and crisis contacts in a clinically actionable format — with a first-page crisis summary for intake staff.

> **DRAFT FOR ATTORNEY REVIEW ONLY — Not legal advice. Not execution-ready without jurisdiction-specific verification of statutory formalities, citations, and Ulysses Clause availability.**

## Pre-Draft Intake

Gather before drafting (skip only if user says "use defaults"):

1. **Jurisdiction** — required; controls enforceability, formalities, Ulysses Clause availability. Flag portability limits for multi-jurisdiction use
2. **Clinical history** — diagnoses (with consent), prior hospitalizations, involuntary holds, current medications, allergies/adverse reactions
3. **Agent designation** — primary + alternate: full legal name, address, phone, email, relationship; identify conflicting statutory default surrogates
4. **Exclusions** — persons blocked from agent role or information access (protective/no-contact/restraining orders)
5. **Treatment preferences** — ECT, seclusion/restraint, psychotropic drug classes, de-escalation techniques, voluntary vs. involuntary admission, peer respite, law enforcement involvement
6. **Crisis activation** — early warning signs, sensory/trauma triggers, preferred first contacts
7. **Existing documents** — general AHCD, health care proxy, guardianship orders, prior PAD
8. **Execution logistics** — notary access, witness availability, statutory disinterest rules, agent acceptance requirement

**Defaults if no response:** General PAD framework without jurisdiction-specific formalities; primary agent + one alternate; standard medication structure; marked **NOT EXECUTION-READY**.

## Workflow

### 1. Build Document Architecture

**First-page crisis summary** (intake staff must find key info in <2 minutes):
- Agent name + 24/7 phone
- Top 3 crisis triggers / early warning signs
- Top 3 treatment preferences (including critical refusals)

**Section map:**

| Section | Content |
|---|---|
| Title & Purpose | PAD title; plain-language purpose; conflict-of-directives priority clause |
| Capacity Affirmation | Principal's voluntariness statement; optional clinician attestation |
| Agent Appointment | Primary + alternate with 24/7 contact; statutory incapacity standard; priority over default surrogates; HIPAA authorization |
| Exclusions | Named individuals barred from role or info access |
| Treatment Preferences | Medications, ECT, hospitalization, de-escalation (Step 2) |
| Ulysses Clause | Non-revocation during incapacity — include only if jurisdiction allows (Step 3) |
| Revocation & Updates | Standard revocation; annual review; supersession of prior PADs |
| Crisis Activation | Warning signs; contact ladder (≤2 contacts); what helps client accept care |
| Override Protocol | Facility obligations when PAD cannot be followed |
| Execution Blocks | Principal, 2 witnesses, notary (if required), agent acceptance (if required) |
| Distribution Log | Agent, alternates, providers, hospital systems, patient portals, state registry |

### 2. Draft Treatment Preferences

**Medication structure** — three categories:

- **PREFERRED:** Drug — reason (prior efficacy, tolerability)
- **CONDITIONAL:** Drug — when (specific circumstances only)
- **REFUSED:** Drug — reason (adverse reaction, date) — acceptable alternative

Pair every refusal with an alternative. Include rationale to reduce best-interests override risk.

**ECT:** Explicit consent/refusal/conditional consent with conditions stated.

**De-escalation:** Concrete staff behaviors that help; specific accommodations to try before restraint; trauma triggers.

**Override protocol:** If facility cannot follow PAD: (a) least restrictive alternative, (b) document deviation reason, (c) notify agent promptly, (d) re-review PAD once stabilized.

**HIPAA authorization:** Authorize agent to receive diagnoses, medications, treatment plans, discharge planning. Note: standalone HIPAA-compliant authorization (45 CFR § 164.502 `[VERIFY]`) may be required; state mental health confidentiality laws may impose higher protections.

### 3. Analyze Ulysses Clause

**Do not include if jurisdiction does not recognize non-revocable PADs.** Including in a non-recognizing jurisdiction risks the document being viewed as coercive or legally defective. If unclear, omit and flag for attorney verification.

Reference frameworks `[VERIFY all citations]`:

| State | Framework | Key Notes |
|---|---|---|
| North Carolina | N.C. Gen. Stat. § 122C-71 et seq. `[VERIFY]` | Specific statutory form; deviation may cause facility rejection |
| Texas | Tex. Civ. Prac. & Rem. Code Ch. 137 `[VERIFY]` | "Declaration for Mental Health Treatment"; expires 3 years |
| California | Probate Code § 4701 `[VERIFY]` | General AHCD framework; mental-health provisions appended |
| Virginia | Va. Code § 54.1-2981 et seq. `[VERIFY]` | Agent may overrule contemporaneous protest if PAD authorizes |

**No explicit PAD statute:** Title as "Mental Health Treatment Preferences and Appointment of Health Care Representative for Psychiatric Decisions"; recommend parallel general durable HCPOA.

### 4. Execution & Distribution

- [ ] 2 disinterested adult witnesses — verify statutory exclusions (not agent, not facility staff, not financial beneficiaries)
- [ ] Notarization — jurisdiction-specific
- [ ] Agent acceptance signature — jurisdiction-specific
- [ ] Copies to: agent, alternates, psychiatrist, therapist, case manager, hospital systems, patient portals
- [ ] Check for electronic advance directive registry
- [ ] Wallet crisis card referencing PAD existence and location
- [ ] Date all signatures; supersession clause for prior PADs
- [ ] Annual reaffirmation or review after any hospitalization

## Post-Draft Review

Confirm with user:

1. Medication preferences (preferred/conditional/refused) accurate with correct rationales?
2. Crisis activation section reflects actual warning signs and preferred contacts?
3. Ulysses clause inclusion confirmed with jurisdictional verification?
4. Facility-specific requirements (state hospitals, VA, specific health systems) addressed?

Default if no response: recommend reviewing medication refusal rationales (most common override point).

## Quality Checks

- [ ] First-page crisis summary present and scannable in <2 minutes
- [ ] Agent chain: primary + alternate with 24/7 contact info
- [ ] Medications structured preferred/conditional/refused with rationales
- [ ] Every refusal paired with acceptable alternative
- [ ] ECT position explicit
- [ ] De-escalation preferences concrete and operationally possible
- [ ] Ulysses clause only if jurisdiction supports (verified)
- [ ] Override protocol in cooperative tone
- [ ] HIPAA authorization included
- [ ] All citations verified or marked `[VERIFY]`
- [ ] No operationally impossible demands (convert to ranked preferences)
- [ ] Execution formalities match jurisdiction

## Guidelines

**Ethics:**

| Rule | Application |
|---|---|
| MR 1.14 | If client appears incapacitated at execution, stop |
| MR 1.1 / 1.4 | Research controlling PAD statute; counsel that emergency statutes may override preferences |
| MR 1.6 | Consider omitting diagnoses in favor of functional descriptions given wide distribution |
| MR 1.7 / 1.8 | Flag conflicts: paid caregiver, estranged spouse, financially interested agent |

**Anti-hallucination:**
- Verify every citation via official state code databases; mark unverified `[VERIFY]`
- Never assert "legally binding" without jurisdiction-specific verification
- Replace aspirational language with concrete operational instructions
- Keep preference rationales to 1–2 sentences