REPORT ON THE USE OF ADVANCE DIRECTIVES FOR

SUBSTANCE USE DISORDERS

Department of Children and Families

Substance Abuse and Mental Health Program Office

January 1, 2017

Mike Carroll Rick Scott

Secretary Governor

TABLE OF CONTENTS

I. EXECUTIVE SUMMARY ........................................................................................................2

II. BACKGROUND...……………………………………………………………………………………2

III. SENATE BILL 12...................................................................................................................3

IV. ADVANCE DIRECTIVES......................................................................................................4

VII.A. Use of Advanced Directives in Mental Health...…………………................................4

VII.B. Use of Advance Directives for Substance Use Disorders in Other States ……….….6

VII.C. Other Instruments to Express Treatment Wishes …..……………….…………………7

V. CONCLUSION AND RECOMMENDATIONS.........................................................................7

ATTACHMENTS

Attachment I

Attachment II

Attachment III

Attachment IV

Attachment V

I. EXECUTIVE SUMMARY

As part of Senate Bill 12, the 2016 Legislature directed the Department of Children and Families

(Department) to convene a workgroup to study the feasibility of individuals using advance

directives to express treatment wishes for substance use disorders, and to submit its findings to

the Governor and Legislature by January 1, 2017.

Specifically, the workgroup was directed to “review the use of advance directives in mental

health, the use of advance directives for substance use disorders in other states, and the use of

similar legal instruments to express the treatment wishes of individuals suffering from substance

use disorders.”

The Department convened the Substance Abuse Advance Directive Workgroup (Workgroup) in

October 2016. The Workgroup was composed of individuals with expertise in the treatment of

substance use disorders, persons with lived experience accessing behavioral health services,

and legal experts. For a list of Workgroup members, please refer to Attachment I. The

Department also reached out to additional community stakeholders to research the use and

effectiveness of mental health advance directives and the feasibility of implementing advanced

directives specific to substance use disorders.

In general, the Workgroup found that using advance directives that specifically address

substance use disorders would be extremely challenging because competence is fluid for

people with addictions. Within hours an individual may go from competent to incompetent and

back, depending on their substance use. However, the Workgroup recognized the overall value

for individuals with mental illnesses and substance use disorders to document preferences

regarding their care in the event of a crisis or when they are unable to make decisions.

This report summarizes Workgroup findings related to advanced directives for substance use

disorders in the context of:

• Changes in involuntary services as a result of SB 12;

• Current use of advance directives;

• Alternative instruments to express treatment wishes; and

• Recommendations for next steps.

II. BACKGROUND

The creation of the Workgroup to evaluate the feasibility of substance use advance directives

has its roots in SB 1336, sponsored by Senator Jack Latvala, to honor a constituent who had

died of an overdose. Filed in January 2016 and known as the Jennifer Act, the bill would have

revised the criteria for involuntary admission of people with substance use disorders and

provided for advance directives for them, including the naming of a surrogate. After unanimously

passing two Senate committees, SB 1336 was merged with SB 12. Senator Latvala’s original

2016 version of the Jennifer Act described its intent as follows:

“The Legislature recognizes that an individual with capacity has the ability to control

decisions relating to his or her own mental health care or substance abuse

treatment…Individuals with substance abuse impairment or mental illness need an

established procedure to express their instructions and preferences for treatment and

provide advance consent to or refusal of treatment. This procedure should be less

expensive and less restrictive than guardianship.”

Although this language was not included in SB 12, the Workgroup noted other provisions that

addressed the intent by loosening restrictions on filing a Marchman Act petition. These are

addressed in more detail in the next section.

III. SENATE BILL 12

By enacting SB 12, the 2016 Legislature created a coordinated system of care in which every

region is responsible for ensuring people in need have access to the right services. The

sweeping new law covers dozens of aspects of treatment delivery, from assessing the need for

services to aligning the Baker Act rules and procedures with those of the Marchman Act. SB 12

went into effect on July 1, 2016.

As part of its charge from the Legislature, the Workgroup analyzed the alignment of the Baker

and Marchman Acts to determine whether this would affect the need for advance directives

specifically for substance-use disorders. Workgroup members concluded that certain provisions

of SB 12 accomplished many of the goals earlier sought under the Jennifer Act. Specifically, the

Workgroup found changes to the Marchman Act now allow more readily for the involuntary

admission of people with substance use disorders. Some of these changes include:

• Eliminating the filing fee for petitioning a court to assess or treat someone under the

Marchman Act;

• Expanding the number of professionals able to approve involuntary assessment or

treatment under the Marchman Act;

• Reducing from three to one the number of notarized witnesses required to detain

someone for involuntary assessment or treatment;

• Creating guardian advocates for those who are incompetent to consent due to a

substance use disorder; and

• Changing the Baker Act to include individuals subject to involuntary admission under the

Marchman Act in transportation and receiving system planning.

Furthermore, workgroup members cited changes to the Marchman Act that they believe will

render moot the question of a health-care surrogate for substance-use disorders. In particular,

they cited s. 397.675, F.S., which states that "A person meets the criteria for involuntary

admission if there is good faith reason to believe that the person is substance abuse impaired or

has a co-occurring mental health disorder and, because of such impairment or disorder:

(1) Has lost the power of self-control with respect to substance abuse; and

(2)(a) Is in need of substance abuse services and, by reason of substance abuse

impairment, his or her judgment has been so impaired that he or she is incapable of

appreciating his or her need for such services and of making a rational decision in that

regard, although mere refusal to receive such services does not constitute evidence of

lack of judgment with respect to his or her need for such services; or

(b) Without care or treatment, is likely to suffer from neglect or refuse to care for

himself or herself; that such neglect or refusal poses a real and present threat of

substantial harm to his or her well-being; and that it is not apparent that such harm may

be avoided through the help of willing family members or friends or the provision of other

services, or there is substantial likelihood that the person has inflicted, or threatened to

or attempted to inflict, or, unless admitted, is likely to inflict, physical harm on himself,

herself, or another.”

The Workgroup concluded that the statute allows for the involuntary admission of people with

substance use disorders if they are harmful to themselves. There was discussion to the effect

that SB 12 has not been fully “realized,” since the legislation is new, and any impact it will have

in the future remains to be seen.

IV. ADVANCE DIRECTIVES

IV.A. Use of Advance Directives in Mental Health

Florida does not have a dedicated mental health advance directive. Instead, individuals use

Chapter 765, F.S., which deals with general health advance directives, to provide instructions or

express a desire concerning any aspect of their health care or health information. This can

include behavioral health. Section 765.101(5), F.S., defines health care to mean:

“care, services, or supplies related to the health of an individual and includes, but is not

limited to, preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative

care, and counseling, service, assessment, or procedure with respect to the individual’s

physical or mental condition or functional status or that affect the structure or function of

the individual’s body.”

In addition to allowing individuals to provide specific instructions and desires about their health

care, Chapter 765 allows Floridians to appoint health care surrogates to make decisions about

their treatment should they become incompetent to make their own medical decisions.

However, not all such instructions are binding. For instance, a person with a substance use

disorder may designate a particular treatment facility in an advance directive, but the treatment

facility may refuse to treat those who lack insurance coverage and cannot pay, regardless of the

provisions in their advance directives.

"You have the right to prepare an advance directive when competent to do so that specifies the

mental health care you want or don't want and to designate a health care surrogate to make

those decisions for you at the time of crisis," states the "Rights of Persons" section of the Florida

Baker Act Manual, last revised in 2014. "The facility is required to make reasonable efforts to

honor those choices or transfer you to another facility that will honor your choices. The facility

must document whether you have an advance directive and inform you about its policies about

advance directives."

Carmen Cantero, the quality improvement and compliance officer at Citrus Health Network, said

advance directives are rare at her facility. She said they often fail to surface at crisis units or

emergency rooms because "we think a large barrier has been that patients and their families do

not understand them or their purpose."

In addition, Cantero said, mental health advance directives can be misleading because "with the

current state of health care, there are many factors influencing the care being provided to the

patients." Many patients want to be transferred to another facility, she said, but the payer or

receiving facility may deny the transfer.

"Patients may also believe they have a right to demand a type of treatment not available at the

facility," Cantero added.

The tension between advance directives and emergency medical priorities drew the attention of

Paul S. Appelbaum, MD, who wrote Psychiatric Advance Directives at a Crossroads – When

Can PADs be Overridden? in The Journal of the American Academy of Psychiatry and the Law

in 2006.

"[J]ust as competent voluntary patients have the right to decline any medical treatment –

psychiatric or otherwise – so they should have the power to incorporate those wishes into a

PAD and to have their objections respected in the future," Applebaum wrote. "However,

requests of competent voluntary patients for particular treatments are not automatically

honored, and the same should be true of the requests in PADs. Treatment availability, medical

appropriateness, and (unfortunately, when the first two criteria have been met) financing to

cover the costs of care all factor into determinations of whether patients will receive a treatment

they request. It is difficult to argue that currently incompetent patients should be able to claim,

through their PADs, treatment that they could not demand directly if competent."

Applebaum wrote that in inpatient settings, voluntary patients should have the right to decline

treatments in advance, but not an absolute right to demand treatments of their choosing.

"The situation of involuntary patients is more complex," he continued. "PADs should not be

permitted to negate the usual mechanisms for involuntary treatment of committed patients; to do

otherwise risks forcing facilities to confine indefinitely persons they cannot treat. Even in those

circumstances, however, where PADs provide evidence of reasonable patient preferences (e.g.,

for one medication over another), the choices they embody should be respected."

Chapter 765 provides for a patient to be transferred if a facility does not comply with the wishes

stated in his or her advance directive. Section 765.1105, F.S., states:

“A health care provider or facility that refuses to comply with a patient’s advance

directive, or the treatment decision of his or her surrogate or proxy, shall make

reasonable efforts to transfer the patient to another health care provider or facility that

will comply with the directive or treatment decision.”

If the facility fails to honor the patient's advance directive or make the transfer within seven

days, then the patient's surrogates can take the facility to court.

The 2014 Baker Act Manual includes a four-page advance directive form (Attachment II) to

provide details about a person's designated health care surrogate and choice of treatment

facilities, physician and certain types of treatments. An advance directive will not take effect

unless a physician decides the individual is not competent to make his/her own treatment

decisions.

The form also notes whether or not the individual has attached a Personal Safety Plan

(Attachment III), which is likewise included in the Baker Act Manual. The Personal Safety Plan

includes information such as calming strategies the person finds useful, triggers that lead to

agitation or distress, questions about "helpful" and "not helpful" medications, and the person's

history with seclusion and restraint.

No data are currently collected in Florida on the use of advance directives and Workgroup

members found no evidence that individuals are using mental health advance directives in large

numbers.

"The prevalence of (psychiatric advance directives) is unknown," Nicole S. Luddington and

Douglas Mossman wrote in Current Psychiatry in 2012. According to the authors, a 2006

survey of 1,011 psychiatric outpatients in California, Florida, Illinois, Massachusetts, and North

Carolina by Swanson et al "found only 4 percent to 13 percent of patients previously executed a

psychiatric advance directive (PAD). However, most participants said that if given the

opportunity and assistance, they would create a PAD."

"I personally feel mental health advance directives in Florida are extremely underutilized," said

Dana Farmer, policy director for Disability Rights Florida, the federally-funded protection and

advocacy organization. "I’ve heard some community mental health centers routinely ask people

if they would like to do one as part of their care plan, but I think that is rare."

Applebaum, Paul S. Psychiatric Advance Directives at a Crossroads – When Can PADs be

Overridden? J Am Acad Psychiatry Law 34:395–7, 2006

Ibid.

Chapter 65E-5 of the Florida Administrative Code, titled Mental Health Act Regulation, requires

receiving facilities designated under the Baker Act to ask a person (or significant other) if an

advance directive is available upon admission. It further requires receiving facilities to provide

information about how to prepare and use advance directives at discharge. If provided, a copy

of the advance directive should be filed in the clinical record where it is easily accessible.

"When you are admitted to a Baker Act unit, you are asked who you would like to be your

representative," Farmer agreed. "If you have one of these advance directives, you should know

to name the person chosen by you and listed in your advance directive as your mental health

care surrogate."

The form in the Baker Act Manual recommends that the person make multiple copies of the

advance directive and give them to providers and medical professionals named in the

document. The form also recommends having a copy on one's person while traveling.

Linda McKinnon, president and CEO for Central Florida Behavioral Network, Inc., the Managing

Entity in the SunCoast Region, said she knew of several Crisis Stabilization Units where

advance directives are “a routine part of the admission packet.”

“In all other health care, when a person is hospitalized, the patient (if competent, or their

surrogate) is asked to complete an advanced directive, unless there is already one provided by

the patient or surrogate that has been notarized, etc.,” McKinnon wrote. “And it is kept with the

clinical record. If a person is transferred to another facility it goes with the transferred

documents.”

"Anecdotally, we understand the use of psychiatric advanced directives is minimal," said

Melanie Brown-Woofter, Interim President & CEO of the Florida Council on Community Mental

Health.

Also anecdotally, the Workgroup found that facilities treating people who had executed a mental

health advance directive did not always know the document existed.

The Workgroup determined that mental health advance directives are not used consistently in

Florida, and this should be addressed through public education, professional training and the

use of peer specialists to help people fill out the forms.

IV.B. Use of Advance Directives for Substance Use Disorders in Other States

The Workgroup did not find other states with dedicated substance abuse advance directives in

statute or in administrative rule. The Department compiled a summary of other state’s advance

directives in Attachment IV. Twenty-eight states have a specific statute for a psychiatric

advance directives and twenty-two states, including Florida, do not. Another eight states

specifically ban the use of advance instructions for psychiatric care in a freestanding document.

Michigan's advance directives form includes a question about preferences in the event of

temporary addiction to pain medication: "I do [_____], or I do not [_____] want maximum pain

relief, if it may result in temporary addiction, if I survived an extended hospital stay."

California's form for mental health advance directives asks, “What other kinds of mental health

treatment do you want and not want (e.g. outpatient therapy, group therapy, family therapy,

substance abuse counseling)?”

Charles Ingoglia, senior vice president for public policy at the National Council of Behavioral

Health, said the question of substance abuse advance directives came up at a recent meeting

of other state-level associations – at the request of Florida.

"And no one had heard of advance directives being used for substance use disorders," Ingoglia

said.

IV.C Other Instruments to Express Treatment Wishes

The Workgroup found states that have created other instruments to express treatment wishes

for persons with substance use disorders. Indiana drew praise for a sample letter (Attachment

V) that can be provided to a surgeon set to operate on a patient with a history of substance

abuse. The patient can choose a course of pain management aimed at lessening the risk of a

relapse, including the use of Toradol, with narcotics given only in an emergency. The

Workgroup said the Indiana letter could be helpful to people in recovery – but for those with an

active substance use issue, a guardianship via the court system might be a better option.

Indiana has a related form (Attachment V), "Advance Directive for Addiction in Remission and to

Ensure Continued Recovery," to reduce the risk of relapse for people in recovery facing surgery

or other conditions in which they will be in physical pain. For instance, the form offers this

option: "I would request if any mood-altering medications are to be given that they are used

sparingly and in amounts and formulations designed for my personal recovery…" However, this

form is not legally binding.

Crisis plans or personal safety plans can also be used for individuals with a mental illness

and/or substance use disorder to express their treatment wishes during a time that they are

competent to do so. These plans may address preferences for treatment facilities, physicians,

and medications. They may also list people that may hinder the person’s recovery. Specific

interventions that have been successful in the past can be specified as well as those that have

not worked. Any allergies or adverse reactions to medications can also be addressed.

V. FINDINGS AND RECOMMENDATIONS

The Workgroup members agreed that advance directives are useful because they can mitigate

or avert a crisis by having a plan in place. Members also agreed that when people with

behavioral health disorders write down their wishes for treatment, it enables them to set

personal goals and gain a measure of control over their lives.

"Research has shown that consumers who executed PADs endorse feelings of self-

determination, autonomy and empowerment," Zelle, Kemp and Bonnie wrote in the October

2015 issue of World Psychiatry.

"In fact, research suggests that 95 percent of PADs are rated

both clinically useful and consistent with clinical treatment standards." It is important to note

that this research is specific to psychiatric advance directives and that the efficacy of advanced

directives specific to substance abuse was not explored.

Overall, it is believed that advance directives have therapeutic value for people with mental

illnesses and addictions, and for the high percentage of those with co-occurring disorders.

Research suggests that advance directives can improve relations between persons served and

providers while lessening the severity of future crises. They also contain critical information,

such as a person's desired health-care surrogate or a medication to which he or she has had a

bad reaction in the past.

The opportunity for persons with substance use disorders to complete an advance directive, if

they so choose, already exits under Chapter 765. The Workgroup noted that for people with

mental illnesses and addictions, creating an advance directive is best done at times of the most

Zelle H., Kemp K, Bonnie RJ. Advance directives in mental health care: evidence, challenges and

promise. World Psychiatry 2015 Oct; 14(3): 278–280

Studies show that for people with mental illnesses and addictions, 60 to 70 percent have both

conditions.

stability, such as shortly before discharge from a state hospital. Members also agreed that

mental health advance directives should include the person’s trauma history.

However, the Workgroup consistently noted the difficulties of implementing advance directives

for people with substance use disorders and agreed that the question of competence in such

cases was hard to pinpoint, so the suitability of a substance use disorder specific advance

directive is questionable. As noted earlier, no other state has a substance use disorder specific

advanced directive.

"In a crisis, it's really difficult to know" whether a person is competent”, Dr. Barnett, who is board

certified in psychiatry with added qualifications in addictions, said. "Once they become clear-

headed, the advance directive is no longer needed."

Dr. Barnett referred the Workgroup to a resource document on Psychiatric Advance Directives

approved by the American Psychiatric Association in 2009. While the document does not

address substance abuse, it notes, "In all advance directives, the legal instrument becomes

effective when a patient loses decision-making capacity; generally, a formal legal finding of

incompetence is not necessary."

She said she didn't think a substance abuse advance directive could accomplish much. Rather,

she foresaw a "circumscribed, limited role" based on identifying the person's desired caregiver

and treatment preferences, such as warning of medications to which he or she has had an

adverse reaction. "It still could be helpful," she said, "in conjunction with a prevention plan."

Workgroup member Dana Foglesong, Manager of Recovery and Resiliency Services at

Magellan Complete Care, has a mental health advance directive. She credited that “there used

to be training and support” for people in treatment to complete the documents. On hers, she

included the medications that were problematic for her, as well as a Personal Safety Plan

containing information about her ‘triggers’ – those conditions she found troubling or soothing.

“It gave me more power in a powerless situation,” Foglesong said. “I viewed it as an expression

of my voice – when I was well – to help nurses and other staff know what would be helpful and

harmful to me when I was in a crisis.”

"Psychiatric advocacy groups have lauded the development of PADs," Luddington and

Rossman wrote. "For example, the National Alliance on Mental Illness’ position is that 'PADs

should be considered as a way to empower consumers to take a more active role in their

treatment, and as a way to avoid conflicts over treatment and medication issues.' Proponents

suggest that PADs promote autonomy, foster communication between patients and treatment

providers, increase compliance with medication and reduce involuntary treatment and judicial

involvement."

Based on review of changes to the Marchman and Baker Acts, Florida advance directives

statute, determination of competence, and advanced directive laws on other states, the

Workgroup makes the following recommendations:

• A specific Substance Use Disorder Advance Directive is not needed.

• Development and use of crisis and personal safety plans should be increased in

behavioral health care practice.

• The current Mental Health Advance Directive form found in the 2014 Baker Act Manual

should be updated to include substance use disorders.

Nicole S. Luddington and Douglas Mossman. "Psychiatric advance directives: May you disregard

them?" Current Psychiatry 2012 September;11(9):30-33

• Education and training should be provided to providers and persons served on

completing and using advanced directives.

• Any advanced directive that address behavioral health conditions and treatment should

include:

o The individual’s trauma history;

o Identification of a health care surrogate;

o Adverse reactions and allergies to medications;

o Individuals that the addicted person is likely to relapse with.

• The use of advance directives should be explained to individuals accessing behavioral

health care by their service provider.

• Peer specialists may be best suited to help persons served complete advanced

directives.

• Implementation of wallet cards to alert providers that a person served has an advance

directive, along with how to locate the document and contact the surrogate.

• The storage of advanced directives should be explored further to ensure that they are

readily accessible, while protecting confidentiality.

ATTACHMENT I

Substance Abuse Advance Directive Workgroup Members

NAME

TITLE

ORGANIZATION

Debra Barnett, M.D. SAMH Medical Director Department of Children and Families

Melanie Brown-Woofter Interim President/CEO

Florida Council for Community Mental

Health

John N. Bryant Assistant Secretary, SAMH Department of Children and Families

Dana Farmer Director of Public Policy Disability Rights Florida

Wesley Evans

Coordinator of Integration and

Recovery Services, SAMH

Department of Children and Families

Dana Foglesong

Manager of Recovery and

Resiliency Services

Magellan Healthcare

Mark Fontaine Executive Director

Florida Alcohol & Drug Abuse

Association

Jill Gran Legislative Affairs Director

Florida Alcohol & Drug Abuse

Association

Ute Gazioch Director, SAMH Department of Children and Families

Nancy Hamilton Executive Director Operation PAR

Margie Menzel Special Projects Department of Children and Families

Jay Reeve Chief Executive Officer Apalachee Center

John Wilson Chief Executive Officer DISC Village

Lacey Kantor Assistant General Counsel Department of Children and Families

Attachment II

Attachment III

Mental Health Advance Directives Summary

• The following states do not have a specific statute for a psychiatric advance directive (PAD) as indicated with a (*) on the table below:

1. Alaska

2. Arkansas

3. California

4. Colorado

5. Connecticut

6. Delaware

7. Florida

8. Georgia

9. Iowa

10. Kansas

11. Massachusetts

• The following states have a specific statute for a psychiatric advance directive:

1. Alabama

2. Arizona

3. Hawaii

4. Idaho

5. Illinois

6. Indiana

7. Kentucky

8. Louisiana

9. Maine

10. Maryland

11. Michigan

12. Minnesota

13. Mississippi

14. Montana

12. Missouri

13. Nebraska

14. Nevada

15. New Hampshire

16. New York

17. Rhode Island

18. South Carolina

19. Vermont

20. Virginia

21. West Virginia

22. Wisconsin

15. New Jersey

16. New Mexico

17. Wyoming

18. North Carolina

19. North Dakota

20. Ohio

21. Oklahoma

22. Oregon

23. Pennsylvania

24. South Dakota

25. Tennessee

26. Texas

27. Utah

28. Washington

• The following states do not allow you to write advance instructions for your psychiatric care in a freestanding document:

1. Arkansas

2. Georgia

3. Iowa

4. Mississippi

5. Missouri

6. Nebraska

7. New Hampshire

8. Wisconsin

Substance Use Advance Directive Summary

• Indiana, New Hampshire, and West Virginia include substance use disorders and advance directives in state statute or code.

• There were some available forms from California, Georgia, Idaho, Indiana, Iowa, Maryland, Michigan, Mississippi, Missouri, New

Jersey, and South Carolina, which include substance use or HIPAA sections.

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Alabama Alabama Advance

Directive for Health Care,

living will and health care

proxy form

http://www.nrcpad.org/i

mages/stories/PDFs/alaba

maad_proxyform.pdf

Instructions

http://www.caringinfo.or

g/files/public/ad/Alabama

.pdf

Alabama Code Title 22. Health, Mental Health, and

Environmental Control. § 22-8A-

http://codes.findlaw.com/al/title-22-health-mental-

health-and-environmental-control/al-code-sect-22-8a-

4.html#sthash.jnbXmAmT.dpuf

The statute includes a form called the “Advance

Directive for Health Care.”

The statute allows you to include “other directions” on

your form, which could include directions about your

mental health treatment.

None None

Alaska* Advance Directives for

Health Care & Mental

Health Care

http://www.touchngo.co

m/lglcntr/spclint/weyh20

04101901i.pdf

Alaska does not currently have a specific statute for a

psychiatric advance directive.

Alaska’s Health Care Decisions Act allows you to create

a PAD, known in Alaska as an “Advance Health Care

Directive”. This document allows you to specify

treatment choices; appoint an agent to make decisions

for you if you become incompetent; or both.

Chapter 13.52. Health Care Decisions Act

13-52-010. Advance health care directives.

13-52-020. Revocation of advance health care

directive.

13-52-030. Surrogates.

13.52.040. Decisions by guardian.

13-52-045. Withholding or withdrawing of life-

sustaining procedures.

13-52-050. Decisions for exceptional procedures.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

13-52-055. Pregnancy.

13-52-060. Obligations of health care providers,

institutions, and facilities.

13-52-065. Do not resuscitate protocol and

identification requirements.

13-52-070. Health care information.

13-52-080. Immunities.

13-52-090. Statutory damages.

http://www.nrc-

pad.org/images/stories/PDFs/alaska_statute.pdf

The statute allows you to consent to, or refuse, any

type of mental health treatment, including medications,

hospitalization and electro-convulsive therapy (ECT).

Arizona State of Arizona

Durable Mental Health

Care Power of Attorney

https://www.azag.gov/sit

es/default/files/sites/all/

docs/lifecare/LCP_Packet

_fillable-mental-

health.pdf

Registry

The Arizona Advance

Directive Registry was

created in May 2004 by

the Arizona State

Title 36

36-3201. Definitions.

36-3281. Mental health care power of attorney; scope;

definition.

36-3282. Execution requirements.

36-3283. Powers and duties of an agent.

36-3284. Operation of mental health care power of

attorney; duties of physician or mental health

care provider.

36-3285. Revocation; disqualification of agent

36-3286. Sample mental health care pow 36-3287.

Surrogate; mental health care power of

attorney.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Legislature. The Registry

is a database for the

storage of advance

directives (Living Will,

Medical Power of

Attorney, and Mental

Health Power of

Attorney). The Arizona

Secretary of State

oversees Registry filings,

its security, and its

operations. Health care

providers may use the

Registry to look up

registered directives using

the information provided

to them by the registrant

or the registrant’s loved

ones.

http://www.azleg.gov/ars

/36/03286.htm

36-3292. Filing requirements.

http://www.nrc-

pad.org/images/stories/PDFs/arizonastatutefull.pdf

The statute allows you to appoint an agent to make

mental health care decisions on your behalf, should you

become unable to make those decisions yourself. There

is no mandatory form as long as your document is

correctly witnessed. The Office of the Arizona Attorney

General has produced a recommended standard form.

The statute allows your agent to admit you to a

behavioral health facility, provided that is your express

wish.

Arkansas* Durable Power of

Attorney for Health Care

http://www.nrc-

pad.org/images/stories/P

DFs/arkansas_hcpaform.p

Brochure

Arkansas does not currently have a specific statute for a

psychiatric advance directive.

Ark. Code Ann.§20-13-104

Durable Power of Attorney for Health Care Act

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

http://humanservices.ark

ansas.gov/dbhs/Docume

nts/DBHS%20Website%2

%20Psychiatric%20Advan

ce%20Directive%20broch

ure%20(consumers)%20J

une%202011.pdf

http://www.nrc-

pad.org/images/stories/PDFs/arkansas_dhcpastatute.p

The Arkansas statute does not allow you to create a

freestanding document for your mental health

treatment wishes.

The statute does not formulate any procedure which

must be followed before your agent’s authority

becomes effective.

California* Advance Health Care

Directive (AHCD)

http://www.nrc-

pad.org/images/stories/P

DFs/ca%20pad.pdf

Instructions

http://www.nrc-

pad.org/images/stories/P

DFs/california%20pad.pdf

The state of California

maintains a central

registry of Advance

Directives

http://www.sos.ca.gov/re

gistries/advance-health-

care-directive-registry/

California does not currently have a specific statute for

a psychiatric advance directive.

Probate Code, Section 4600-4643

http://www.leginfo.ca.gov/cgi-

bin/displaycode?section=prob&group=04001-

05000&file=4600-4643

California’s Health Care Decisions Law allows you to

appoint an agent to make decisions about your

treatment if you become incompetent to make

decisions; write instructions about how you would like

your health care to proceed; or both. This law covers all

types of health care, including psychiatric treatment.

The statute allows you to set out your instructions on

any aspect of your health care treatment, which could

http://www.disabili

tyrightsca.org/pubs

/540701.htm

Asks “What other

kinds of mental

health treatment do

you want and not

want (e.g.

outpatient therapy,

group therapy,

family therapy,

substance abuse

counseling)?”

None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

include advance decisions about psychiatric

medications and/or hospitalization. The statutory form

gives a variety of prompts for you to state your

instructions in the event of a crisis.

The California statute allows you to choose when your

AHCD must be followed. Your AHCD will be followed

when your primary physician determines that you do

not understand the benefits and/or risks of a particular

mental health care decision.

Colorado* There is no official form

for appointing an agent,

but you must create a

written document.

Example

http://www.caringinfo.or

g/files/public/ad/Colorad

o.pdf

Colorado does not currently have a specific statute for

a psychiatric advance directive.

15-14-506. Medical durable power of attorney.

http://www.nrc-

pad.org/images/stories/PDFs/colorado_mpoastatute.pd

Colorado’s Medical Durable Power of Attorney statute

allows you to appoint an agent to make health care

decisions for you in the event that you become unable

to make those decisions yourself. These decisions could

be about any type of health care, including mental

health care. In appointing an agent, you may wish to

specify how he/she should make decisions by

documenting preferences about your mental health

treatment. The

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Connecticut* There is no official form

but the Office of the

Attorney General has

information regarding a

Living Will

http://www.ct.gov/ag/cw

p/browse.asp?A=2130&B

MDRN=2000&BCOB=0&C

=19278

Connecticut does not currently have a specific statute

for a psychiatric advance directive.

Chapter 368w- Removal of Life Support Systems

https://www.cga.ct.gov/current/pub/chap_368w.htm#s

ec_19a-575

The statute does not require a particular form of words.

It allows you to set out your instructions on any aspect

of your health care treatment, which could include

advance decisions about psychiatric medications and/or

hospitalization. This is called a “Living Will”. If you

wish, you may use a Living Will to make advance

decisions to refuse medications or hospitalization,

although state law may operate to require your

hospitalization in an emergency, even if you have

declined it in your instructions.

None None

Delaware* Advance Health Care

Directive

http://www.nrc-

pad.org/images/stories/P

DFs/delaware_ad_hcpa_c

omboform.pdf

Delaware does not currently have a specific statute for

a psychiatric advance directive.

Title 16, Health and Safety, Regulatory Provisions

Concerning Public Health.

Chapter 25. Health Care Decisions

http://delcode.delaware.gov/title16/c025/

Delaware’s Health Care Decisions statute allows you to:

(1) appoint an agent to make health care decisions for

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

you in the event that you become unable to make those

decisions yourself (called “executing a power of

attorney”); and/or (2) create an “individual instruction”

in which you specify how you would like your health

care to proceed. The statute covers all types of health

care, including mental health care.

Florida* Florida Advance Directive

Planning for Important

Health Care Decisions

general example:

http://www.caringinfo.or

g/files/public/ad/Florida.

pdf

Designation of Health

Care Surrogate

http://www.myfloridaleg

al.com/DesigSurrogFAQ.p

Florida does not currently have a specific statute for a

psychiatric advance directive.

Chapter 765- Health Care Advance Directives

http://www.leg.state.fl.us/statutes/index.cfm?App_mo

de=Display_Statute&URL=0700-0799/0765/0765.html

Chapter 765 of the Florida Statutes, entitled “Health

Care Advance Directives” allows you to appoint an

agent to make decisions about your treatment if you

become incompetent to make decisions. In Florida,

such a person is known as a “Health Care Surrogate”.

The Florida statute also allows you to write instructions

about how you would like your mental health care to

proceed. This is known as a “Declaration”.

The statute allows you to set out your instructions on

any aspect of your health care treatment, which could

include advance decisions about psychiatric

medications and/or hospitalization. The statute also

permits a person who has already become incompetent

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

to designate an agent simply by informing his/her

mental health care providers orally.

If you are subject to the Baker Act, the state will be able

to hospitalize and/or treat you against your will, which

may include a decision not to follow your written

instructions, or the instructions of your Health Care

Surrogate. If you do become subject to the Baker Act,

your health care decisions must be governed by a court-

appointed Guardian Advocate.

Georgia* Statute Form

http://law.justia.com/cod

es/georgia/2010/title-

31/chapter-32/31-32-4/

Georgia Advance

Directive for Health Care

http://aging.dhr.georgia.g

ov/sites/aging.dhs.georgi

a.gov/files/imported/DHR

-DAS/DHR-

DAS_Publications/GEORG

IA%20ADVANCE%20DIRE

CTIVE%20FOR%20HEALT

H%20CARE-10.pdf

Georgia does not currently have a specific statute for a

psychiatric advance directive.

2010 Georgia Code

Title 31 – Health.

Chapter 32 – Advance Directives for Health care.

31-32-1. Short title.

31-32-2. Definitions.

31-32-3. Savings clause for existing living wills and

durable powers of attorney for health care.

31-32-4. Form.

31-32-5. Execution; use of form or other forms;

witnesses; copies; amendment.

31-32-6. Revocation; declarant's marriage or

appointment of a guardian.

31-32-7. Duties and responsibilities of health care

agents.

31-32-8. Duties and responsibilities of health care

providers.

file:///C:/Users/cast

ro-

sindie/Downloads/6

241%20Advance%2

0Directives.pdf

This form asks

“What can’t my

‘health care agent’

do?

Your agent would

not be allowed to

consent to

psychosurgery,

sterilization or

hospitalization for

mental illness or

substance abuse. In

addition, your

None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

31-32-9. Conditions precedent to carrying out health

care treatment preferences; physician's failure

to comply with treatment preferences.

31-32-10. Immunity from liability or disciplinary action

31-32-11. Advance directive for health care's

relationship to criminal and insurance laws.

31-32-12. Restriction on requiring and preparing

advance directives for health care.

31-32-13. Penalties and legal sanctions for violations

31-32-14. Effect of chapter on other legal rights and

duties.

http://law.justia.com/codes/georgia/2010/title-

31/chapter-32

Georgia’s Advance Directive for Health Care Act allows

you to appoint a health care agent to make health care

decisions for you if you become incompetent to make

those decisions yourself, with certain exceptions. Health

care decisions may include decisions about mental

health.

The Georgia statute does not allow you to write

advance instructions for your psychiatric care in a

freestanding document.

physician can

administer

treatment for your

comfort or to

relieve pain without

the permission of

your agent.”

Hawaii Advance Mental Health

Directive

Chapter 327G- Advance Mental Health Care Directives

327G-1. Purpose.

327G-2. Definitions.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

https://health.hawaii.gov

/amhd/files/2013/06/AM

HCD-Short-Form1.pdf

327G-3. Advance mental health care directive;

designation of agent.

327G-4. Revocation of advance mental health care

directive.

327G-5. Authority and duty of agent; limitations on

liability.

327G-6. Withdrawal of agent; rescission of withdrawal

327G-7. Presumption of capacity; determination of lack

of capacity; recovery of capacity.

327G-8. Limitations on applicability of advance mental

healthcare directive.

327G-9. Decisions by guardian.

327G-10. Obligations of health care providers;

limitations on liability.

327G-11. Statutory damages.

327G-12. Effect of copy.

327G-13. Judicial relief.

327G-14. Optional form.

http://www.nrc-

pad.org/images/stories/PDFs/hawaiipadstatute.pdf

Chapter 237G allows you to write instructions for your

psychiatric treatment in the event that you are

incapable to make or communicate those instructions.

It also allows you to appoint an agent to make

instructions for you.

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

You can make choices about both medications and

hospitalization, including refusals of consent. You may

also make choices about matters other than your

treatment.

Idaho Idaho: Declaration for

Mental Health Treatment

http://www.nrc-

pad.org/images/stories/P

DFs/idahopadform.pdf

Title 66- State Charitable Institutions, Chapter 6-

Declarations for Mental Health Treatment.

https://legislature.idaho.gov/idstat/Title66/T66CH6SEC

T66-613PrinterFriendly.htm

Using the part of the Idaho statute entitled Declarations

for Mental Health Treatment, you may appoint an agent

to make decisions about your psychiatric treatment if

you become incompetent to make those decisions;

write instructions about how you would like your

psychiatric treatment to proceed; or both. You need

not use any particular form, as long as you comply with

the witness requirements and include the wording set

out in Chapter 66-613, or substantially similar language.

This Advance

Directive Planning

for Important

Healthcare

Decisions

Caring form

includes a HIPAA

Release Authority

section.

http://www.caringi

nfo.org/files/public/

ad/Idaho.pdf

None

Illinois Declaration for Mental

Health Treatment

http://www.nrc-

pad.org/images/stories/P

DFs/illinoispadform.pdf

Mental Health Treatment Preference Declaration Act.

http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=21

12&

Illinois’ Mental Health Treatment Preference

Declaration Act allows you to document choices about

psychotropic (psychiatric) medications,

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

electroconvulsive therapy (ECT) and/or psychiatric

hospitalization. It also allows you to appoint an agent

to make mental health treatment decisions for you,

should you become incompetent to make those

decisions yourself. In Illinois, such an agent is known as

an “attorney in fact”. There is a standard form, the

“Declaration for Mental Health Treatment”, which

covers both treatment choices and the appointment of

an agent.

You can document your wishes regarding medications,

hospitalization and/or electroconvulsive therapy,

including refusal of certain treatments. You may

consent in advance to hospitalization in a mental health

facility, but only for a maximum of seventeen days.

Indiana* There is no standard form

You may appoint an

agent without writing

instruction; both appoint

an agent and write

instructions; but not

write instructions without

appointing an agent.

IC 16-36-1.7 Chapter 1.7. Psychiatric Advance

Directives.

http://policy.mofcom.gov.cn/GlobalLaw/english/flaw!fe

tch.action?id=4faef68d-39ec-46f1-b753-5ed37c1faf0a

Title 16, Article 36 of the Indiana Code allows you to use

a Psychiatric Advance Directive to document

preferences about, and consent to: (1) admission to

hospital, (2) the use of restraint, (3) seclusion, (4)

electroconvulsive therapy (ECT) and/or (5) mental

health counseling.

Advance Directive

for Addiction in

Remission and to

Ensure Continued

Recovery

http://www.in.gov/

bitterpill/files/Iatro

genic2.pdf

http://policy.mofcom.gov.cn/GlobalLaw/en

glish/flaw!fetch.action?id=4faef68d-39ec-

46f1-b753-5ed37c1faf0a

IC 16-36-5-22

Petition for review

“Sec. 22. (a) A person may challenge the

validity of an out of hospital DNR

declaration and order by filing a petition for

review in a court in the county in which the

declarant resides.

(b) A petition filed under subsection (a)

must include the name and address of the

declarant's attending physician.

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

under subsection (a) may declare an out of

hospital DNR declaration and order void if

the court finds that the out of hospital DNR

declaration and order was executed:

(1) when the declarant was

incapacitated due to insanity, mental

illness, mental deficiency, duress, undue

influence, fraud, excessive use of drugs,

confinement, or other disability”

Iowa* Durable Power of

Attorney for Health Care

Decisions

http://www.nrc-

pad.org/images/stories/P

DFs/iowa_hcpaform.pdf

Iowa does not currently have a specific statute for a

psychiatric advance directive.

https://www.legis.iowa.gov/DOCS/ACO/IC/LINC/2013.C

hapter.144B.PDF

Iowa’s Durable Power of Attorney for Health Care

statute allows you to appoint an agent (called an

“Attorney in fact”) to make healthcare decisions for you

if you become incompetent to make those decisions

yourself. “Health care” may include mental health care.

The Iowa statute does not allow you to write advance

instructions for your psychiatric care in a freestanding

document.

This form includes

an Authority to

Release Information

section on page 4.

Combined Living

Will and Medical

Power of Attorney

http://c.ymcdn.com

/sites/www.iowaba

r.org/resource/res

mgr/forms/123.pdf

None

Kansas* State of Kansas Durable

Power of Attorney for

Health Care Decisions

Kansas does not currently have a specific statute for a

psychiatric advance directive.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

General statement of

Authority Granted

http://www.nrc-

pad.org/images/stories/P

DFs/kansas_dpoaform.pd

Kansas Statute- Powers and Letters of Attorney .

58-625 - 58-632

http://www.nrc-

pad.org/images/stories/PDFs/kansas_dpoa.pdf

The Kansas statute entitled Powers and Letters of

Attorney allows you to appoint an agent to make health

care decisions for you if you become incompetent to

make those decisions yourself. “Health care” may

include mental health care.

Kentucky 202A.430 Form of

advance directive for

mental health treatment

http://www.lrc.ky.gov/St

atutes/statute.aspx?id=7

506

Chapter 202A.426.

http://www.nrc-

pad.org/images/stories/PDFs/kentuckypadstatute.pdf

Chapter 202A.428.

http://www.nrc-

pad.org/images/stories/PDFs/kentuckypadstatute.pdf

You may use the part of the Kentucky statute entitled

Advance Directives for Mental Health Treatment to

write instructions about how you would like your

psychiatric treatment to proceed in the event that you

are incompetent to make decisions yourself. You may

appoint an agent (called a “Surrogate” in Kentucky) to

make decisions for you in accordance with your

instructions.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

The statute does not contain any restrictions on who

can be your agent (“surrogate”), as long as that person

agrees to act and signs your form or other document.

The statute provides that your providers may decline to

follow your instructions, or those of your agent, when

they are outside professional standards for health care.

Louisiana Advance Directive for

Mental health Treatment

http://www.nrc-

pad.org/images/stories/P

DFs/lousianapadform.pdf

221. Definitions.

http://www.nrc-

pad.org/images/stories/PDFs/lousiannastatute.pdf

Title 28-Mental Health.

http://law.justia.com/codes/louisiana/2011/rs/title28

The Louisiana Revised Statute, Title 28, Chapters 221-

236 allow you to create a PAD, known in Louisiana as an

“Advance Directive for Mental Health Treatment”. This

document allows you to specify treatment choices;

appoint an agent to make decisions for you if you

become incompetent; or both.

The statute allows you to consent to, or refuse, any

type of mental health treatment, including medications,

hospitalization and electro-convulsive therapy (ECT).

None None

Maine Health Care Directive and

Power of Attorney

Title 18-A: Probate Code.

Article 5: Protection of Persons Under Disability and

Their Property.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

http://www.nrc-

pad.org/images/stories/P

DFs/mainepadandhcpafor

m.pdf

Health Care Power of

Attorney

http://www.nrc-

pad.org/images/stories/P

DFs/mainehcpaonly.pdf

Health Care Directive

http://www.nrc-

pad.org/images/stories/P

DFs/mainepadonly.pdf

Part 8: Uniform Health-Care Decisions Act Heading: PL

1995, C. 378, PT. A, 1.

http://legislature.maine.gov/statutes/18-a/title18-

Asec5-801.html

Two Maine laws, the Uniform Health Care Decisions Act

and the less protective Medical Treatment of Psychotic

Disorders allow you to write instructions about how you

would like your mental health treatment to proceed. In

addition, the Uniform Health Care Decisions Act, which

covers all types of health care, including mental health

care, allows you to appoint an agent to make health

care decisions for you in the event that you become

unable to make those decisions yourself. The Disability

Rights Center of Maine has published a helpful guide to

the Uniform Health Care Decisions Act, including forms.

Under the Uniform Health Care Decisions Act you may

state that you wish to be admitted to a psychiatric

facility in a crisis for a period of up to five days, even if

you object at the time. (The Medical Treatment of

Psychotic Disorders Act does not place a limit on the

length of time to which you may consent to be

hospitalized through your PAD.) Under both laws, you

may state preferences regarding medications or

hospitals. You may also refuse hospital treatment or

medications, although the law of emergency

involuntary treatment will still apply. The Disability

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Rights Center’s guide explains these topics in more

detail.

Maryland Advance Directive for

Mental Health Treatment

http://www.nrc-

pad.org/images/stories/P

DFs/marylandpadform.pd

Article-Health-General.

Part I. Advance Directives.

5-601. Definitions.

5-601.1. Electronic signatures.

5-602. Procedure for making advance directive; notice

to physician - Living wills.

5-603. Suggested forms - Living wills.

5-604. Revocation of an advance directive.

5-604.1. Anatomical gifts in advance directives.

5-605. Surrogate decision making.

http://www.nrc-

pad.org/images/stories/PDFs/marylandpadstatute.pdf

Maryland’s Health Care Decisions Act allows you to

appoint an agent to make decisions about your mental

health treatment if you become incompetent to make

decisions; to write instructions about how you would

like your mental health care to proceed; or both. In

Maryland, a PAD is known as an “Advance Directive for

Mental Health Treatment”. A set of standard forms

with instructions, produced by the Maryland

Department of Health and Mental Hygiene, is available.

HIPAA

Authorization is

included in this

form on page 4

http://www.maryla

ndattorneygeneral.

gov/Health%20Polic

y%20Documents/ad

irective.pdf

None

Massachuset

ts*

Massachusetts Health

Care Proxy

Information, Instructions,

and Form

Massachusetts does not currently have a specific

statute for a psychiatric advance directive.

Chapter 201D- Health Care Proxies

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

http://www.massmed.or

g/Patient-Care/Health-

Topics/Health-Care-

Proxies-and-End-of-Life-

Care/Massachusetts-

Health-Care-Proxy---

Information,-Instructions-

and-Form-(pdf)/

https://malegislature.gov/Laws/GeneralLaws/PartII/Titl

eII/Chapter201D

Under the law entitled “Health Care Proxies”, you may

appoint an agent to make decisions for you if you are

unable to make those decisions yourself. Your agent

will have the authority to make any and all health care

decisions for you, which could include decisions about

psychiatric treatment. To appoint an agent, you must

use the form entitled “Massachusetts Health Care

Proxy”.

Michigan

Advance Directive

For Mental Health Care

http://www.nrc-

pad.org/images/stories/P

DFs/michigan%20durable

_power_of_attorney.pdf

Michigan Advance

Directive for Mental

Health Care

http://www.nrc-

pad.org/images/stories/P

DFs/michigan%20advanc

e%20directive%20for%20

Act 386 of 1998

Part 5- Durable Power of Attorney and Designation of

Patient Advocate.

http://www.legislature.mi.gov/(S(jzidl1rw2nz4lr5rwqn3

w1xc))/mileg.aspx?page=getObject&objectName=mcl-

386-1998-V-5

Michigan’s Durable Power of Attorney and Designation

of Patient Advocate statute allows you to appoint a

patient advocate to make mental health care decisions

for you if you become incompetent to make those

decisions yourself. You may also state your wishes

regarding mental health treatment. In Michigan, a PAD

is known as an “Advance Directive for Mental Health

Care”. The Michigan Bar Association has published a

helpful pamphlet and forms.

Page 4 of this form

includes temporary

addiction to pain

medication.

https://www.lifecar

edirectives.com/ass

ets/statutory_ads/

MICH%20SS%20AD

%2009%20-

%2017%20p%20Dw

nld.pdf

None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

mental%20health%20for

m.pdf

The statute says that your patient advocate must act in

your best interests, but also states that wishes of yours

within the patient advocate’s knowledge are by

definition, in your best interests.

Minnesota Health Care Directive

Suggested Form in

Statute

https://www.revisor.mn.

gov/statutes/?id=145C.16

Chapter 145C. Health Care Directives

145C.01. Definitions.

145C.02. Health Care Directive.

145C.03. Requirements.

145C.04. Executed in Another State.

145C.05. Suggested Form: Provisions that may be

included.

145C.06. When Effective.

145C.07. Authority and Duties of Health Care Agent.

145C.08. Authority to Review Medical Records.

145C.09. Revocation of Health Care Directive.

145C.10. Presumptions.

145C.11. Immunities.

145C.12. Prohibited Practices.

145C.13. Penalties.

145C.14. Certain Practices not Condoned.

145C.15. Duty to Provide Life-Sustaining Health Care.

145C.16. Suggested Form.

https://www.revisor.mn.gov/statutes/?id=145C

The statute allows you to appoint an agent (“proxy”) to

make decisions about your “intrusive mental health

treatment” if you become incompetent to make

decisions; to write instructions about how you would

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

like any “intrusive mental care” to proceed (“a

declaration”); or both. “Intrusive mental health

treatment” means treatment with neuroleptics

(antipsychotic drugs) or convulsive therapy (ECT). There

is no mandatory form as long as you comply with the

correct witness requirements.

You may write advance instructions about neuroleptic

medications, including refusals. The statute does not

give you the power to make hospitalization decisions in

advance, although any wishes you document may

influence the decisions of your providers.

Mississippi Mississippi Advance

Health-Care Directive

http://www.nrc-

pad.org/images/stories/P

DFs/mississippi_hcpa.pdf

MS Code 41-41-211 (2013)

http://law.justia.com/codes/mississippi/2013/title-

41/chapter-41/uniform-health-care-decisions-

act/section-41-41-211

41-41-201 through 41-41-229

http://www.nrc-

pad.org/images/stories/PDFs/mississippi_adstatute.pdf

Mississippi’s Uniform Health Care Decisions Act allows

you to appoint an agent to make health care decisions

for you if you become incompetent to make those

decisions yourself. Health care decisions may include

decisions about mental health.

This form includes a

summary of HIPAA

on pages 4 and 5.

http://www.southe

rncancercenter.com

/wp-scc/wp-

content/uploads/20

16/02/Mississippi-

Advance-

Directive.pdf

None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

The Mississippi statute does not allow you to write

advance instructions for your psychiatric care in a

freestanding document.

The statute states that your PAD becomes effective

when your primary physician determines that you lack

the ability to understand the risks, benefits and

alternatives of the proposed treatment.

Missouri*

Durable Power of

Attorney for Health Care

and/or Health Care

Directive

http://www.mobar.org/u

ploadedFiles/Home/Publi

cations/Legal_Resources/

Durable_Power_of_Attor

ney/final-dpa-forms-

fillable.pdf

Missouri does not currently have a specific statute for a

psychiatric advance directive.

Chapter 404- Transfers to Minors--Personal Custodian

and Durable Power of Attorney.

http://www.moga.mo.gov/mostatutes/stathtml/40400

008001.html

Missouri’s Durable Power of Attorney for Health Care

Act allows you to appoint an agent to make healthcare

decisions for you if you become incompetent to make

those decisions yourself. Healthcare decisions may

include decisions about mental health.

The Missouri statutes do not allow you to write advance

instructions for your psychiatric care in a freestanding

document, unless they concern end-of-life (life

sustaining) procedures.

This forms includes

a HIPAA

Authorization Form

on page 9.

http://www.mobar.

org/uploadedFiles/

Home/Publications/

Legal_Resources/Du

rable_Power_of_Att

orney/complete-

dpa-packet.pdf

None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

The statute requires that your agent “seek and consider

information” relating to your diagnosis, prognosis,

benefits and burdens of the proposed treatment, every

time a decision is made.

Montana

Durable Power of

Attorney for Health Care

Medical Treatment

http://www.nrc-

pad.org/images/stories/P

DFs/montana_hcpaform.

pdf

Title 53, Chapter 21

Montana Code - Part 13: Mental Health Care Advance

Directives.

53-21-1301. Purpose.

53-21-1302. Definitions.

53-21-1303. Presumption of capacity.

53-21-1304. Scope of mental health care advance

directive.

53-21-1305. Validity of appointment of agent.

53-21-1306. RESERVED.

53-21-1311. Prohibited elements.

53-21-1312. When a directive takes effect --

determination of incapacity.

53-21-1313. Provider of mental health services.

53-21-1314. Duties of agent.

53-21-1315. Health care decisions in event of the

principals protest.

53-21-1316. RESERVED.

53-21-1321. Explicit authorization required for certain

treatment.

53-21-1322. Authorization for admission to inpatient

treatment -- effect of directive.

53-21-1323. Expiration.

53-21-1324. Revocation.

53-21-1325. Effect of directive on existing law.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

53-21-1326. RESERVED.

53-21-1331. Nomination of guardian or conservator.

53-21-1332. Decisions by guardian or conservator.

53-21-1333. Health care information.

53-21-1334. Immunities.

http://codes.lp.findlaw.com/mtcode/53/21/13

Title 53, Chapter 21, Part 13, of the Montana statute

allows you to write instructions for your mental health

care treatment and any other medical treatment that

may directly or indirectly affect your mental health and

general care during a period of time in which you have

been determined by a court or your healthcare provider

as unable to give or withhold consent to medical

treatment. This document also allows you to appoint an

agent to make mental health care treatment decisions

on your behalf.

You can make choices about medications and

hospitalization, including consent or refusal of consent

to specific types of mental health care treatment,

including medical, behavioral, and social interventions.

You may also include but are not limited to including,

descriptions of situations that may cause you a mental

health crisis, descriptions of behavior that may indicate

you are incapacitated, instructions to apply or avoid

certain interventions that may deescalate or escalate

crisis, instructions on who should or should not be

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

notified or allowed to visit if you are admitted to a

treatment facility, and instructions that limit the

directive's revocability.

Nebraska*

Nebraska

Power of Attorney for

Health Care

http://www.nrc-

pad.org/images/stories/P

DFs/nebraska_hcpa.pdf

Nebraska does not currently have a specific statute for

a psychiatric advance directive.

Chapter 30

http://nebraskalegislature.gov/laws/statutes.php?statu

te=30-3402

Nebraska’s Health Care and Treatment Decisions

statute allows you to appoint an agent (called an

“Attorney in fact”) to make healthcare decisions for you

if you become incompetent to make those decisions

yourself. “Health care” may include mental health care.

The Nebraska statute does not allow you to write

advance instructions for your psychiatric care in a

freestanding document.

The statute states that your provider is not required to

treat you according to your Attorney in fact’s

instructions if they are contrary to the facility’s formal

policies of care. The statute also states that your

Attorney in fact’s instructions must be followed subject

to “independent medical judgment.”

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Nevada*

State of Nevada Durable

Power of Attorney for

Health Care Decisions

http://www.nrc-

pad.org/images/stories/P

DFs/nevada_hcpaform.pd

Nevada does not currently have a specific statute for a

psychiatric advance directive.

Chapter 449 – Medical Facilities and Other Related

Entities

https://www.leg.state.nv.us/nrs/NRS-449.html

Nevada’s Durable Power of Attorney for Health Care

statute allows you to appoint an agent to make

healthcare decisions for you if you become

incompetent to make those decisions yourself.

Healthcare decisions may include decisions about

mental health.

None None

New

Hampshire*

Form

http://www.nrc-

pad.org/images/stories/P

DFs/newhampshire_dpoa

form.pdf

New Hampshire does not currently have a specific

statute for a psychiatric advance directive.

Title: Public Health

Chapter: Durable Power of Attorney for Health Care

http://www.dhhs.nh.gov/hie/documents/laws.pdf

(page 15)

New Hampshire’s Durable Power of Attorney for Health

Care statute allows you to appoint an agent to make

healthcare decisions for you if you become

incompetent to make those decisions yourself.

Healthcare decisions may include decisions about

mental health.

none New Hampshire Code of Administrative

Rules.

Chapter He-P 800 Residential and Health

Care Facility Rules

http://www.dhhs.nh.gov/oos/bhfa/docum

ents/he-p807.pdf

The rule states that a “licensee shall not

deny admission to any person because that

person does not have a guardian or an

advanced directive, such as a living will or

durable power of attorney for health care,

established in accordance with RSA 137-H

or RSA 137-J.”

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

The New Hampshire statute does not allow you to write

advance instructions for your psychiatric care in a

freestanding document, unless they concern end-of-life

(life sustaining) procedures.

The statute states that the agent’s authority goes into

effect as soon as you “lack capacity to make health care

decisions”.

It states that a client’s record should

include “Copies of any executed legal

orders and directives, such as guardianship

orders issued under RSA 464-A, a durable

power of attorney for healthcare, or a living

will”

New Jersey The New Jersey

Department of Mental

Health Services has

published a standard

form

http://www.state.nj.us/h

umanservices/dmhas/for

ms/Advance%20Directive

s/PAD_English.pdf

Instructions

http://www.state.nj.us/h

umanservices/dmhas/for

ms/Advance%20Directive

s/PAD_Instructions_Engli

sh.pdf

Brochure

http://www.state.nj.us/h

umanservices/dmhas/for

ms/Advance%20Directive

P.L. 2005, c. 233

Title 10. Human Services.

Chapter 32. Advance Directives for Mental Health Care

http://www.state.nj.us/humanservices/providers/rulef

ees/regs/NJAC%2010_32%20Advance%20Directives%2

0for%20Mental%20Health.pdf

The New Jersey Advance Directives for Mental Health

Care Act allows you to write instructions for your

psychiatric treatment in the event that you are

incapable to make or communicate those instructions.

The statute also allows you to appoint an agent to

instruct mental health care professionals for you. In

New Jersey, this person is called a “mental health care

representative.”

Psychiatric Advance

Directive

(PAD)/Crisis Plan.

New Jersey

Advance Directives

for Mental Health

Care Act.

http://www.mhanj.

org/wp-

content/uploads/20

13/01/Psychiatric-

Advance-Directive-

Form-Print-Out-to-

Handwrite.pdf

This form asks

about substance

use.

This form gives

permission to the

None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

s/Adv_Directive_brochur

e.pdf

representative to

receive information

about alcohol and

substance abuse

diagnosis and

treatment on page

https://www.ecare

diary.com/advance

ddirectives/New%2

0Jersey%20Advance

d%20Directives.pdf

New Mexico Optional Form

http://www.nrc-

pad.org/images/stories/P

DFs/newmexicopadform.

pdf

HB 459

http://www.nrc-

pad.org/images/stories/PDFs/newmexicopadstatute.pd

New Mexico’s Mental Health Care Treatment Decisions

Act allows you to write instructions for your psychiatric

treatment in the event that you are incapable to make

or communicate those instructions. The statute also

allows you to appoint an agent to instruct mental health

care professionals for you. In New Mexico, a PAD is

known as an “advance directive for mental health

treatment.” The statute includes a standard form.

None None

New York* Planning Your Health

Care in Advance

New York does not currently have a specific statute for

a psychiatric advance directive.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

https://www.ag.ny.gov/si

tes/default/files/pdfs/pu

blications/Planning_Your

_Health_Care_in_Advanc

e.pdf

Health Care Proxy

https://www.health.ny.g

ov/publications/1430.pdf

The New York Health Care Proxy Law

https://www.health.ny.gov/professionals/patients/heal

th_care_proxy/

The New York law entitled “Health Care Agents and

Proxies” allows you to appoint an agent who will make

decisions for you if you are unable to make those

decisions yourself. In addition, or alternatively, you

may write instructions for your future mental health

treatment in a Living Will.

North

Carolina

Statutory Short Form

Power of Attorney

http://www.ncga.state.nc

.us/EnactedLegislation/St

atutes/PDF/BySection/Ch

apter_32A/GS_32A-1.pdf

Registry

https://www.sosnc.gov/a

hcdr/

Chapter 32A: Powers Of Attorney.

http://www.ncga.state.nc.us/gascripts/Statutes/Statute

sTOC.pl?Chapter=0032A

North Carolina provided for mental health treatment

consumers (MHT consumers) can plan ahead for mental

health treatment they might want to receive if they are

in a crisis and are unable to communicate for

themselves or make voluntary decisions of their own

free will. An Advance Directive for Mental Health

Treatment allows MHT consumers to write treatment

preferences or instructions if they had a crisis in the

future and could not make their own mental health

treatment decisions.

None None

North Dakota

Guidance for Mental

Health Advance

Directives

Chapter 23-06.5

23-06.5-01. Statement of purpose.

23-06.5-02. Definitions.

23-06.5-03. Health care directive.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

http://ndpanda.org/docs/

mhad-guidance0514.pdf

Statutory Form on page 6

http://www.legis.nd.gov/

cencode/t23c06-

5.pdf#nameddest=23-

06p5-16

23-06.5-04. Restrictions on who can act as agent.

23-06.5-05. Health care directive requirements ‑

Execution and witnesses.

23-06.5-05.1. Suggested health care directive form.

23-06.5-06. Acceptance of appointment ‑ Withdrawal.

23-06.5-07. Revocation.

23-06.5-08. Inspection and disclosure of medical

information.

23-06.5-09. Duties of provider.

23-06.5-10. Freedom from influence.

23-06.5-11. Reciprocity.

23-06.5-12. Immunity.

23-06.5-13. Presumptions and application.

23-06.5-14. Liability for health care costs.

23-06.5-15. Validity of previously executed durable

powers of attorney or other directives.

23-06.5-16. Use of statutory form.

23-06.5-17. Optional health care directive form.

23-06.5-18. Penalties.

23-06.5-19. Health care record registry ‑ Fees.

http://www.legis.nd.gov/cencode/t23c06-5.pdf

The North Dakota statute entitled “Health Care

Directives” allows you to appoint an agent to make

decisions about your psychiatric treatment if you

become incompetent to make those decisions; or to

write instructions about how you would like your

psychiatric treatment to proceed; or both. A standard

form is provided in the statute.

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

The statute says that your providers may decline to

follow your instructions, or those of your agent, in three

situations: (1) The provider feels unable to follow the

instructions for “reasons of conscience or other

conflict”; in that situation, the provider must try to find

another provider who will follow the instructions; (2)

The provider considers that the instructions run

contrary to “reasonable medical standards”; (3) You are

considered to require ”comfort, care or alleviation of

pain”, and the treatment required for those purposes

would be in conflict with your instructions.

Ohio

State of Ohio

Declaration for Mental

Health Treatment

http://www.nrc-

pad.org/images/stories/P

DFs/ohiopadform.pdf

2135.01. Declaration for mental health treatment

definitions.

2135.02. Declaration governing use or continuation, or

the withholding or withdrawal, of mental

health treatment.

2135-03. Validity and effect - revocation.

2135-04. When declaration becomes operative.

2135-05. Designation of proxy to make mental health

decisions.

2135-06. Execution of declaration.

2135-07. Treatment provider unwilling to comply with

declaration.

2135-08. Liability and duty of proxy.

2135-09. Revoking declaration.

2135-10. Liability of mental health treatment provider.

2135-11. No requirement to execute declaration.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

2135-12. Declaration does note supersede other

advanced health directives.

2135-13. Application opposing decisions.

2135-14. Printed form of declaration.

http://codes.ohio.gov/orc/2135

A Declaration for Mental Health Treatment gives more

specific attention to mental health care. It allows you,

while capable, to appoint a representative to make

decisions on your behalf when you lack the capacity to

make a decision. In addition, the declaration can set

forth certain wishes regarding treatment.

Ohio’s Declarations for Mental Health Treatment

statute allows you to write instructions (a “declaration”)

about how you would like your future mental health

treatment to proceed in the event of a crisis.

Additionally, Ohio’s Durable Power of Attorney for

Health Care statute allows you to appoint an agent to

make health care decisions for you, including mental

health decisions, in the event of a crisis.

The statute says that the provider is only obliged to

follow the PAD so far as it is “consistent with

reasonable medical practice, the availability of

treatments, and applicable law.”

Oklahoma Advance Directive for

Mental Health Treatment

Title 43A Mental Health

43A-11-101. Short title.

43A-11-102. Legislative findings.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

http://www.nrc-

pad.org/images/stories/P

DFs/oklahomapadform.p

43A-11-103. Definitions.

43A-11-104. Execution - Rights not affected -

Presumptions.

43A-11-105. Validity - Witnesses - Eligibility as attorney-

in-fact.

43A-11-106. Form of advance directive - Designation

and authority of attorney-in-fact.

43A-11-107. When advance directive becomes

operative - Contrary or conflicting

instructions given by attorney-in-fact.

43A-11-108. Delivery of advance directive to attending

physician or psychologist - Duty of

attending physician or other mental health

treatment provider.

43A-11-109. Revocation - Actual notice.

43A-11-110. Examination of declarant - Certification -

Duty to follow terms of advance directive.

43A-11-111. Petition for appointment of guardian.

43A-11-112. Immunity from civil or criminal liability.

43A-11-113. Violations - Penalties.

http://www.nrc-

pad.org/images/stories/PDFs/oklahomapadstatute.pdf

Oklahoma’s Advance Directives for Mental Health

Treatment Act allows you to write instructions (a

“declaration”) for your psychiatric treatment in the

event that you are incapable to make or communicate

those instructions. The statute also allows you to

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

appoint an agent, known as an “attorney in fact”, to

instruct mental health care professionals for you. You

may choose to make a declaration, appoint an attorney

in fact, or do both.

Oregon Guide and Form

https://www.oregon.gov/

oha/amh/forms/declarati

on.pdf

Chapter 784 Oregon Laws 2009

https://www.oregonlegislature.gov/bills_laws/lawsstat

utes/2009orLaw0784.html

Oregon’s statute entitled, “Declarations for Mental

Health Treatment,” allows you to appoint an agent to

make decisions about your treatment if you become

incompetent to make decisions; write instructions

about how you would like your mental health care to

proceed; or both.

The statute allows you to set out your instructions on

any aspect of your mental health treatment or your

personal affairs. This may include medication and/or

hospital preferences, including refusals of medication or

hospitalization. You may provide advance consent to

admission in a facility for mental health treatment for a

period of seventeen days or less.

None None

Pennsylvania Mental Health

Declaration

http://www.nrc-

pad.org/images/stories/P

DFs/pa%20mental%20he

alth%20declaration.pdf

Chapter 58

Mental Health Care.

http://www.legis.state.pa.us/cfdocs/legis/LI/consCheck

.cfm?txtType=HTM&ttl=20&div=0&chpt=58

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Mental Health Power of

Attorney

http://www.nrc-

pad.org/images/stories/P

DFs/pa%20mental%20he

alth%20power%20of%20

attorney.pdf

Combined Mental Health

Care Declaration and

Power of Attorney Form

http://www.nrc-

pad.org/images/stories/P

DFs/pacombinedform.pdf

Title 20, Chapter 58, of the Pennsylvania Consolidated

Statutes allows you to write instructions for your

psychiatric treatment in the event that you are

incapable to make or communicate those instructions.

In Pennsylvania, the document in which you record your

instructions is called a Mental Health Declaration. The

statute also allows you to appoint an agent to instruct

mental health care professionals for you. This is called

a Mental Health Power of Attorney. You may choose to

make a Mental Health Declaration, a Mental Health

Power of Attorney, or both.

Rhode

Island*

Durable Power of

Attorney for Health Care

http://www.nrc-

pad.org/images/stories/P

DFs/rhodeisland_hcpa.pd

Rhode Island does not currently have a specific statute

for a psychiatric advance directive.

Chapter 23-4.11

Rights of the Terminally Ill Act.

http://webserver.rilin.state.ri.us/Statutes/TITLE23/23-

4.11/INDEX.HTM

Chapter 23-4.10

Health Care Power of Attorney.

http://webserver.rilin.state.ri.us/Statutes/TITLE23/23-

4.10/INDEX.HTM

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Rhode Island’s Health Care Power of Attorney statute

allows you to appoint an agent to make health care

decisions for you in the event that you become unable

to make those decisions yourself. These decisions could

be about any type of health care, including mental

health care. In appointing an agent, you may wish to

specify how he/she should make decisions by

documenting preferences about your mental health

treatment.

The statute does not specify how incompetence is to be

assessed.

South

Carolina*

Health Care Power of

Attorney

http://www.state.sc.us/d

mh/consumer_resources/

powerofattorney.pdf

South Carolina does not currently have a specific

statute for a psychiatric advance directive.

Policy

Office of the State Director of Mental Health Directive

No. 804-97

http://www.state.sc.us/dmh/804-97.htm

The Code of South Carolina provides for Advanced

Directives but not Psychiatric Advance Directives (PAD).

The South Carolina Department of Mental Health has

recently published a PAD, known as a “Declaration for

Mental Health Treatment.”

This form includes a

HIPAA

Authorization on

page 3

http://aging.sc.gov/

SiteCollectionDocu

ments/S/SCHealthC

arePowerOfAttorne

y.pdf

None

South Dakota

Declaration and Power of

Attorney for Mental

Health Treatment

Chapter 59-7

Termination of Agency

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

http://www.nrc-

pad.org/images/stories/P

DFs/southdakotapadform

.pdf

59-7-1. Acts constituting termination.

59-7-2. Termination where power of agent not coupled

with an interest.

59-7-2.1. Continuing authority of agent notwithstanding

disability of principal when intent shown.

59-7-2.2. Recording of continuing power of attorney--

Force and effect--Duration.

59-7-2.3. Binding effect of agent's acts under continuing

power.

59-7-2.4. Nomination by principal of guardian or

conservator.

59-7-2.5. Health care decisions by agent.

59-7-2.6. Physician's determination of principal's

decisional capacity.

59-7-2.7. Comfort care required--Conditions for

withdrawal of artificial nutrition or hydration.

59-7-2.8. Artificial nutrition and hydration for pregnant

woman--Certification by physicians.

59-7-3 Actual knowledge of death or disability required

to terminate agency as to persons acting in good

faith--Binding effect of agent's actions.

59-7-4. Affidavit of want of knowledge of death--Proof

of nontermination of agency.

59-7-5. Report of missing in action does not constitute

actual knowledge of death.

59-7-6. Provision for revocation or termination

contained in power of attorney unaffected.

59-7-7. Severability of provisions.

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

59-7-8. Immunity of health care provider acting or

declining to act in reliance on attorney-in-fact or

agent--Decisional capacity of principal.

59-7-9. Acts pursuant to durable power of attorney--

Absent termination provision, authority not

affected by time lapse since execution of

instrument.

59-7-10. Appointment of conservator terminates power

of attorney.

59-7-11. Appointment of guardian terminates power of

attorney.

http://www.sdlegislature.gov/Statutes/Codified_Laws/

DisplayStatute.aspx?Type=Statute&Statute=59-7

South Dakota’s statute does not provide specifically for

PADs, Title 59, Chapter 7 of South Dakotas statutes

allows you to appoint an agent to make decisions for

you in the event that you are unable to make them for

yourself. In South Dakota, this person is known as an

“Attorney in Fact” or "Agent" and the document naming

the individual is known as a “Durable Power of Attorney

for Health Care”. There is no mandatory form.

Tennessee Declaration for Mental

Health Treatment

https://tn.gov/assets/enti

ties/behavioral-

health/attachments/Decl

Tennessee Code Annotated, Title 33, Chapter 6, Part 10.

33-06-1001. Declaration for mental health treatment

authorized -- Contents.

33-06-1002. "Incapable of making mental health

treatment decisions" defined.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

aration_for_Mental_Heal

th_Treatment-Form.pdf

33-06-1003. Duration of declaration -- Expiration --

Revocation.

33-06-1004. Signature required -- Witnesses.

33-06-1005. Effective date and applicability of

declaration -- Compliance.

33-06-1006. Care contrary to declaration --

Authorization by review committee --

Emergency.

33-06-1007. Declaration superior to powers of

conservator.

33-06-1008. New mental health care provider to receive

copy of declaration.

33-06-1009. Effect of declarations executed in another

state.

33-06-1010. Incorporation into durable power of

attorney for health care.

33-06-1011. Immunity for actions taken or not taken in

good faith reliance on declaration.

33-06-1012. Admission to treatment not to be

conditioned on execution of declaration

for mental health treatment.

33-06-1013. Destruction or alteration of declaration

prohibited -- Penalty.

33-06-1014. Standard form for declaration for mental

health treatment.

33-06-1015. Providers to have written policies and

procedures relating to declarations for

mental health treatment.

http://search.mleesmith.com/tca/33-06-1000.html

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Tennessee Statute entitled “Durable Power of Attorney

for Health Care.” This is separate from the PAD. It

allows you to appoint a person to make decisions if you

become incompetent, whether those decisions relate to

psychiatric or other medical treatment.

Your mental health providers could lawfully decline to

follow your PAD if you were involuntarily committed to

the hospital under State law and a treatment review

committee authorized such a course, or if there was an

emergency endangering your life or health: Chapter 33-

6-1006.

Texas Declaration for Mental

Health Treatment

http://www.dph.illinois.g

ov/sites/default/files/for

ms/declaration-mental-

health-treatment-

040416.pdf

Civil Practice and Remedies Code.

Title 6. Miscellaneous Provisions

Chapter 137. Declaration for Mental Health Treatment.

http://www.statutes.legis.state.tx.us/Docs/CP/htm/CP.

137.htm

Chapter 137 of the Texas Civil Practice and Remedies

Code allows you to write advance instructions for

psychiatric treatment in a “Declaration for Mental

Health Treatment.”

Health and Safety Code.

Title 2. Health.

Subtitle H. Public Health provisions.

Chapter 166. Advance Directives.

Subchapter A. General Provisions.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

http://www.statutes.legis.state.tx.us/docs/Hs/htm/HS.

166.htm

Chapter 166 of the Health and Safety Code, allows you

to appoint an agent to make any health care decisions,

including mental health care decisions, in the event that

you are unable to make those decisions yourself. This is

called a Power of Attorney.

Utah

Advance Directive Utah

State Declaration for My

Mental Health Treatment

http://www.nrc-

pad.org/images/stories/P

DFs/utahpadform.pdf

Title 62A, Chapter 15, Part 10, Section 1002.

http://le.utah.gov/xcode/Title62A/Chapter15/62A-15-

S1002.html

Utah Code.

Declaration for Mental Health Treatment

https://le.utah.gov/xcode/Title62A/Chapter15/C62A-

15-P10_1800010118000101.pdf

Utah’s Substance Abuse and Mental Health Act allows

you to appoint an agent to give instructions for you in

the event of a mental health crisis. In Utah, the

document in which you record your instructions is

called a Declaration for Mental Health Treatment.

None None

Vermont* Vermont Advance

Directive for Health Care

http://healthvermont.gov

/vadr/documents/AD_att

achmentA.pdf

Vermont does not currently have a specific statute for

a psychiatric advance directive.

Title 18: Health.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Chapter 231: Advance Directives For Health Care And

Disposition Of Remains.

http://legislature.vermont.gov/statutes/chapter/18/23

9700. Purpose and policy.

9701. Definitions.

9702. Advance directive.

9703. Form and execution.

9704. Amendment, suspension, and revocation.

9705. Duty to deliver.

9706. When advance directive becomes effective.

9707. Authority and obligations of health care

providers, health care facilities, and residential

care facilities regarding health care instructions.

9708. Do-not-resuscitate orders and clinician orders for

life-sustaining treatment.

9709. Obligations of health care providers, health care

facilities, residential care facilities, and health

insurers regarding protocols and

nondiscrimination.

9710. Consent for hospice care.

9711. Authority and obligations of agent.

9712. Obligations of funeral directors, crematory

operators, cemetery officials, procurement

organizations, and individuals appointed to

arrange for the disposition of the principal's

remains.

9713. Immunity.

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

9714. Failure to follow advance directive; unauthorized

access of registry; administrative penalties.

9715. Interpretation with other laws.

9716. Reciprocity; choice of law.

9717. Presumption of validity.

9718. Petition for review by Probate Division of the

Superior Court.

9719. Obligations of state agencies.

9720. Severability.

Title 18, Chapter 231 of the Vermont statutes allows

you to appoint an agent to make decisions about your

treatment if you become incompetent to make

decisions; write instructions about how you would like

your health care to proceed; or both. This law covers all

types of health care, which could include psychiatric

treatment. There is no mandatory form as long as you

follow the procedural rules in the statute.

The statute allows you to set out your instructions on

any aspect of your health care treatment, which could

include advance decisions about psychiatric

medications and/or hospitalization.

Virginia* Virginia Advance

Directive for Health Care

http://www.nrc-

pad.org/images/ad%20fo

Virginia does not currently have a specific statute for a

psychiatric advance directive.

Health Care Decisions Act.

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

rm%20for%20physical%2

0and%20mental%20healt

h%20care%20.pdf

https://www.dhp.virginia.gov/dhp_laws/Health_Care_D

ecisions_Act.doc

Virginia’s Health Care Decisions Act authorizes advance

directives for mental health as well as other medical

treatment. Multiple forms are provided by the Virginia

Hospital and Healthcare Association and the Virginia

Advance Health Care Directives website, but you are

not required to use any specific form. The only

requirements are that you put your wishes in writing,

sign them, and have two adult witnesses who see you

sign, sign as well. If you are appointing an agent to

make health care decisions on your behalf, that person

should not be one of your two witnesses. The Health

Care Decisions Act provides the full legal code

governing the use of advance health care directives in

Virginia.

All variations of Virginia's advance directive for health

care form allow you to set out your instructions on any

aspect of your psychiatric treatment, which could

include advance decisions to request or refuse

medications or hospitalization.

Washington Mental Health Advance

Directive

http://www.nrc-

pad.org/images/stories/P

Chapter 71.32 RCW

Mental Health Advance Directives

http://apps.leg.wa.gov/rcw/default.aspx?cite=71.32

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

DFs/washingtonpadform.

pdf

Statute form

http://app.leg.wa.gov/RC

W/default.aspx?cite=71.3

2.260

Washington State’s statute entitled, “Mental Health

Advance Directives,” allows you to appoint an agent to

make decisions about your treatment if you become

incompetent to make decisions; write instructions

about how you would like your health care to proceed;

or both. There is no mandatory form, but the statute

provides a suggested form.

The statute allows you to set out your instructions on

any aspect of your mental health treatment or your

personal affairs. This may include medication and/or

hospital preferences, including refusals of either or

both.

West

Virginia*

State of West Virginia

Medical Power of

Attorney

http://www.nrc-

pad.org/images/stories/P

DFs/westvirginia_hcpa.pd

State of West Virginia

Living Will

http://www.nrc-

pad.org/images/stories/P

DFs/westvirginia_lwform.

pdf

Statute form

West Virginia does not currently have a specific statute

for a psychiatric advance directive.

Living Will/Medical Power of Attorney Statute

http://www.nrc-

pad.org/images/stories/PDFs/westvirginia_mpoastatut

e.pdf

The West Virginia Health Care Decisions Act allows you

to: (1) appoint an agent to make health care decisions

for you in the event that you become unable to make

those decisions yourself (known as making a “medical

power of attorney”); and/or (2) create a “living will” in

which you write instructions about how you would like

your health care to proceed. The statute covers all

None Living Will/Medical Power of Attorney

Statute.

http://www.nrc-

pad.org/images/stories/PDFs/westvirginia_

mpoastatute.pdf

Statute states that you can get a second

opinion if you have an addiction.

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

http://www.nrc-

pad.org/images/stories/P

DFs/westvirginia_mpoast

atute.pdf

types of health care, which may include mental health

care.

Wisconsin* Declaration to Physicians

(Living Will)

https://www.dhs.wiscons

in.gov/forms/advdirective

s/f00060.pdf

Power of Attorney for

Health Care

https://www.dhs.wiscons

in.gov/forms/advdirective

s/f00085.pdf

Wisconsin does not currently have a specific statute for

a psychiatric advance directive.

Chapter 155

Power of Attorney for Health Care

http://www.nrc-

pad.org/images/stories/PDFs/wisconsin_hcpastatute.pd

Wisconsin's POA-HC statute prohibits Developmentally

Disabled or Mentally Ill principals from appointing a

health care agent with the power to admit to a nursing

home or group home over 16 beds:

155.0(2)(c)2.c, Wis Stats. states, "A healthcare agent

may consent to the admission of a principal to the

following facilities, under the following conditions: (c.)

to a nursing home or a CBRF if the principal is not

diagnosed as having a developmental disability or as

having a mental illness at the time of the proposed

admission."

None None

State Mental Health Forms Mental Health Statute/Rule/Policy Substance Use

Disorders

Forms

Substance Use Disorders

Statute/Rule/Policy

Wisconsin’s Power of Attorney for Health Care statute

allows you to appoint an agent (called a “health care

agent”) to make healthcare decisions for you if you

become incompetent to make those decisions yourself.

“Health care” may include mental health care. You

must use the state’s standard form.

The Wisconsin statute does not allow you to write

advance instructions for your psychiatric care in a

freestanding document.

Wyoming Psychiatric Advance

Directive

http://www.nrc-

pad.org/images/stories/P

DFs/wyomingpadform.pd

Title 35, chapter 22, article 3.

https://legisweb.state.wy.us/statutes/compress/title35.

doc (page 758)

http://www.nrc-

pad.org/images/stories/PDFs/wyomingstatute.pdf

Wyoming’s statute allows you to appoint an agent to

make decisions about your mental health treatment if

you become incompetent to make decisions; to write

instructions about how you would like your mental

health care to proceed; or both.

None None

Advance Directive for Addiction in Remission and to Ensure Continued Recovery

Patient Last Name

Patient First Name

Middle Initial

Birth Date

Medical Record Number

Date Prepared

In event of my inability to speak for myself, I am recovering from addiction to

( ) Alcohol ( ) Opioids ( ) Benzodiazepines ( ) Amphetamine ( ) Cocaine ( ) Other

I would request if any mood altering medications are to be given that they are used sparingly

and in amounts and formulations designed for my personal recovery to minimize iatrogenic

relapse. Signed document allows for permission to use INSPECT at any time

USE: Long acting ( ) morphine ( ) oxycodone ( ) methadone ( ) oxymorphone ( ) other

USE: Short Acting ( ) morphine ( )oxycodone ( ) hydrocodone ( ) other

Responsible Party for post procedural take home medications

Scheduled ( ) Every [ ] hours for [ ] days no longer than [ ] days

Responsible prescribing clinician/Pharmacy (one of each only)

Copy of current treatment agreement attached

Sponsor/Recovery Coach

Attachment V

DRAFT