UNDERSTANDING

1
UNDERSTANDING

• MENTAL HEALTH ADVANCE DIRECTIVES
• (RCW 71.32)

2
Purpose of RCW 71.32

• To help people express choices for mental health
  treatment when incapacitated.
• A validly executed MHAD is to be respected by
  (among others) health care providers,
  professional persons, and health care facilities.

3
What is a MHAD?

• A written document
• by an adult with capacity
• Expressing instructions or preferences regarding
  mental health treatment
• For use when a person is incapacitated
• And (if desired) naming an agent to act on
  his/her behalf

4
What is in a MHAD?

• May include instructions and preferences about
  any aspect of mental health treatment or care
  for example
• Consent for or refusal of specific types of
  treatment
• What has worked well in the past
• Appointment of an agent to make treatment
  decisions on principals behalf

5
The model MHAD form (RCW 71.32.260)

• Includes
• Statement of intent
• When it becomes effective
• Duration
• Revocability
• Preferences and instructions
• Appointment of agent (language in RCW 71.32.060)
• Notification of others and care of personal
  affairs
• Signature

6
Requirements of valid MHAD

• In writing, dated, signed, witnessed
• Clear intent to create MHAD
• Designates whether principal can revoke during
  periods of incapacity
• If an agent is appointed, specifies that the
  agent has authority even if the principal is
  incapacitated.

7
What Does It Mean to Be Incapacitated?

• Unable to give informed consent
• found incompetent by a court

8
Determination of Capacity

• An adult is presumed to have capacity
• Incapacity may only be declared by
• A court (request by principal or agent)
• One MHP and one health care provider
• Two health care providers
• Initial determination must be made within 48
  hours of request

9
If an agent is appointed...

• Must act in good faith
• Must make decisions consistent with principals
  instructions or preferences, or if not known, in
  principals best interest
• Has same right as principal to make decisions or
  share information

10
Agent (Cont.)

• May resign at any time by written notice to
  principal and providers
• Not liable for cost of treatment
• May not be paid
• May not be the principals provider (unless
  related)
• Decisions subordinate to decisions of a competent
  principal

11
Revocation of MHAD

• In writing, but no special form needed - just
  clear intent
• Incapacitated principal cannot revoke unless
  he/she elected to do so when competent
• Principal must provide a copy of revocation to
  agent and providers(s), and it becomes part of
  record

12
Revocation (Cont.)

• Can be superceded or revoked by court order,
  involuntary hospitalization, or incarceration
• A new directive revokes previous one
• Expiration date revokes directive, unless
  principal incapacitated at time

13
Provider Responsibilities

• Act in accordance with provisions of MHAD to
  fullest extent possible unless
• Violates accepted standard of care
• Requested treatment is not available
• Compliance would violate applicable law
• Compliance would endanger anyone
• Inconsistent with purpose of court order relating
  to commitment (e.g.ITA)

14
Responsibilities (Cont.)

• If the provider does not/cannot comply with the
  directive, he/she must
• Notify the principal and agent
• Document the reason for the non-compliance in the
  principals medical record

15
What to document

• Place Advance Directives in the client record
• Note revocation/changes in the client record
• Document when unable to comply for any reason

16
Providers Immunity

• Providers are not civilly liable if, acting in
  good faith and without negligence
• They provide treatment based on MHAD and capacity
  determination
• They provide treatment without actual knowledge
  of a MHAD or revocation
• They act in accord with a MHAD that is later
  found to be invalid
• They validly refuse to provide treatment in
  accord with MHAD

17
MHAD and Inpatient Treatment

• If principal consents to inpatient treatment in
  MHAD and is currently in need but refusing
• MD and another health care provider evaluate to
  determine incapacity
• Obtain consent of agent (if any)
• MD makes written finding of need for treatment
  and that no less restrictive alternative is
  available

18
MHAD and Inpatient (Cont.)

• Principal admitted to inpatient treatment on the
  basis of a MHAD is a voluntary patient and may
  not be forcibly held against his or her will
  unless detained under RCW 71.05
• Can be encouraged to stay
• Must state desire to leave and take action
  consistent with that desire

19
An MHAD May Not

• Create an entitlement to treatment
• Obligate any health care provider or agent to pay
  treatment costs or be responsible for
  non-treatment personal care of principal
• Be used for consent to inpatient for more than 14
  days in any 21 day period

20
Some Interpretive Provisions

• If more than one directive, most recent MHAD
  agent controls
• Requiring a directive is prohibited
• Principals do not lose their bed at a long-term
  care facility as a result of an inpatient stay
  pursuant to MHAD

21
Implementing MHADs

• Understand the law
• Develop policies and procedures
• Figure out how access will work
• Educate consumers Ask about MHAD
• Document in client record
• Integrate with treatment
• Monitor use and issues