So, B.B. and Marvin, we have quite a few questions, so let me get right to that. Is a healthcare entity immune from some sort of legal consequence if, in the process of honoring a PAD, there's a negative outcome? For example, a patient's PAD instructs withholding treatment under circumstances, and in doing so, the patient has a negative outcome. Yes. Yes, so let me jump in, B.B., so if you go into your specific statute in that state, you can see the, usually there's a reference to immunity related to good faith efforts to honor PAD, so that usually it says something to the effect that if someone in good faith honors a PAD as a facility does, then they are immune from liability. Having said that, there are very complicated situations, and that would lead to consulting with attorneys, and on specific situations like that, I think the facility really needs to make sure it has some legal advice to approach that specific situation. Great. We have a person who wrote in who works in South Carolina in the Department of Mental Health and would like to know, could they come to a PAD training website workshop available? Is that something they could sign up for? Why don't you take that, B.B.? So, I think that that's something that if you want to shoot me an email, I think my email should be somewhere in this, I could probably provide some information. You know, we do, we're based in Fayetteville, Southern Regional AHEC is based in Fayetteville, North Carolina, and people could come up from another state, South Carolina is pretty close by, and take some of our continuing education workshops, and we are periodically offering those on psychiatric advance directives, and potentially we might be able to figure something out for nearby states. Of course, it would have to be your laws. Yeah. Yeah, this person actually lives in South Carolina. Okay. Great. Is it legal for a PAD notary to be an employee of a treatment facility or provider? I think, Marvin, you talked about this, but can you answer that? Yes. There's not a problem with the notary being an employee. The problem is with a witness. The witness has to be independent of the facility. For patients who have been suicidal in the past, or even had ideation, would PADs be a protective factor? Do you want to take that, B.B.? Well, I think that the main thing that I would see with PADs, and I think it would be depending on the individual situation. I do think that it would give people sort of a sense of more control in what happened in their treatment, and more of a voice, and I think that that can be clinically very helpful to people. So, yeah, that might not be directly answering the question, but I think if people feel like they've got more of a voice in their treatment, that that might lead to more engagement in treatment efforts. Yeah, and let me jump in, too. So in the advanced instruction piece, that person could put into the advanced instruction maybe some description of the past precipitance of the suicidal ideation, and what they found helpful and not helpful, so that could be documented for the subsequent providers to see. Do you find there are challenges in getting psychiatrists to comply with PADs, and if so, under what circumstances? So I'll take that. You know, we've seen, so we've worked with a lot of clinicians and talked to a lot of clinicians, done surveys with mental health clinicians, psychiatrists, you know, and all other mental health professionals, and when people don't know much about them, there's some resistance. So, you know, sometimes people will say, well, I'm not going to, you know, I'm not going to take a piece of written, you know, a written piece of paper and follow it if I don't know the context or the patient very well or, you know, so on and so forth. But once they see the caveats and hear the caveats that I mentioned, that one, the psychiatrist doesn't need to, isn't required to provide any treatment that he or she essentially feels is not consistent with community practice standards. So if it's something that they're not comfortable with, they don't have to do it. Or if it's not feasible, or if it conflicts with some other law or involuntary commitment, those are all ways that it, you know, preserves the discretion of the treating clinician. So once clinicians hear that, I think they feel very much that, you know, that these are things that should be honored and respected. I will say that one gap that we're trying to address that is sort of problematic is that many clinicians are not in the practice of systematically assessing whether the person has capacity. So if, you know, if someone is psychotic and unable to communicate or make mental health decisions, they're likely to be incapacitated. And so then documenting that the person is incapacitated would, in effect, activate or put into place the advanced directive. So remembering that that's in place, I think is an important part of practice that we need to address. It also means that clinicians should not be taking consent from people who are not capable of giving consent. And I think that that's a common gap in practice among clinicians is, you know, busy clinicians often are apt to say, well, if the patient's agreeing with the plan or not resisting to the plan, then that consent is valid. Well, sometimes those consents are not valid, and we need to be more careful about that. I might just add that there's a kind of a little bit of a culture shift to really doing some shared decision-making with people who live with serious mental illness, that there are some principles that underlie what would go along with increased use of psychiatric advanced directives. So we've had a couple questions about minors and adolescents. And here's one. My question is, how do we handle pediatric or adolescent rights related to the PAD, knowing that their parents or authorized representatives have authorization? So how do we balance that? What happens? Yeah. So that's a great question, and the person's quite right that, you know, until one reaches the age of consent, which varies from state to state, an advanced directive would not take effect because it's still the consenting party is the parents and the child is assenting to treatment. So these are really more designed for adult patients. There's no reason, though, that the process might not be used, like the advanced instructions could be very informative in the form of a crisis plan that's done collaboratively between the patient and the parents and the clinician. So we would probably advise developing a crisis plan, but not expect it to have the same legal authority that an adult one would. And I will add to that. I think in North Carolina, we had seen that a lot of parents of transition age youth were getting recommendations to pursue guardianship of their children as they were approaching the age of 18. So a psychiatric advanced directive can be a less restrictive kind of thing to do with an adolescent as they are approaching adulthood. It can be a way to work more collaboratively with a family, but to give the young adult more say in what's happening in their treatment, but to do it in a way that is not restricting their rights. Yeah, let me add to that. Let me add to that. I'm glad Phoebe brought that up. So there are a fair number of people who are concerned about guardianship and the notion that here we're talking more about adults, but that guardianship often is a one way street in that a person is declared incompetent, is put under guardianship, and there's not much review of whether the person could return to a self-determined state and make their own decisions. And so folks who are involved in guardianship issues have been interested in psychiatric advanced directives as an alternative to guardianship, because you can think of it as an emergency form of guardianship, because once the healthcare agent steps in and makes decisions, that has the same force of law generally as a guardianship, it's just that it will automatically turn off when the person regains capacity. If someone isn't returning to capacity, they may transition from the advanced directive to permanent guardianship, and there's a provision for that. But the intent of the advanced directive among some people is to use it as this emergent form of guardianship and as an alternative form of it. We also have had a couple people write in and say something to the effect of, could this be part of the end of an inpatient hospitalization, where at the end of an inpatient hospitalization before discharge or part of discharge planning would be to develop a pad? Is that possible or would it need to be when they're an outpatient? Well, there's no requirement that you wait to be an outpatient. Generally, we recommend that it be introduced as part of the discharge plan, and certainly if there's an existing one to have there, but it may be better to get some time to reflect on the inpatient experience before doing it. But there's no reason, I mean, there's no legal reason or practical reason not to do it then. Yeah. And I think we've sort of seen that the best time for someone to create a pad is when they are in a very good frame of mind and kind of in a good place of recovery. And oftentimes when people are discharged from the hospital, they're still a little bit maybe not in the best frame of mind. So that's kind of what we've been seeing. Okay. Several people have written in and asked about their particular state. So there's two issues with this. One, how do people find out if their state have pads, number one? And number two, and I think Marvin talked about this, if someone writes a pad in a state that doesn't have it, I think you said that it can be covered under another mechanism. So can you speak to that? Sure. So if you go to our web portal to the National Resource Center on Psychiatric Advance Directive, we have a state-by-state guide in which we indicate what the law is in the state. We have links to the relevant forms, and we have 10 questions, in effect, FAQs that we answer about each state. And we do our best to keep that up to current, although covering 50 states sometimes is a challenge. That information is in NRCPAD, it's the state-by-state guide, and you can also ask questions through that website if you have questions about whether the information is there or valid or whatever. So that's one issue. Generally advance directives do not transfer across states. There was proposed legislation several years ago, and unfortunately it got politicized, and we have Sarah Palin, in effect, to thank for this, in that she sort of started to talk about advance directives and their transportability in a negative way as death panels. So that legislation got de-sticked in front of Congress. It would have allowed transportability of advance directives, but that hasn't happened. We hope that Congress will do that in the future and make them transportable. Right now they're not. What I said about medical advance directives is that generally, under medical advance directives within one state, you could do a psychiatric advance directive if you don't have a specific statute that covers psychiatrically. What if someone has a sister listed on their health care POA, but has someone else listed as their agent on their PAD? Which form should medical providers follow for decision-making? So part of the facilitation that we do, this is an important question, an important issue, is that we don't want there to be discrepancies so that busy providers can look at the documents and get unambiguous clarity about this. So in a situation like this, I couldn't tell you across states which would have precedence. It would depend on the state and probably be something that would require legal advice. Several people have written in, not surprisingly, that many of their patients don't have two people to be witnesses. And they've sort of said, what would you recommend or what have you done in the past in order to get a couple witnesses for someone who wants to write a PAD? Yeah, I'll take that one. So a lot of the things that we've done in training our facilitators is try to find sort of like practical strategies that get around some of these barriers. The thing that has seemed to work best were these workshops where we, a PAD creation workshop, because there's a group of people there that people can witness each other's, be the witnesses for each other. So that has worked. The other thing is sort of just working with a strategy. Might there be somebody from a person's church? Might there be people in the community? The idea of the witnesses is that they don't have to be somebody who knows the person like really, really well, but is able to just sort of say, yes, I see this person. They seem like they're in a good frame of mind and no one seems to be coercing them and they are who they say they are. So that's double checked in North Carolina with through the notary having to verify identity. Yeah, those are, so we try to just find some practical strategies and they may vary for the individuals. Got it. So, unfortunately, go ahead. I'm sorry, this is Marvin. I would say that, I mean, Bibi is an expert in this and I would say that it is one of the reasons why we're doing what we're doing is to try to help people solve these barriers. A lot of people who would want to do these are pretty disenfranchised or poor. So it might be hard for them to go to a bank and get it done. So it takes a village and these types of initiatives have to solve these kinds of problems.

psychiatric advance directives

healthcare entities

Southern Regional AHEC

suicidal tendencies

National Resource Center on Psychiatric Advance Directive