Guide to Psychiatric Advance Directives

About PADs

Psychiatric advance directives (PADs) are a specific type of advance directives — a legal document that allows a person to state what they want to happen with medical treatment and who they want to make decisions for them in advance of a crisis. Any adult who has the “capacity” to make health care decisions and is acting of their own free will may make an Advance Directive. “Capacity” means the person’s ability to understand a decision’s consequences and to make and communicate the decision.

A PAD details a peer’s (individual living with mental health conditions) preferences for future mental health treatment and/or assigns an individual as a medical proxy to make treatment decisions if the person is in crisis and unable to do so. In California, a PAD can include the appointment of an agent for health care and individual health care instructions; peers can complete one or both parts of the PAD, and either part is legally binding by itself. If the peer decides to appoint an agent, they have the right to limit the agent’s power. The agent must make decisions in the way the peer would have themselves (“substituted judgement”) and cannot authorize treatment over the peer’s objection.

Approaching PADs

PADs have three primary components. While peers can choose to complete either one of the first two components or both, the third component must be completed for legal validation:

  1. Designation of a Health Care Agent (or Power of Attorney for Health Care): This enables the peer to name a Health Care Agent. An agent is responsible for making health care decisions for the person with “substituted judgement” should they lose the ability to make these decisions. 
  2. Individual Health Care Instructions: This enables the peer to write specific instructions about the care and treatment they would want in certain situations. This could cover both physical and mental health treatment. 
  3. Signature Pages: In order to be valid, a PAD must have the peer’s signature, the date the PAD was made, and the signature of either two witnesses or an acknowledgement by a notary public.

Peers should explain the reasons for their choices in the PAD as much as possible. The more they explain the reasoning behind their choices, the more difficult it will be for someone to argue that the peer lacked capacity when they wrote and signed the PAD.

No specific form must be used, but a sample California Advance Health Care Directive Form with instructions is linked here. After completing and signing their PAD, the peer should make multiple copies of it to distribute to their providers, family, and friends. In California, a PAD can, but does not need to, also be filed with the Secretary of State’s Advance Health Care Directive Registry (instructions here). If a PAD is filed with the California Secretary of State, the peer will receive a wallet card indicating that they have registered an advance health care directive with instructions on how to access it.