Washington Mental Health Advance Directive Form

Mental Health Advance Directive
NOTICE TO PERSONS
CREATING A MENTAL HEALTH ADVANCE DIRECTIVE
This is an important legal document. It creates an advance directive for mental health
treatment. Before signing this document you should know these important facts:
(1) This document is called an advance directive and allows you to make decisions in
advance about your mental health treatment, including medications, short-term
admission to inpatient treatment and electroconvulsive therapy.
YOU DO NOT HAVE TO FILL OUT OR SIGN THIS FORM.
IF YOU DO NOT SIGN THIS FORM, IT WILL NOT TAKE EFFECT.
If you choose to complete and sign this document, you may still decide to leave some
items blank.
(2) You have the right to appoint a person as your agent to make treatment decisions
for you. You must notify your agent that you have appointed him or her as an agent.
The person you appoint has a duty to act consistently with your wishes made known by
you. If your agent does not know what your wishes are, he or she has a duty to act in
your best interest. Your agent has the right to withdraw from the appointment at any
time.
(3) The instructions you include with this advance directive and the authority you give
your agent to act will only become effective under the conditions you select in this
document. You may choose to limit this directive and your agent's authority to times
when you are incapacitated or to times when you are exhibiting symptoms or behavior
that you specify. You may also make this directive effective immediately. No matter
when you choose to make this directive effective, your treatment providers must still
seek your informed consent at all times that you have capacity to give informed
consent.
(4) You have the right to revoke this document in writing at any time you have capacity.
YOU MAY NOT REVOKE THIS DIRECTIVE WHEN YOU HAVE BEEN FOUND TO BE
INCAPACITATED UNLESS YOU HAVE SPECIFICALLY STATED IN THIS
DIRECTIVE THAT YOU WANT IT TO BE REVOCABLE WHEN YOU ARE
INCAPACITATED.
(5) This directive will stay in effect until you revoke it unless you specify an expiration
date. If you specify an expiration date and you are incapacitated at the time it expires, it
will remain in effect until you have capacity to make treatment decisions again unless
you chose to be able to revoke it while you are incapacitated and you revoke the
directive.
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(6) You cannot use your advance directive to consent to civil commitment. The
procedures that apply to your advance directive are different than those provided for in
the Involuntary Treatment Act. Involuntary treatment is a different process.
(7) If there is anything in this directive that you do not understand, you should ask a
lawyer to explain it to you.
(8) You should be aware that there are some circumstances where your provider may
not have to follow your directive.
(9) You should discuss any treatment decisions in your directive with your provider.
(10) You may ask the court to rule on the validity of your directive.
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Mental Health Advance Directive
PART I.
STATEMENT OF INTENT TO CREATE A
MENTAL HEALTH ADVANCE DIRECTIVE
I, ____________________________being a person with capacity, willfully and
voluntarily execute this mental health advance directive so that my choices regarding
my mental health care will be carried out in circumstances when I am unable to express
my instructions and preferences regarding my mental health care. If a guardian is
appointed by a court to make mental health decisions for me, I intend this document to
take precedence over all other means of ascertaining my intent.
The fact that I may have left blanks in this directive does not affect its validity in any
way. I intend that all completed sections be followed. If I have not expressed a choice,
my agent should make the decision that he or she determines is in my best interest. I
intend this directive to take precedence over any other directives I have previously
executed, to the extent that they are inconsistent with this document, or unless I
expressly state otherwise in either document.
I understand that I may revoke this directive in whole or in part if I am a person with
capacity. I understand that I cannot revoke this directive if a court, two health care
providers, or one mental health professional and one health care provider find that I am
an incapacitated person, unless, when I executed this directive, I chose to be able to
revoke this directive while incapacitated.
I understand that, except as otherwise provided in law, revocation must be in writing. I
understand that nothing in this directive, or in my refusal of treatment to which I consent
in this directive, authorizes any health care provider, professional person, health care
facility, or agent appointed in this directive to use or threaten to use abuse, neglect,
financial exploitation, or abandonment to carry out my directive.
I understand that there are some circumstances where my provider may not have to
follow my directive.
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PART II.
WHEN THIS DIRECTIVE IS EFFECTIVE
YOU MUST COMPLETE THIS PART FOR YOUR DIRECTIVE TO BE VALID.
I intend that this directive become effective (YOU MUST CHOOSE ONLY ONE):
_______Immediately upon my signing of this directive.
_______If I become incapacitated.
_______When the following circumstances, symptoms, or behaviors occur:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
PART III.
DURATION OF THIS DIRECTIVE
YOU MUST COMPLETE THIS PART FOR YOUR DIRECTIVE TO BE VALID.
I want this directive to (YOU MUST CHOOSE ONLY ONE):
_______Remain valid and in effect for an indefinite period of time.
_______Automatically expire _____ years from the date it was created.
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PART IV.
WHEN I MAY REVOKE THIS DIRECTIVE
YOU MUST COMPLETE THIS PART FOR THIS DIRECTIVE TO BE VALID.
I intend that I be able to revoke this directive (YOU MUST CHOOSE ONLY ONE):
_______Only when I have capacity.
I understand that choosing this option means I may only revoke this directive if I have
capacity. I further understand that if I choose this option and become incapacitated
while this directive is in effect, I may receive treatment that I specify in this directive,
even if I object at the time.
_______Even if I am incapacitated.
I understand that choosing this option means that I may revoke this directive even if I
am incapacitated. I further understand that if I choose this option and revoke this
directive while I am incapacitated I may not receive treatment that I specify in this
directive, even if I want the treatment.
PART V.
PREFERENCES AND INSTRUCTIONS ABOUT TREATMENT, FACILITIES, AND
PHYSICIANS
A. Preferences and Instructions About Physician(s) to be Involved in My
Treatment
I would like the physician(s) named below to be involved in my treatment decisions:
Dr. ___________________ Contact information:_______________________________
Dr. ___________________ Contact information:_______________________________
I do not wish to be treated by Dr.____________________________________________
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B. Preferences and Instructions About Other Providers
I am receiving other treatment or care from providers who I feel have an impact on my
mental health care. I would like the following treatment provider(s) to be contacted
when this directive is effective:
Name ________________________________ Profession _______________________
Contact information ______________________________________________________
Name ________________________________ Profession _______________________
Contact information ______________________________________________________
C. Preferences and Instructions About Medications for Psychiatric Treatment
(initial and complete all that apply)
_______I consent, and authorize my agent (if appointed) to consent, to the following
medications: ___________________________________________________________
______________________________________________________________________
_______I do not consent, and I do not authorize my agent (if appointed) to consent, to
the administration of the following medications: ________________________________
______________________________________________________________________
_______I am willing to take the medications excluded above if my only reason for
excluding them is the side effects which include _______________________________
______________________________________________________________________
and these side effects can be eliminated by dosage adjustment or other means.
_______I am willing to try any other medication the hospital doctor recommends.
_______I am willing to try any other medications my outpatient doctor recommends.
_______I do not want to try any other medications.
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Medication Allergies
I have allergies to, or severe side effects from, the following:
______________________________________________________________________
Other Medication Preferences or Instructions
I have the following other preferences or instructions about medications
______________________________________________________________________
Preferences and Instructions About Hospitalization and Alternatives
(initial all that apply and, if desired, rank "1" for first choice, "2" for second choice, and so on)
_______In the event my psychiatric condition is serious enough to require 24-hour care
and I have no physical conditions that require immediate access to emergency medical
care, I prefer to receive this care in programs/facilities designed as alternatives to
psychiatric hospitalizations.
_______I would also like the interventions below to be tried before hospitalization is
considered:
_______Calling someone or having someone call me when needed.
Name:________________________________ Telephone:_______________________
_______Staying overnight with someone.
Name:________________________________ Telephone:_______________________
_______Having a mental health service provider come to see me.
_______Going to a crisis triage center or emergency room.
_______Staying overnight at a crisis respite (temporary) bed.
_______Seeing a service provider for help with psychiatric medications.
_______Other, specify:___________________________________________________
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Authority to Consent to Inpatient Treatment
I consent, and authorize my agent (if appointed) to consent, to voluntary admission to
inpatient mental health treatment for _______ days (not to exceed 14 days)
(Sign one):
_______If deemed appropriate by my agent (if appointed) and treating physician.
______________________________________________________________________
(Signature)
or
_______Under the following circumstances (specify symptoms, behaviors, or
circumstances that indicate the need for hospitalization) _________________________
_____________________________________________________________________.
__________________________________________
(Signature)
or
_______I do not consent, or authorize my agent (if appointed) to consent, to inpatient
treatment.
__________________________________________
(Signature)
Hospital Preferences and Instructions
If hospitalization is required, I prefer the following hospitals:
________________________________________________________________
I do not consent to be admitted to the following hospitals:
________________________________________________________________
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E. Preferences and Instructions About Pre-emergency
I would like the interventions below to be tried before use of seclusion or restraint is
considered (initial all that apply):
_______"Talk me down" one-on-one
_______ More medication
_______ Time out/privacy
_______ Show of authority/force
_______ Shift my attention to something else
_______ Set firm limits on my behavior
_______ Help me to discuss/vent feelings
_______ Decrease stimulation
_______ Offer to have neutral person settle dispute
_______ Other, specify _____________________________________________
F. Preferences and Instructions About Seclusion, Restraint, and Emergency
Medications
If it is determined that I am engaging in behavior that requires seclusion, physical
restraint, and/or emergency use of medication, I prefer these interventions in the order I
have chosen (choose "1" for first choice, "2" for second choice, and so on):
_______Seclusion
_______Seclusion and physical restraint (combined)
_______Medication by injection
_______Medication in pill or liquid form
In the event that my attending physician decides to use medication in response to an
emergency situation after due consideration of my preferences and instructions for
emergency treatments stated above, I expect the choice of medication to reflect any
preferences and instructions I have expressed in Part III C of this form. The
preferences and instructions I express in this section regarding medication in
emergency situations do not constitute consent to use of the medication for nonemergency treatment.
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G. Preferences and Instructions About Electroconvulsive Therapy (ECT or Shock
Therapy)
My wishes regarding electroconvulsive therapy are (sign one):
_______I do not consent, nor authorize my agent (if appointed) to consent, to the
administration of electroconvulsive therapy.
___________________________________________________
(Signature)
_______I consent, and authorize my agent (if appointed) to consent, to the
administration of electroconvulsive therapy
___________________________________________________
(Signature)
_______I consent, and authorize my agent (if appointed) to consent, to the
administration of electroconvulsive therapy, but only under the following conditions: ___
______________________________________________________________________
___________________________________________________
(Signature)
H. Preferences and Instructions About Who is Permitted to Visit
If I have been admitted to a mental health treatment facility, the following people are not
permitted to visit me there:
Name: ______________________________________________
Name: ______________________________________________
Name: ______________________________________________
I understand that persons not listed above may be permitted to visit me.
I. Additional Instructions About My Mental Health Care
Other instructions about my mental health care:
______________________________________________________________________
______________________________________________________________________
In case of emergency, please contact:
Name:_____________________Address:____________________________________
Work telephone:___________________ Home telephone: _______________________
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Physician: ________________________ Address: _____________________________
Telephone: _____________________________
The following may help me to avoid a hospitalization:
______________________________________________________________________
I generally react to being hospitalized as follows:
______________________________________________________________________
Staff of the hospital or crisis unit can help me by doing the following:
______________________________________________________________________
J. Refusal of Treatment
I do not consent to any mental health treatment.
_____________________________________________
(Signature)
PART VI.
DURABLE POWER OF ATTORNEY (APPOINTMENT OF MY AGENT)
(Fill out this part only if you wish to appoint an agent or nominate a guardian.)
I authorize an agent to make mental health treatment decisions on my behalf. The
authority granted to my agent includes the right to consent, refuse consent, or withdraw
consent to any mental health care, treatment, service, or procedure, consistent with any
instructions and/or limitations I have set forth in this directive. I intend that those
decisions should be made in accordance with my expressed wishes as set forth in this
document. If I have not expressed a choice in this document and my agent does not
otherwise know my wishes, I authorize my agent to make the decision that my agent
determines is in my best interest. This agency shall not be affected by my incapacity.
Unless I state otherwise in this durable power of attorney, I may revoke it unless
prohibited by other state law.
A. Designation of an Agent
I appoint the following person as my agent to make mental health treatment decisions
for me as authorized in this document and request that this person be notified
immediately when this directive becomes effective:
Name:_____________________Address:____________________________________
Work telephone:___________________ Home telephone: _______________________
Relationship: _________________________
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B. Designation of Alternate Agent
If the person named above is unavailable, unable, or refuses to serve as my agent, or I
revoke that person's authority to serve as my agent, I hereby appoint the following
person as my alternate agent and request that this person be notified immediately when
this directive becomes effective or when my original agent is no longer my agent:
Name:_____________________Address:____________________________________
Work telephone:___________________ Home telephone: _______________________
Relationship: _________________________
C. When My Spouse is My Agent (initial if desired):
_______If my spouse is my agent, that person shall remain my agent even if we
become legally separated or our marriage is dissolved, unless there is a court order to
the contrary or I have remarried.
D. Limitations on My Agent's Authority
I do not grant my agent the authority to consent on my behalf to the following:
______________________________________________________________________
______________________________________________________________________
E. Limitations on My Ability to Revoke this Durable Power of Attorney
I choose to limit my ability to revoke this durable power of attorney as follows:
______________________________________________________________________
______________________________________________________________________
F. Preference as to Court-Appointed Guardian
In the event a court appoints a guardian who will make decisions regarding my mental
health treatment, I nominate the following person as my guardian:
Name:_____________________Address:____________________________________
Work telephone:___________________ Home telephone: _______________________
Relationship: _________________________
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The appointment of a guardian of my estate or my person or any other decision maker
shall not give the guardian or decision maker the power to revoke, suspend, or
terminate this directive or the powers of my agent, except as authorized by law.
____________________________________________________
(Signature required if nomination is made)
PART VII.
OTHER DOCUMENTS
(Initial all that apply)
I have executed the following documents that include the power to make decisions
regarding health care services for myself:
_______ Health care power of attorney (chapter 11.94 RCW)
_______ "Living will" (Health care directive; chapter 70.122 RCW)
_______ I have appointed more than one agent. I understand that the most recently
appointed agent controls except as stated below:
PART VIII.
NOTIFICATION OF OTHERS AND CARE OF PERSONAL AFFAIRS
(Fill out this part only if you wish to provide nontreatment instructions.)
I understand the preferences and instructions in this part are NOT the responsibility of
my treatment provider and that no treatment provider is required to act on them.
A. Who Should Be Notified
I desire my agent to notify the following individuals as soon as possible when this
directive becomes effective:
Name:_____________________Address:____________________________________
Day telephone:___________________ Evening telephone: ______________________
Name:_____________________Address:____________________________________
Day telephone:___________________ Evening telephone: ______________________
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B. Preferences or Instructions About Personal Affairs
I have the following preferences or instructions about my personal affairs (e.g., care of
dependents, pets, household) if I am admitted to a mental health treatment facility:
______________________________________________________________________
______________________________________________________________________
C. Additional Preferences and Instructions:
______________________________________________________________________
______________________________________________________________________
PART IX.
SIGNATURE
By signing here, I indicate that I understand the purpose and effect of this document
and that I am giving my informed consent to the treatments and/or admission to which I
have consented or authorized my agent to consent in this directive. I intend that my
consent in this directive be construed as being consistent with the elements of informed
consent under chapter 7.70 RCW.
Signature: _________________________________ Date: _______________________
Printed Name:__________________________________________________________
This directive was signed and declared by the "Principal," to be his or her directive, in
our presence who, at his or her request, have signed our names below as witnesses.
We declare that, at the time of the creation of this instrument, the Principal is personally
known to us, and, according to our best knowledge and belief, has capacity at this time
and does not appear to be acting under duress, undue influence, or fraud. We further
declare that none of us is:
(A) A person designated to make medical decisions on the principal's behalf;
(B) A health care provider or professional person directly involved with the provision of
care to the principal at the time thedirective is executed;
(C) An owner, operator, employee, or relative of an owner or operator of a health care
facility or long-term care facility in which the principal is a patient or resident;
(D) A person who is related by blood, marriage, or adoption to the person, or with
whom the principal has a dating relationship as defined in RCW 26.50.010;
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(E) An incapacitated person;
(F) A person who would benefit financially if the principal undergoes mental health
treatment; or
(G) A minor.
Witness 1: Signature: ________________________________Date: _______________
Printed Name:__________________________________________________________
Telephone _________________ Address_____________________________________
Witness 2: Signature: ________________________________Date: _______________
Printed Name:__________________________________________________________
Telephone _________________ Address_____________________________________
PART X.
RECORD OF DIRECTIVE
I have given a copy of this directive to the following persons:
______________________________________________________________________
______________________________________________________________________
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DO NOT FILL OUT PART XI UNLESS YOU INTEND TO REVOKE
THIS DIRECTIVE IN PART OR IN WHOLE
PART XI.
REVOCATION OF THIS DIRECTIVE
(Initial any that apply):
_______I am revoking the following part(s) of this directive (specify):
______________________________________________________________________
_______I am revoking all of this directive.
By signing here, I indicate that I understand the purpose and effect of my revocation
and that no person is bound by any revoked provision(s). I intend this revocation to be
interpreted as if I had never completed the revoked provision(s).
Signature: ______________________________________Date: __________________
Printed Name:__________________________________________________________
DO NOT SIGN THIS PART UNLESS YOU INTEND TO REVOKE THIS DIRECTIVE IN
PART OR IN WHOLE
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