casemark/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