As we review survey results for our clients surveyed under TJC’s Behavioral Health standards, we see the issue of psychiatric advance directives (PADs) being cited more frequently so thought it was time for a refresher on this topic. The standard regarding PADs is in the Care, Treatment, and Services chapter of the BH manual and was added in 2011:

CTS.01.04.01 The organization supports the adult’s decisions (psychiatric advance directives) about how care, treatment, or services are to be delivered during times when he or she is unable to make such decisions.

It applies only to organizations serving adults with serious mental illness. The elements of performance require the following:

1. The organization documents whether the adult has a PAD.
2. Upon request, the organization shares with the adult sources of help in formulating a PAD.
3. If the adult has a PAD, clinical staff are aware that it exists and how to access it.

Typically, surveyors will ask BH organizations serving SMI clients what their process is for determining if a client has a PAD and what resources they provide to clients who are interested in developing one. Surveyors have also reviewed records to find documentation of this process.

One complicating issue is that although TJC specifies that this standard applies only to organizations that serve adults with serious mental illness (SMI), they do not define SMI.  While definitions vary, the National Institute for Mental Health has used the following definition of SMI:

• A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders)
• Diagnosable currently or within the past year
• Of sufficient duration to meet diagnostic criteria specified within the DSM-V.
• Resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. (Serious functional impairment has been further defined as impairment equivalent to a Global Assessment of Functioning (GAF) score of less than 60.)

One of the challenges in formulating a PADs policy is that laws vary from state to state. There are 25 states that have specific PAD statutes.  Thus, it’s critical to research your state laws re PADs in order to develop a policy compliant with state statute. The National Resource Center on Psychiatric Advance Directives provides information on the different state laws pertaining to PADs and is an excellent resource on this subject.

So, in order to be fully compliant, we recommend the following steps:

• Research your state law on PADs.
• Research the resources that you can provide to your clients about PADs.
• Develop a written policy/procedure.
• Educate staff about your PADs policy and their role in the process.
• Monitor your records for compliance with documentation of the PADs process.

In addition to the National Resource Center on Psychiatric Advance Directives, another good resource is the presentation Integrating Psychiatric Advance Directives into Clinical Practice by Dr. Eric Elbogen of University of North Carolina-Chapel Hill School of Medicine.