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

2. Marcus Boyd, MA, LPC, LCAS, CCS
Presenters
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.

3. Objectives of this presentation
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.

4. Prevalence of Use
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

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 individual can have one or both of these legal tools.
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.

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

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. Treatment providers are required to follow a PAD, with these exceptions:
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

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. What does a person do with a PAD?
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

15. FAMILY/SOCIAL NETWORK
PADs and the CJ System
PERSON WITH PAD
POLICY
PEER PROVIDERS
OUTPATIENT PROVIDERS
CRISIS RESPONSE
HEALTH SYSTEM
JUDICIAL SYSTEM
HOUSING
ACT TEAMS
FAMILY/SOCIAL NETWORK

16. Where/when PADs may come into play:
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

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

19. Thank you! Marcus Boyd, LPC, LCAS, CCS Marcus.boyd@mecknc.gov
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
Melissa Zhiss, LPA