Patients Adding Psychiatric Advance Directives to Medical Records

Even if they have not encountered them in practice yet, health information management (HIM) professionals may want to familiarize themselves with documents called psychiatric advance directives (PADs), a tool mental health professionals are using to help patients receive better care.

Although they are not yet recognized in every state, PADs have become a way that individuals with mental illness can help mental health providers respond to a psychiatric crisis in a way that minimizes harm to the patient. These documents are usually created by the patients themselves, with the help of a psychiatrist or a social worker and the assistance of a notary who notarizes the document so that it can be added to a patient’s existing medical record, according to a recent article in the New York Times.

Like a typical advance directive that dictates a person’s end of life wishes, a PAD contains specific instructions from patients on how they would like to be treated when they present for care either on their own or if they need to be involuntarily committed by a friend or family member. These patients have typically been hospitalized in the past and often have preferences for the medications they respond to best, as well as medications to which they respond poorly. They also provide direction for how caregivers should respond to delusions and hallucinations.

For example, one patient profiled by the Times writes: “I consent to the administration of the following medications: Valium, Lamictal, Depakote, Risperdal, Wellbutrin, Synthroid, and Pravastatin. I do not consent to the administration of the following medications: Haldol, Ativan or antipsychotic medications until you receive permission from my daughter.” The patient then explains that he has atypical reactions to those medications even though they may be a standard of care for other patients with the same symptoms.

In other cases, patients who have the same recurrent delusions or hallucinations suggest wording and phrases that caregivers can use to help calm them down. One patient listed 15 activities that help distract him during an episode.

“Sometimes I think that people are not who they say they are,” he advised. “Please let me know you are real by saying things like: ‘We drove here. We did not warp here,’” his directive states, according to the Times.

Although hospitals are required to ask patients about traditional advance directives, experts say use of PADs isn’t widespread enough for hospitals to embrace. And some hospitals are hesitant to add anything to a patient’s record that would supersede a treating physician’s authority.

For more information about PADs and the states where they are accepted, click here to visit the National Resource Center on Psychiatric Advance Directives.

Mary Butler is the associate editor at Journal of AHIMA.

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