For individuals living with schizophrenia, periods of relapse – marked by psychosis, paranoia, and impaired decision-making – are often inevitable. When symptoms return, clear communication about treatment preferences can become impossible. A psychiatric advance directive (PAD) is a legal tool designed to address this challenge, ensuring your wishes are honored even when you lack the capacity to express them.
What Is a Psychiatric Advance Directive?
A PAD is a legally binding document that outlines your desired mental healthcare in the event of a crisis. It specifies preferred hospitals, medications (including dosage and timing), and designates a trusted proxy decision-maker to enforce your instructions. Creating this document during periods of stability allows you to maintain control over your treatment when symptom severity impairs your judgment.
As Dr. Marvin Swartz of Duke University School of Medicine explains, “This is an important tool for patient autonomy, providing peace of mind that preferences will be considered even during incapacity.”
Why Relapse Makes Advance Planning Critical
Research confirms that relapse is a recurring reality for many with schizophrenia, especially when medication adherence lapses. During these episodes, individuals may experience intense symptoms leading to diminished cognitive function and an inability to participate in healthcare decisions.
A PAD functions similarly to a medical directive for physical health, but is specifically tailored to psychiatric needs. While standard medical directives can include some mental health preferences, a PAD offers detailed, targeted guidance for acute psychiatric crises.
Key Components of an Effective PAD
A comprehensive PAD should include:
- Designated Proxy: A trusted individual empowered to make decisions on your behalf.
- Medication Preferences: Specific drugs, dosages, and timing to avoid adverse reactions or ineffective treatments.
- Treatment Settings: Preferred hospitals, clinics, or facilities for care.
- Capacity Indicators: Observable behaviors signaling a loss of decisional capacity and the need to activate the PAD.
- Life Needs Provisions: Instructions for handling essential responsibilities like childcare, pet care, and financial obligations.
Ken Duckworth, MD, of the National Alliance on Mental Illness, emphasizes, “With a PAD, there’s much more clarity, which is important for both the person with schizophrenia and their care team.”
Creating Your PAD: A Step-by-Step Guide
- Gather Information: Compile all relevant details, including medications, treatment locations, and the rationale behind your choices. Document past side effects or ineffective treatments to inform future decisions.
- Name a Proxy: Choose someone who knows you well and understands your preferences. Note that some states prohibit appointing a direct treatment provider as your proxy.
- Simplify and Distill: Keep the document concise and easy to read, even during a crisis. The Substance Abuse and Mental Health Services Administration offers wallet-sized templates for quick reference.
- Legal Compliance: Consult an attorney to ensure your PAD aligns with state regulations. At a minimum, have the document witnessed and notarized for legal validity.
- Distribute Copies: Share your PAD with your proxy, mental health provider, and anyone else involved in your care.
Ongoing Maintenance
Review your PAD at least annually to ensure it reflects current preferences. Circumstances can change – you may alter medication choices, select a new proxy, or adjust preferred treatment locations. Regular updates ensure the document remains relevant and effective.
The Bottom Line
Schizophrenia relapses are common and can impair decision-making. A psychiatric advance directive empowers individuals to maintain control over their care by clearly outlining preferences in advance. By creating a PAD, you ensure your voice is heard even when you cannot speak for yourself.
If you or someone you know is in crisis, call or text 988 to reach the 988 Suicide & Crisis Lifeline.
