Understanding Mental Health Advance Directives

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Understanding Mental Health Advance Directives Powered By Docstoc
					 UNDERSTANDING


  MENTAL HEALTH
ADVANCE DIRECTIVES
     (RCW 71.32)


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Purpose of RCW 71.32

   To help people express choices for
    mental health treatment when
    incapacitated.
   A validly executed MHAD is to be
    respected by (among others) health
    care providers, professional persons,
    and health care facilities.

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What is a MHAD?
   A written document
   by an adult with capacity
   Expressing instructions or preferences
    regarding mental health treatment
   For use when a person is incapacitated
   And (if desired) naming an agent to act
    on his/her behalf
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What is in a MHAD?

   May include instructions and
    preferences about any aspect of mental
    health treatment or care; for example:
    – Consent for or refusal of specific types of
      treatment
    – What has worked well in the past
    – Appointment of an agent to make treatment
      decisions on principal’s behalf


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The model MHAD form                                 (RCW 71.32.260)




   Includes:
    –   Statement of intent
    –   When it becomes effective
    –   Duration
    –   Revocability
    –   Preferences and instructions
    –   Appointment of agent (language in RCW 71.32.060)
    –   Notification of others and care of personal affairs
    –   Signature



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Requirements of valid MHAD

   In writing, dated, signed, witnessed
   Clear intent to create MHAD
   Designates whether principal can
    revoke during periods of incapacity
   If an agent is appointed, specifies that
    the agent has authority even if the
    principal is incapacitated.

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What Does It Mean to Be
Incapacitated?

   Unable to give informed consent
   found ‘incompetent’ by a court




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Determination of Capacity

   An adult is presumed to have capacity
   Incapacity may only be declared by:
    – A court (request by principal or agent)
    – One MHP and one health care provider
    – Two health care providers
   Initial determination must be made
    within 48 hours of request

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If an agent is appointed...

   Must act in good faith
   Must make decisions consistent with
    principal’s instructions or preferences,
    or if not known, in principal’s best
    interest
   Has same right as principal to make
    decisions or share information

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Agent (Cont.)

   May resign at any time by written notice to
    principal and providers
   Not liable for cost of treatment
   May not be paid
   May not be the principal’s provider (unless
    related)
   Decisions subordinate to decisions of a
    competent principal

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Revocation of MHAD

   In writing, but no special form needed -
    just clear intent
   Incapacitated principal cannot revoke
    unless he/she elected to do so when
    competent
   Principal must provide a copy of
    revocation to agent and providers(s),
    and it becomes part of record
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Revocation (Cont.)

   Can be superceded or revoked by court
    order, involuntary hospitalization, or
    incarceration
   A new directive revokes previous one
   Expiration date revokes directive, unless
    principal incapacitated at time


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Provider Responsibilities

   Act in accordance with provisions of MHAD to
    “fullest extent possible” unless:
     – Violates accepted standard of care
     – Requested treatment is not available
     – Compliance would violate applicable law
     – Compliance would endanger anyone
     – Inconsistent with purpose of court order
       relating to commitment (e.g.ITA)
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Responsibilities (Cont.)

   If the provider does not/cannot comply
    with the directive, he/she must
    – Notify the principal and agent
    – Document the reason for the non-
      compliance in the principal’s medical record




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What to document

 Place Advance Directives in the
  client record
 Note revocation/changes in the
  client record
 Document when unable to comply
  for any reason

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Provider’s Immunity

   Providers are not civilly liable if, acting in
    good faith and without negligence:
    – They provide treatment based on MHAD and
      capacity determination
    – They provide treatment without actual knowledge
      of a MHAD or revocation
    – They act in accord with a MHAD that is later found
      to be invalid
    – They validly refuse to provide treatment in accord
      with MHAD
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MHAD and Inpatient Treatment

   If principal consents to inpatient treatment in
    MHAD and is currently in need but refusing:
     – MD and another health care provider
       evaluate to determine incapacity
     – Obtain consent of agent (if any)
     – MD makes written finding of need for
       treatment and that no less restrictive
       alternative is available

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MHAD and Inpatient (Cont.)

   Principal admitted to inpatient treatment on
    the basis of a MHAD is a voluntary patient
    and may not be forcibly held against his or
    her will unless detained under RCW 71.05
   Can be encouraged to stay
   Must state desire to leave and take action
    consistent with that desire


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An MHAD May Not:

   Create an entitlement to treatment
   Obligate any health care provider or
    agent to pay treatment costs or be
    responsible for non-treatment personal
    care of principal
   Be used for consent to inpatient for
    more than 14 days in any 21 day period

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Some Interpretive Provisions

   If more than one directive, most recent
    MHAD & agent controls
   Requiring a directive is prohibited
   Principals do not lose their bed at a
    long-term care facility as a result of an
    inpatient stay pursuant to MHAD


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Implementing MHADs

   Understand the law
   Develop policies and procedures
   Figure out how access will work
   Educate consumers; Ask about MHAD
   Document in client record
   Integrate with treatment
   Monitor use and issues

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