Psychiatric Advance Directives (PAD) Mecklenburg County - Criminal Justice Services

1. Psychiatric Advance Directives (PAD)Mecklenburg County - Criminal Justice Services CIT International Presentation, August 2019

2. Marcus Boyd, MA, LPC, LCAS, CCS • 18 years of clinical experience in Mental Health and Substance Abuse Treatment, including Community Outreach, ACT Team Leader, Intake/Triage for LME/MCO and Program Coordinator for MeckFUSE housing program for homeless/mentally ill individuals • Criminal Justice-Mental Health experience with NOVA (DV treatment program), Consultant/Clinician for individual and group sex offender treatment, NC Certified Forensic Screener • Melissa Zhiss, MA, LPA • 23 years of experience working with severe, persistent mentally ill individuals; many who had substance addictions and/or criminal justice involvement. • Current position: Mental Health Jail Liaison in the Forensic Evaluations Unit under Mecklenburg County Criminal Justice Services; diverting individuals with serious mental illness, intellectual/developmental deficits, and/or substance abuse from jail. Presenters

3. Participants will be able to identify the core components and uses of the psychiatric advance directive (PAD). • Participants will be able to identify potential uses of PADs in their local community. • Participants will be able to identify the appropriate population of potential PAD creators. Objectives of this presentation

4. Currently, 25 states have laws that permit psychiatric advance directives. For states that do not, an individual can still draft a PAD under the more general statutes connected to health care directives, or Living Wills. However, a PAD is preferred because of the unique issues of mental health care and treatment. Source: NAMI.org Prevalence of Use

5. Psychiatric Advance Directive (PAD) Proactive • A Psychiatric Advance Directive (PAD) is a legal tool that can allow a person’s voice to be heard when they are in mental health crisis. • It is created before a crisis occurs, when person is unable to make reasonable decisions for themselves.

6. Underlying Principles • Competent adults have the right to make decisions about their healthcare, including mental health treatment. • The legal documents that make up a PAD support an individual’s rights are based on the NC General Statutes and are supported by the Patient Self-Determination Act of 1990.

7. Key Points 1. A PAD is primarily used in treatment settings to communicate with providers. 2. A PAD is a tool that can let treating providers know what works and what does not work for an individual. 3. A PAD is usually temporary and goes into effect if a physician or psychologist finds a person lacks decision-making capacity, based on their examination.

8. Two Parts to a PAD • An Advance Instruction that allows an individual to consent to treatment in advance, and to state their preferences for treatment, including medications, and the preferred facility if they need to be hospitalized. • A Health Care Power of Attorney that allows the individual to select a person they trust to represent them if they cannot speak for themselves. This person is called the health care agent, and should represent an individual’s preferences and serve as their advocate. An individual can have one or both of these legal tools.

9. Advance Instructional Directive Hospital admission Medications Electroconvulsive treatment (ECT) Other treatments for mental illness Care for children Arrangement for pets Payment of bills Usually permits an individual to plan for, consent to, or refuse:

10. Health Care Power of Attorney (HCPA) • Allows a person to appoint someone to make treatment decisions when an individual is “incapable” or “incompetent” • Person designated is called the Health Care Agent (can be more than one person) • Any capable adult may execute

11. If request is for something that is not “standard care” • If request is for something not available or not feasible • If it is an emergency • If there are safety issues present and person is under an involuntary commitment (IVC) Even with these exceptions, a PAD can include helpful information for an individual’s treatment Treatment providers are required to follow a PAD, with these exceptions:

12. Creating a PAD • Any adult “of sound mind” can make • Signed in presence of two witnesses: • Not a relative • Not person’s doctor, mental health provider or other staff • Not staff of a health care facility in which the client is a patient • Must be notarized • Present to doctor and other mental health treatment providers

13. Activating the PAD and the power of attorney • The person must be deemed incapable by a physician or psychologist who has examined the person • The finding must be documented in the medical record • At this point, the PAD is in effect, and if there is a health care agent, that person can make decisions for the incapacitated person • The treating providers should follow the guidance of the advance instruction and honor the person’s wishes when possible

14. Share copies with all treatment providers • File in the medical record of any potential treatment facility • Give copies to support people/health care agents • Have a copy available when accessing crisis services • Store at the NC Secretary of State’s website https://www.sosnc.gov/ahcdr/ What does a person do with a PAD?

15. PADs and the CJ System

16. Upon presentation to Psychiatric ED by law enforcement • Use by ACT team/Mobile Crisis/Community Police Crisis Response Team in response to emergency • Individuals involved with Wellness Court/Recovery Court programs • During initial assessment in Arrest Processing • Inability to comply with Community Supervision Where/when PADs may come into play:

17. Why use a PAD within the CJ System? • Allow an individual to have a say in their treatment • Identify and mobilize resources to support an individual • Give first responders and providers information to guide treatment • Provide an alternative to incarceration for some individuals

18. Cherene Caraco (Promise Resource Network) • Bob Ward (Public Defender) • Bebe Smith (Southern Regional AHEC) Thanks to:

19. Thank you! • For more information about PADs, you can visit the SAMHSA website and search “Psychiatric Advance Directives” or “Advance Directives for Behavioral Health”. NAMI has additional information and their position statement available through their national website. Marcus Boyd, LPC, LCAS, CCS Marcus.boyd@mecknc.gov 704-534-8306 Melissa Zhiss, LPA Melissa.zhiss@mecknc.gov 704-330-9033