The Hope and Promise of Advance Directives

As the debate heats up over mandatory outpatient treatment for behavioral conditions, it is exceptionally important to recognize that other options do exist to link people to needed treatment. However, these options, including outreach from consumer operated service programs and peer care coordinators, hardly are ever discussed. Here, I would like to explore the very important, but neglected role of advance directives.

Advance directives provide guidance about one’s desired health care in the future. Usually, they consist of two components. First, the person giving the advance directive designates another person to have “medical power of attorney” and a second person to have “legal power of attorney”. Obviously, if desired, the two powers can be designated to the same person.  Second, the person provides binding guidance about desired future care in the event of incapacitation. Typically, these advance directives are contained in a will or a related legal document.

Designations of power of attorney have two goals. Medical power of attorney vests in that person authority to make decisions about one’s future care in the event of mental or physical incapacitation. Incapacitation usually is defined in these documents so that it is clear when the medical power of attorney actually takes effect and when it ends. Similarly, legal power of attorney vests in another person the right to commit one’s funds to pay bills, including those for health care, and to sign legal documents on one’s behalf, if one becomes incapacitated. Clearly, both powers may be needed if one becomes incapacitated.

The second feature of advance directives is a formal expression of personal wishes regarding one’s future care. When combined with medical power of attorney, these directives provide guidance to the person vested with this power regarding one’s wishes about care. They can include an expression of wishes regarding end of life care, such as “do not resuscitate” or do not put on life support, and they can provide an expression of wishes regarding behavioral health care, types of desired providers, etc.

Advance directives are receiving broader acceptance, and they are being adopted more frequently in general health care. Thus, it seems surprising that they receive such little attention in the mental health and substance use care fields.

Several recommendations seem worthy of exploration:

• The US Department of Health and Human Services should undertake collaboration with the American Bar Association to organize workgroups to explore and plan the broader application of advance directives in the behavioral health field.
• As the Affordable Care Act moves us into the era of electronic health records and personal health records, we should explore how advance directives can be made a permanent feature of these records. Obviously, this will require a capacity for setting the advance directives up initially, as well as for updating them when necessary.
• We from the behavioral health field need to foster discussions about advance directives in our own community. Consumer and family points of view will need to be prominent in these discussions.

Work on advance directives should have been undertaken more than a quarter century ago when living wills were originally introduced. Now, it will be critical to play catch-up.

Advance directives clearly are to be preferred over mandatory outpatient treatment.