Hello and welcome. I am Jose Villarreal, Clinical Director of Behavioral Health at Erie Family Health Centers and Community Care Expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar on Psychiatric Advance Directives, a Tool for Improving Crisis Care and Legal Issues for Implementation. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI community, our efforts have been focused on helping you receive the answers you need for the care of your patient. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Social Work Continuing Education Credit, and one Nursing Continuing Professional Development Contact Hour. Participants who are participating in today's webinar will be available until November 8th of 2021. The slides from the presentation are available in the handout area found in the lower portion of your control panel. Just select the link to download the PDF. And please feel free to submit questions throughout the presentation by typing them in the question area also found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for question and answer. And now I would like to introduce to you the faculty for today's webinar, Dr. Deb Pinos and Dr. Marvin Schwartz. Dr. Deb Pinos is the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. Dr. Pinos is also the Director of the Program in Psychiatry, Law, and Ethics at the University of Michigan. Dr. Pinos' research interests include the legal regulation of psychiatry practice, law, and psychiatry, and justice and behavioral health. Dr. Marvin Schwartz is a professor of psychiatry and behavioral science at Duke University School of Medicine. His research interests include psychiatric advanced directives and mental health services for persons with serious mental illness. I would like to thank you both for leading today's seminar. Great. Thank you so much for that nice introduction and welcome everyone to this webinar. Neither Dr. Schwartz nor I have any conflicts of interest to disclose for this presentation. I'm going to just launch right in and talk about what we hope to accomplish over the next hour. Our learning objectives for today are to describe for you the legal origins of psychiatric advanced directives, and you'll see the acronym PADDS on some of these PowerPoints. We also want to have you be able to identify barriers and promoters of PADD implementation, and then finally summarize legal principles and controversies around psychiatric advanced directives. Let me start with a case example that may seem somewhat familiar to you, but may have an ending that's less familiar. Ms. Jones is picked up by police after she's found wandering in mute, wearing sandals and a t-shirt in cold weather. She's transported to a crisis facility. While in the crisis facility, the providers look in her electronic health record, and there is an indication that she has a psychiatric advanced directive, and that may be the part that you're not as familiar with, which we're hoping to cover today. The advanced instruction gives information about her history and her medication preferences. She also has a healthcare power of attorney identified, and her sister is her healthcare agent. The psychiatrist examines Ms. Jones and finds that she currently is lacking capacity based on her inability to attend to the psychiatrist's questions, and her statements do not seem to be related to reality. The psychiatrist documents that Ms. Jones is currently incapacitated in her medical record. He then calls her sister, who gives him further information about what Ms. Jones would want in terms of treatment. The sister comes to the crisis facility and signs paperwork allowing Ms. Jones to be admitted voluntarily to the hospital. Ms. Jones is relieved by the presence of her sister, whom she trusts to speak for her, and Ms. Jones calmly agrees to the hospitalization. So in this scenario, we are depicting a situation in which a psychiatric advanced directive has been completed prior to Ms. Jones' recent return of her psychiatric symptoms. So what are psychiatric advanced directives? They are legal documents that allow persons when of sound mind to refuse or give consent to future psychiatric treatment. In other words, they're written at one point in time with the idea that they will be implemented at another point in time, and so they provide advanced instructions. They may authorize another person to make future decisions about mental health care on behalf of the person with mental illness should they become incapacitated. In this way, it reflects a healthcare power of attorney. So we're going to be talking a lot about these psychiatric advanced directives, and I just want to review some of the benefits that we see with their use. First of all, these psychiatric advanced directives authorize permission to consult with the family in the role of healthcare agent. They also authorize in advance permission to speak with other providers. They provide a history and a crisis plan via these advanced instructions, and they further can authorize admission to a psychiatric hospital by the healthcare agent, and therefore avoid the necessity of any kind of involuntary admission procedure. The goals of an advanced directive generally are to ensure that patients are treated according to their wishes, even when they cannot speak for themselves. Even when the person is unable to communicate coherently, they provide a mechanism for the exchange of clinical information, and they provide a mechanism for the individual to have consented or refused treatment. And the way they work is that they appoint a proxy decision-maker, sometimes referred to as the healthcare agent, when the patient is incapacitated. And so that healthcare agent becomes activated, their authority becomes activated when there is a determination that the patient is incapacitated in their decision-making ability. Where did these advanced directives come from? In terms of the legal origins, there's a very interesting history. There was a Supreme Court case called Kruzan versus the Director of the Missouri Department of Health in 1990, and in this case, this was a young woman who had a traumatic brain injury after a motor vehicle accident. And the question on the table was, what was required for her family to make end-of-life decisions for her? And essentially, the U.S. Supreme Court said that they required clear and convincing evidence of a patient's wishes in order to withdraw life-sustaining medical treatment. And part of the problem with Nancy Kruzan's family situation in the beginning was that there really wasn't anything in advance that was sufficient to satisfy the court's requirement to allow them to withdraw life-sustaining medical treatment. So the family ended up in a very long legal battle regarding this until this case went up to the U.S. Supreme Court. And so what this case really did is it defined the need for written documentation as evidence of what one would want should they become incapacitated. And so we very often talk about these end-of-life directives in a medical context, but through psychiatric advanced directives, we're now moving to discuss them in a psychiatric context. These advanced directives then, following that Kruzan case, also came through this Patient Self-Determination Act of 1991. And in this act, it was written to help implement medical advanced directives and end-of-life living wills. And it requires hospitals receiving federal funds to ask patients if they have an advanced directive at the time they are admitted to the hospital, also to document advanced directives where they exist, and to follow them when they are invoked. And also it requires hospitals that are receiving federal funds to have a written policy for implementing these advanced directives. And this occurs every day today in the United States in terms of medical services. Now I'm going to turn the rest of this presentation over to my colleague, Dr. Swartz, until we get to the question and answer period. Thanks very much. So following the passage of the Patient Self-Determination Act in the 1990s, states began to adapt advanced directives for mental health purposes in the hopes of strengthening patient self-determination and really to try to reduce the use of involuntary commitment. So the idea there was that there's all too many people who are being involuntarily committed who otherwise would have consented to admission, but for the fact that they weren't able to speak for themselves and give competent consent. The one big difference, though, between psychiatric advanced directives and end-of-life directives is that they have built into them, in most states, a self-binding aspect. And that means that the person, when they're well and able to formulate a plan, construct an advanced instruction, so a treatment plan, and appoint a proxy, so someone that they trust, to have a treatment plan that they're locked into. So the idea is that once a crisis starts, the pad is activated, as Dr. Pinals mentioned, and while it's activated, it's binding and cannot be changed. Now before and after, the person can change their advanced directive in any way they choose, but once incapacitated, the patient cannot change his or her mind about their treatment preferences. So in the late 1990s, there were a number of states that passed the pad statutes, and I'll give you a number of examples from North Carolina, just because, you know, states vary, so we might as well pick a state that we can speak about. And in fact, North Carolina achieves this by having two separate pieces of statute. One is the advanced instructions for mental health treatment, and then there's the health care power of attorney, and that allows the appointment of a general health care power of attorney, and also a mental health power of attorney. And the idea is that a person can have, at least in North Carolina, one or both of these. However, in many states, this is achieved in one document and not two. Next slide, please. So and then next. So in these are the states that have passed these standalone pad statutes up through 2017. So now we have 27 states that have written these statutes, and generally, they're pretty close to what I described. However, one of the controversial aspects of psychiatric advanced directives is that self-binding aspect of it. And so in some states, the two that I'm most aware of is the state of Washington, and to some extent, the state of Virginia, a person can choose whether the pad will be binding or not self-binding. Just by way of explanation, end-of-life directives are not really binding, and I'll give you an example that if a person puts in a medical advanced directive that they don't want any extraordinary treatment and say, for example, they don't want to be intubated, at the end of life or during a crisis, if a person, say, has respiratory failure and would need to be intubated, he or she can change their minds at the last minute and say, no, I know I said I didn't want to be intubated, but please go ahead and do it. And a physician isn't going to say, no, this document says I can't do that. So generally, the medical advanced directives are not as binding. The idea of the pads, more or less, is to lock people into a decision so that they won't change it during incapacitating state, because so many folks, when they get really sick, or some folks, when they get very sick, make decisions that they regret during a mental health crisis. So next, please. So we did a study through the MacArthur Network on mandated community treatment, in which we went to five cities in the country, to community mental health centers, and said, do you have a mental health advanced directive, or have you appointed a health care agent or a health care power of attorney for future treatment? And we found that, generally, the real average here is about 4%, 5%. There was one state that, in Tampa, people said that they had more of them. But generally, a very low number of folks with severe mental illness have them. And so you could conclude from that that there's not much demand to create these documents. Next. The next question we asked was, would you want to complete a PAD if someone showed you how and helped you to do it? Next. And there, we see it jumps up to about 2 thirds, or 75%, of people said yes. So they either had one already, or they really wanted to have one. And what this demonstrates is that there's a big latent demand among persons with mental illness to have psychiatric advanced directives. But there's a big gap between wanting one and being able to complete one and file it appropriately. So I think this was, for some skeptics who think, well, this isn't really a high priority for folks with mental illness. It seems that it really is. And actually, in follow-up studies that we've done, we found that that number of 2 thirds to 3 quarters pretty much holds up. Because in studies in which we've then offered assistance to people to complete psychiatric advanced directives, the uptake was about 2 thirds to 3 quarters. So when we offered assistance to people to complete them, about 2 thirds to 3 quarters went ahead and did them. They did them with assistance. So there was a person who helped and facilitated the completion of the forms, helped them get notarized and helped them, well, witnessed and notarized, and then helped them, put them in an appropriate medical record or website. Next. So why is this important? Well, as we saw in the case study, one of the things that PADS do is that they allow families or proxies, so significant others or someone who the person trusts, to speak directly with providers during crises. And in so many emergency rooms, you hear the story, or crisis centers, you hear stories where because of the belief that you have to get consent to communicate with the families, families are kind of locked out of the process when they could be very helpful during a crisis. So this opens the door to let in the families and the proxies so they can speak with the providers, give relevant history, and also make the decisions during the crises. Remember that someone who is appointed legally as a healthcare power of attorney or proxy can actually make decisions for the person during the crisis. The other important idea here is that this whole notion supports patient autonomy and empowerment in mental health care. So that a person can, with mental illness, has the peace of mind to know that even when they can't speak for themselves, even when they're very sick, their wishes will be carried out and be reinforced by the proxy. As a result, as you saw in the case history, this might reduce the need for involuntary treatment. So many times, people are involuntarily committed when they really don't object to hospitalization, but they really can't consent to it because they're not well enough to give valid informed consent. Also because of the content of advanced instructions, which essentially provides a pricey of the medical record, it can improve continuity of care. So say if a patient shows up somewhere for care where they're not known and there isn't a record, access to the advanced instructions provides information that providers can use to direct care and or the proxy can fill in the providers. Another reason this is important is that honoring pads, just like the other types of advanced instructions as in the Patient Self-Determination Act, that is a condition of participation in Medicaid and Medicare for treatment facilities. So what a condition of participation means is that if a provider does not honor the Patient Self-Determination Act and the need to search out and consult with advanced directions, they can lose their Medicaid and Medicare funding until they correct that problem. So there are very serious consequences to an institution if they do not follow the Patient Self-Determination Act. And the Patient Self-Determination Act not only covers medical advanced directives, it also covers psychiatric advanced directives. Just to make one other point, I said that there were 27 states that have these standalone statutes. But just to be clear, in the states that don't have these standalone psychiatric statutes, generally, with very few exceptions, a person can complete a psychiatric advance directive under the general advance directive statutes. Next please. So this is the documentation of the condition of participation. And this was most clearly articulated during the final rules on seclusion and restraint. But it clearly says that hospitals have to protect patients' rights. And one of those rights is to formulate an advance directive and have them respected by the institution. And that failure to do this could lead to suspension of reimbursement from Medicare and Medicaid. Next please. So just to clarify, again, there's really two parts to the psychiatric advance directive, whether they're in two different pieces of statute or one piece of statute. There's the advance instructions, which is similar to a living will, which documents the wishes, consent, or refusal of future care. And then there's a health care power of attorney. And this construct has different names in different states. But the general idea is that it's the legal power to appoint another person to make decisions during a crisis. And that person can be designated with limited or broad powers. So if a person wants, say, their mother to make all medical decisions, but not psychiatric ones, that can be written into the form. Or if different people are designated for different powers, or there are some things that the person never wants for themselves, those things generally can be written into either the advance instructions or the health care power of attorney. So for example, say if a person never wants to go to a particular hospital, that can be documented. Or if the person never wants the proxy to have them admitted to the hospital at all, that could be, or give them authorization to consent to admission. That can be written in. I will say then, in all the advance instructions we've done, or pads we've done in North Carolina, and we've facilitated quite a number, probably on the order of five to 750, we've never had a person who used the document to refuse all treatment. They certainly made some stipulations about things they wanted and did not want, but no one used it as a document to refuse all treatment. And just to be clear, this process might only involve one document in the state that you're in. Next, please. So again, the instructional directive usually permits the individual to plan for, consent, or refuse hospital admission, medications, even electroconvulsive treatment, unless there's particular stipulations in the statute about any of these things, or other treatments for mental illness. The person can also stipulate other things that they would like to happen, like who should take care of their kids, or who will watch their apartment, so on and so forth. But it is only activated or only takes effect in the event the individual loses their ability to make decisions and is deemed incapable. Next. So what should a doctor or staff do with an instructional directive? Well, one, if they receive it, they should make it part of the medical record, and then act in accordance with the instructional directive when the patient's determined to be incapable. And they may also notify all other providers to follow the instructional directive. Next, please. So let's get to this issue of, well, what does that mean, incapable? Now, one thing to be clear is that being incapable is different than being incompetent. Incompetent is a legally adjudicated process whereby someone presents evidence to a judge that a person is unable to care for themselves in some important domains, and the judge then decides whether the person has those capacities, and if necessary, appoints a guardian for that person to make those decisions indefinitely. What incapable means is that a person's in the opinion of a physician or eligible psychologist, which is generally a licensed psychologist, the person currently lacks sufficient understanding or capacity to make and communicate mental health treatment decisions. So the person's either incoherent or can't speak for themselves, or just as grossly illogical. That is not a legal process. It is a bedside determination. So the clinician examines the patient, and if he or she thinks that the person lacks capacity, that is documented in the medical record, takes effect until it's reversed in the record where the physician or the psychologist writes in the record the person's regained capacity. So when the incapacity takes effect with that note in the chart, the advanced instructions and the healthcare power of attorney is activated, and when the person regains capacity, it's turned off. And so in some ways, you can think of this as a temporary form of guardianship. Not exactly, but pretty much. And those of you who followed the Britney Spears case, wouldn't have this, would this not have been a good alternative that if Britney Spears really was having a period in which she could not make and communicate mental health treatment decisions, that a healthcare power of attorney could have been appointed through this mechanism and only temporarily. But as you know, what happened was that she was placed under a form of guardianship, and that has persisted for a long, long time. Now, I'm not saying that this is a complete solution to her problems because I'm not close enough to them, but the idea that there are alternatives to guardianship in this form, I think is a very important concept because for many, many people with severe mental illness, guardianship is a one-way street, that they appointed a guardian and that persists for a long, long time and is rarely reversed. Next. So often clinicians say, well, do I really have to honor the instructions? And generally, yes. Now there may be specifics that are outlined in state provisions. And in North Carolina, for example, a clinician does not have to follow the instructions or the wishes of the proxy if they're not consistent with generally accepted community practice standards. So for example, if a patient or a proxy said, well, I only want to be treated with ginkgo for my psychosis. Well, there's no generally accepted community practice that that's a standalone treatment for psychosis. And so the clinician in that case would merely document in the chart that that's not accepted community practice. And we're going to have to deviate from the advanced instructions in that specific aspect, but still try to follow the advanced instructions otherwise. The clinician also doesn't have to follow treatment requests when they're not feasible or unavailable. And this is only logical. Say if a patient says, I only want to go to hospital X, if that hospital has no beds, then the clinician would really only document that those services aren't available or are not feasible, but still try to follow the rest of the document. The clinician can also override the pad when treatment requests would interfere with treating an emergency, and it can be trumped by involuntary inpatient commitment, or can be trumped by some other state law that may conflict with the advanced instructions. But absent these exceptions, yes, a clinician needs to honor it. The good news is that when you show this to clinicians, that it's not preempting their good care, and it's not forcing them to do things that they don't think is good medical care. They generally understand that this is a win-win for patients and for providers. Next. So let's talk a little bit about the healthcare power of attorney. It allows a patient to appoint someone they trust to make decisions when he or she is incapable and not when they're incompetent. That's a typo. It can be combined with an instructional directive, although in some states, those are different forms, and any capable adult may execute one. Next, please. So who can serve as the proxy? Well, that's any competent adult, 18 or older, and that individual cannot be providing healthcare to that consumer, logically, because that would be a conflict of interest. And they can, and we encourage the person to name several alternative proxies to serve if one's unavailable. So say a crisis is occurring at midnight on a Monday, well, the designated proxy might not be available. They may be out of state. They may be unavailable. So having several alternatives, and we generally try to appoint three people or put three people on the form so that there's a backup in case the healthcare power of attorney can't be reached. Next, please. And when does it take effect? When does the healthcare power of attorney take effect? Well, just as in the advanced instruction, it is activated when a patient is found to be incapable and continues during that period of incapacity. That incapacity is usually determined by the physician or a psychologist, and they're finding that the patient is incapable must be in writing and in the relevant clinical record. Next. So what powers does the healthcare power of attorney have? Now, this is sort of remarkable to think about because generally the answer is the healthcare power of attorney can consent to whatever a patient could consent for themselves. So they can make whatever treatment decisions the patient could usually make unless, and this is an important caveat, unless the patient limits the authority of the healthcare power of attorney and says, well, I don't want the healthcare power of attorney to be able to do X, Y, or Z. And the patient can instruct healthcare power of attorneys on decisions about medications, possible admission, even electroconvulsive treatment. So the healthcare power of attorney really has extraordinary discretion. But the important caveat here is that the idea is not that the healthcare power of attorney substitutes their own sense of what is in the patient's best interest. Their role is wherever possible to merely articulate the patient's wishes and preferences. And we all know from following what happens with medical advanced directives, that often there's not enough detail in an advanced instruction or medical advanced directive to make a specific decision. And there's much more granularity to healthcare decisions than what goes in these documents. And so the great power of the healthcare power of attorney is to interpret the wishes of that person and to fill in the gaps in their advanced instructions. But again, it is not their role to preempt the wishes of the individual and to, in effect, make up decisions that the person wouldn't make. If they really disagree with the patient about important decisions, then they really should not be serving as the healthcare power of attorney for that particular person. Next. So why aren't psychiatric advanced directives in the mainstream yet? Why aren't they widely used and ubiquitous? Well, one simple answer is that the whole movement towards psychiatric advanced directives is about a decade behind medical advanced directives. And if you follow the progress there, it's taken a lot to get medical advanced directives into the mainstream. And there's been many campaigns, even some more recently, from various healthcare organizations to get people to write medical advanced directives. So psychiatric advanced directives as a subset, that whole movement and that advocacy about that, you could argue is actually a decade behind and that may be a decade from now, what we'll be seeing is that people have embraced these. I will say though, many patients, many clinicians and families have not yet been sold on their benefit. One aspect of that may be that there are so many advocacy issues in mental health and advocacy groups have such a long list of people who and advocacy groups have such a long list of things that they need to bring services up to an adequate level is that this may not have gotten to the top of the list for those advocacy organizations. So if you look at the major advocacy organizations in the country, they have statements supporting psychiatric advanced directives like NAMI, Mental Health America, and others, but it isn't the top of their priorities, at least right now, not yet. One other reason it isn't maybe on the top of everybody's list is that as we saw, about 27 states have these specific laws, although the remaining states would allow them under medical advanced directives so that there are states in which they do not have this law. And so advocacy and that sort of the critical mass of people pushing for them may not be there. Another big barrier is that these types of advanced directives may be difficult to complete for some patients. And most of our research work at Duke has been how to help people to complete them. If you look at them, look at the one in your state, you'll see that the standard forms created by the state are very hard to read. There's usually a lot of legalese. There are concepts that are hard to understand. There are concepts that people might be suspicious of. What is this healthcare prof attorney? What can they do? Why is this a good idea? And so I think it's very important for there to be resources in communities to walk through and help people complete them. And one of the things we've tried to do, say in North Carolina, is try to embed people in the community by working with NAMI and peer support organizations to train them in facilitation of advanced directives so that they're community resources for people who need them. We also have trained clinicians so that clinicians and community practices can facilitate them as well. But unfortunately, helping completing advanced directives may not always be available. And there's unfortunately many, many communities in which there isn't a ready source for someone to help them. Of course, attorneys could be helpful, but that may be financially out of reach for many families who might have to hire a private attorney. And to my knowledge, there are not a lot of indigent attorneys who do this. Now, one of the exciting new developments coming out of the APA and SAMHSA is an app. So an app, as you see the link there, which is called My Mental Health Crisis Plan, which allows a person using a computer to complete one. Now, we haven't tested them enough to know that people can actually do them on their own or they still need explication. And for some people, a computer application may be too daunting. But this is an exciting new development that has a lot of potential, is the fact that there's guidance online and how to complete them. Now, clearly, because there's one app, if there are vagaries in a particular state, there need to be some modifications. So say in some states, you need two witnesses and a notary to complete them. In other states, maybe that's not necessary or you only need one witness. So the idea is you complete them in the app and then print them out and get them witnessed and notarized. Next, please. So this is a screen that shows you the app on a smartphone and you can get it at the app store or Google Play. And this is what it looks like. And it has a lot of questions answered, an FAQ section, and then it walks you through what can be a pretty straightforward process. The underlying decisions that people need to make in advance directive should be something that people have thought about and be able to complete. Next. So what are some of the other resources on PADS? These are links. You can find information about PADS on NAMI's state or national website. The Bazelon Center for Mental Health Law has a great section. Mental Health America does. The Crisis Navigation Project does. And then we operate a website called NRC PADS, the National Resource Center on Psychiatric Advanced Directives, in which we compile state-by-state information about psychiatric advanced directives in each state, try to keep up with the forms that are in use, and provide a lot of general information. But all these resources are out there and very valuable in learning more about PADs. Next. So, here are some references from the literature about psychiatric advanced directives. So they're in the slide deck for people to use, and we can go to the Q&A. Thank you very much. Wow, thank you for such an interesting presentation. Before we move into the Q&A section, I want to take a quick moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, and complete mental health rating skills, and even submit questions directly to our SMI team of experts. Download the app now at smiadvisor.org or slash app. Okay, so now we're going to jump into the Q&A section. We have a lot of questions in the chat box. So, the first question I'm going to field is, can you briefly describe an example of a person who is considered incapable? Sure. Marvin, you want to take that one? Sure. Again, the definition in many states is unable to make or communicate health care, mental health decisions. So, an example would be someone who is mute, which is not an uncommon psychiatric presentation, so the person can't speak at all, or someone who just is incoherent, that they're just speaking in a way that doesn't make sense to the provider. So it is a judgment decision, but those would be two examples. Thank you so much. Another question that we have here in the chat is, how can we help clients who are socially isolated identify people to be reliable proxies? So I'll jump in again. So that is a great question. Many folks with serious mental illness are isolated or have lost a lot of their social contacts. So one of the things we do in facilitation is try to identify people who can be proxies. But there are two barriers. One is, there may be no one that the person trusts to do this, and then we just go with the advanced instruction. Or we work with the person to understand, well, who is out there available? Who might you call on? But for some people, this is a barrier that they just don't have someone they trust. As we know, many people with severe mental illness, their social networks have shrunk to a point where the only people really in their networks are their providers, and providers cannot serve as proxies in this arrangement. Thank you so much. Okay. So the questions are flooding the chat. So we have a whole bunch of questions. So the next question is, where does a person with substance abuse fit on their path? Is it under medical or is it under mental health? Good question. So if the person who has substance use disorder does have periods incapacity, they can complete one of these directives. But it really is for people who have had a period, who can anticipate that they'll lose their ability to make decisions. It may be that a medical advance directive is preferred, but that's a great question. And it would be a matter of thinking it through with a provider. Sounds good. Thank you. So another question is, when a patient stipulates that they don't ever want to be hospitalized, what happens in the case of emergency? Do they become involuntary? Yes. Yeah, they would have to, in that case, be involuntarily committed. And they would have to meet the criteria for the involuntary commitment of the state. Can you share more about that criteria, if you have additional details? Go ahead, Deb. Sure. I mean, every state has its own statute for involuntary commitment. Usually it requires mental illness causing a substantial risk of harm to oneself or others or what we call grave disability. And so I think that's important to realize that somebody who lacks capacity may not always be ill, have symptoms of mental illness to the point that they meet involuntary commitment criteria. And so that's part of the issue around trying to get more psychiatric advance directives so people can get admitted with their health care agent. Yeah, that's a great point. You know, it's a great question and a great point. And we're not here to say that psychiatric advance directives are the solution to all our problems in mental health care. And what Dr. Pinals is pointing out is that there are still holes. And there are people who don't meet commitment criteria who were kind of stuck not being able to serve if they're refusing treatment and don't have a PAD. Well, that's fascinating. So we have a lot of questions pertaining to the process. I'm going to ask a few questions subsequently. Who can complete a patent and where does the patent get filed? So I'll take that. So generally the person can file it. So once it's witnessed and notarized, a person can make whatever number of copies they wish because they may want to bring it to a number of different people. But there's an option. The first option is to take it to your wherever you're getting mental health care and they can put it in the record there. But because of the ubiquity of electronic records, it's wise to try to put it somewhere where it becomes part of the electronic record because those records can be shared. And then finally, in many states now, there are electronic vaults in essence for advanced care planning. So in North Carolina, the Secretary of State has a website where you can file them there so that they're available 24 hours a day, even if you're not in a medical setting. But any of those is acceptable. It's more a matter of what's the most effective thing to do. And we would say, well, certainly give them to all your providers and places you go for care and try to get them into an electronic record. Thank you so much for your answer. Okay. So another one here. Can you please provide more details on the term self-binding, the difference between path and end of life? Sure. What that means is that in end-of-life decision-making for advanced instruction, advanced directive in medical setting, they are guidelines and that's what providers would follow. But generally, if a person changes their mind during a medical crisis, providers honor that. They don't say no. You know, the example I gave is if it says, I don't want to be intubated, I don't want to be on life support, but if the person at that moment changes their mind, the providers are going to change course and intubate or whatever. But in the psychiatric advanced directive, and this is a controversial aspect of it, it's binding in the sense that during the period of incapacity, the plan is followed. It's not deviated from except for those examples I gave you where it can't be followed. So it's binding in that sense in that the person with mental illness is saying, this is what I want to happen. And no matter what I say during that crisis, follow this plan. Thank you. So I'm going to keep shooting some questions here. Is there a time limit for how long the path or path? So that's a great question too. In some states they do sunset, but most of the states that I'm aware of, they do not have to be renewed or redone and they last indefinitely. We recommend that people look at them and redo them at least every two years. And one of the biggest things that does change is that people change their preferences about their agent. They may wish someone else, they may feel that a sister would be a better agent than their mother, even though their mother was previously. But we recommend every two years you redo them. But there's very few states in which they lapse. And a follow up to that statement, is there a website where other participants can find these laws according to the states? Yes, the website I mentioned, our website, the National Resource Center on Psychiatric Advanced Directive. So you can Google NRC pad and it will come up. Thank you. Okay. We have a lot of questions coming in. We'll have time for maybe two or three more. So do you have any information on how the path will play a role in 988? In what? In 988, the crisis number from the top? I can speak to that. Yeah. So 988 is the new crisis number that's going to be coming out. The vision is that it's going to link together all aspects of services. So ideally, if somebody is in a crisis, the 988 response would be able to look up whether somebody's got a Psychiatric Advanced Directive, or a person might be able to say that they have a Psychiatric Advanced Directive and the 988 responder will know what that is and what that means. Obviously, there's a lot of bridge building that still needs to be done with that, but what the hope is, is that Psychiatric Advanced Directives become things that people know about and use, and it just becomes part of the common parlance in how individuals with serious mental illness can have their plans put in place. I don't know, Marvin, if you have more to add. No, that's perfect answer. So for a long time, there's been interest among CIT teams, Crisis Intervention Police, and to try to get pads to them so that they could populate their databases, because they don't generally have access to people's mental health or health records. So bridging that with Psychiatric Advanced Directives, both in that case or in 988, would be ideal. Okay. So thank you for your answer on that. We have a few more minutes for questions. The next question is, how does PAD apply to a prison setting, or maybe to someone in prison? Yeah, that's another interesting question. Theoretically, it would apply just the same as it would in a community setting. You know, unless there's an issue within the prison around a treatment override that's statutorily allowed, a PAD would really be, I would imagine, executed the same. Okay. So maybe we'll take one more question here. Are state laws regarding PADs relatively stable? So I'll take that. They, yes, generally. The biggest action is states who, you know, enact new statutes, but the ones that are on the books, they don't change that much. Not commonly, but we try to keep up with it. Thank you. Thank you so much for answering all these questions. We don't have time for all the questions in the chat, but if you have any follow-up questions about this topic or any evidence-based care for SMI, our clinical experts are here to help with online consultations. Any mental health clinician can submit a question and receive a response from one of our SMI advisors. Consultations are free and completely confidential. SMI advisor is proud to partner with the American Psychiatric Association on the Mental Health Service Conference, which will take place October 14th and 15th. The keynote address for this conference features Dr. Myriam Delfor-Rittner, the new appointed Assistant Secretary of Mental Health and Substance Use for HHS and Administrator of SAMHSA. The conference agenda features topics such as climate change and mental health, sociopolitical determinants, structural racism, mental health in rural and indigenous populations, and much more. I encourage you to learn more and register now at psychiatry.org slash MHSC dash SMI. To claim credits for participating in today's webinar, you will need to have met the required attendance thresholds for the profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. And finally, I want to encourage everyone to attend in two weeks on October 21st of 2021 as Gabriela Zapata-Alma presents on intimate partner violence and disabling psychiatric conditions, unique risks, needs, and strategies. Again, this free webinar will be on October 21st of 2021 from 3 p.m. to 4 p.m. Eastern Standard Time. Thank you for joining us and until next time, and I hope everyone has a wonderful day. Thank you. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic and SMI Advisor is here to help. Information is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. 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Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and more. Browse by key topics and select View All to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use, mobile-friendly format. You can download the app for both Apple and Android devices. Submit questions, browse courses, and access clinical rating scales that you can use in your practice with individuals who have SMI. SMI Advisor also created My Mental Health Crisis Plan, a smartphone app that helps individuals in your care to create a crisis plan. The app is available on both Apple and Android devices. It helps people prepare in case of a mental health crisis. They can make their treatment preferences known and specify who should be contacted and who should make decisions on their behalf. The app even guides individuals through the process to turn their crisis plan into a psychiatric advance directive. Thank you for your interest in SMI Advisor. Access our free education, consultations, and more on smiadvisor.org at any time.

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