Friday, February 22, 2013

Tell Me What To Do

Note: As I was writing this post, Pete Earley reran a post he wrote in 2010 about this identical topic. Spooky! Please go over to his blog and read what he has to say about it here.

Now that states are moving to create registries of involuntarily admitted patients, I think the time has come to reconsider an old idea, specifically the use of of psychiatric advance directives (PADS).

For those who have never heard of this idea, a psychiatric advance directive is a form of durable power of attorney. It's a document that a patient creates which states the kind of treatment the patient would like in the future, if he becomes ill and loses the ability to make treatment decisions. The document may designate a person the patient wants to make decisions on his behalf---a person known as a health care proxy---or may just list the patient's wishes about various things. Here is a partial list of the issues that get addressed in a psychiatric advance directive:

- the choice of hospital the patient would like to be admitted to
- an affirmative statement requesting admission
- the types, frequency and dose of preferred medication
- consent for use of seclusion or restraint
- designation for care of children, property or pets
- person to notify or next of kin designation
- consent for use of electroconvulsive or ECT treatment

Of course, the obvious thing about this list is that there is an assumption that the person is using it to request treatment when ill, but it can also be used to document which treatments, if any, the patient wants to refuse.

But what if a patient uses an advance directive to refuse all treatment? Here likes the conundrum. What if the patient becomes violent or threatens someone else? What if the patient's condition deteriorates to the point that his life is in jeopardy? For example, someone who is catatonic and unable to eat or drink fluids? What if the patient is not dangerous or doing anything violent, but just needs supervision and nursing care (help bathing or dressing or eating) and can't live outside an inpatient unit? Should this person be allowed to stay in a hospital indefinitely (when there is a huge demand for psychiatric bedspace for voluntary patients) when a short course of involuntary medication might make them better enough to live independently, outside a hospital?

And what if the patient wants treatment, but the advance directive dictates a treatment that is experimental, ineffective, or even potentially harmful? Should an advance directive be allowed to contain a patient's request for medical marijuana? In some states, the treating psychiatrist is bound by law to follow the instructions in an advance directive and there are civil penalties for not following them.

Also, in certain cases an advance directive can be overridden by the court if the patient becomes dangerous to other patients. Depending on how the directive is written, it can also be revoked by the patient once he's in the hospital which makes the whole document rather pointless. Finally, many patients and doctors have either never heard of PADS or are not familiar enough with them to use them.

This is why I'm putting up this post now. I think the PADS have potential utility and are certainly better than the outpatient commitment laws that many states have (and that our state is considering). To keep things simple, let's start with the assumption that the patient actually wants to be treated when they are sick but loses the ability to make that decision. (In other words, the patient agrees with the treatment in retrospect---ie. "I didn't like it, but I know it had to be done.")

I'd like our readers to discuss this so we can figure out better ways to make them useful. Have you ever written or used a PAD (from either a psychiatist or patient standpoint)? What worked, what didn't? What would you like to see changed? How could it be improved? Do you have a better idea than a PAD?

If you want more information before commenting, here's a one-stop-shopping site for PAD information.


Anonymous said...

Why is there a psychiatric advance directive at all? There is no GI advance directive, no neurology advance directive, no oncology advance directive, for all other patients there is just an advance directive. I don't think it helps psychiatric patients to be treated as if they need a special advance directive; I think that's kind of insulting.

At one point in time I looked into creating one and when I learned the psychiatrist could override my wishes in case of emergency, I decided that rendered the whole exercise pointless. Why should they have the right to override my wishes made when I was legally competent to make these decisions?

Get rid of the psychiatric advance directive, and just have the advance directive. Or if they insist on the special psych advance directive, make it enforceable, and impossible for the psychiatrist to override a person's wishes made when they were legally competent, regardless of the outcome.

I also do not care for the "rank in the order of preference: chemical restraint, seclusion, physical restraint..." How about options that are less extreme?

Joel Hassman, MD said...

Current issue of Psychiatric Times has an article about this very topic.

Worth finding the link and sharing with readers? I leave to you to do, I don't have a membership.

Sunny CA said...

It is a great idea only if doctors were legally bound to follow the advance directive. Without that, it is a waste of time.

ClinkShrink said...

Thanks Joel, I hadn't seen that article. Here's the link (free registration required):

To Sunny and Anonymous, good point about having a single advance directive that could cover both psychiatric and somatic issues. A few states do have physicians bound to follow the directive, and the article I linked to says that one state has a statutory time limit during which a PAD can't be overridden.

It seems to me you can think about this in terms of 3 groups of people:
1. People who accept both admission and meds but want to ensure preferences are respected
2. People who will accept admission but not meds
3. People who want to reject both admission and meds

PADS are probably most useful for people in group 1, somewhat useful for people in group 2 (in states that require affirmative acceptance of a voluntary admission rather than mere "assent" or "going with the flow."). In a state where someone loses the ability to consent to admission they'd otherwise have to be admitted involuntarily unless there was a PAD consenting to admission.

For people in group 3, I think there may still be a way to make a PAD useful even if it doesn't involve traditional psychiatric intervention. This is the aspect I'm most curious about and want to engage people in thinking about. Here's what I'm thinking, using a hypothetical patient scenario:

Imagine you get manic sometimes in spite of meds, you know exactly what's going to happen when you get sick but you don't want to go into the hospital. Maybe you go out and buy three cars at once or make lots of long distance phone calls to Asia or drive recklessly or stop eating and lose weight, or stop bathing and dressing. You adamantly don't want to go into the hospital. How could a PAD be used in a situation like this?

First, I think you could use it to set up a home care plan. You could designate a trusted friend or relative to intervene when you see the episode coming on. Give that person power of attorney to stop your cell phone plan, freeze your bank accounts, take away your car keys or make financial decisions for you. You could designate someone to act as temporary guardian for your kids or pets and to make arrangements for a visiting nurse (similar to what they do for new mom's after discharge, to make sure everything is going OK at home after delivery). You could maybe decide what your own personal endpoint should be, just in case there's a chance this particular episode could kill you and you really really don't want to die---maybe advance consent for a medical (not psychiatric) admission for fluid, hydration and nurishment.

Or maybe I'm totally full of it. It's just a thought and I thought I'd throw the idea out there for discussion. If nothing else, maybe I've raised some questions for people to talk to their loved ones or companions about.

jesse said...

Clink's idea is truly something that should occur with anyone managing such an illness. It means that the patient would have the foresight to do this, or that relatives, friends, or a clinical team would be helping to structure such a plan.

What is left out of the idea of psychiatric advance directives as presented is the response of the insurance company. Remember, "Philosophy Follows Funding."

Anonymous said...

"I also do not care for the "rank in the order of preference: chemical restraint, seclusion, physical restraint..." How about options that are less extreme?"

Anonymous, get real, it is too humane.

Yes, I am being sarcastic because Clink, while your intentions are great, it is the same old worn out advice that doesn't work that is being recycled.

I mean as as the other posters have pointed out, advanced psychiatric directives are pretty useless if they can be overridden.

Until psychiatry decides to really commit to exploring non med options which has about as much chance of happening as my being a millionaire, we will continue to have the same discussions with the same results.


Anonymous said...

Where is the graphic???

Anonymous said...

It's nice to learn that at least a few states may have some common sense and require physicians to follow the psychiatric advance directive. We clearly have a long way to go, though. I have read everything I can find on creating a psychiatric advance directive, and in my state, unfortunately, they are worthless. Discrimination against psychiatric patients is alive and well in most states.

As I mentioned before, the psychiatric advance directive in my state asks patients to list in order of preference: chemical restraint, seclusion, physical restraint. This shows the extreme bias of the creators of this document. There is no "none of the above" option. Why not? It assumes that all people in times of psychiatric crisis would want force, this is untrue. Does anyone here think Rob would want forced psychiatric treatment were he incompetent to make decisions? I think not. I feel the same way.

I am a patient who voluntarily takes psychiatric medication and voluntarily sees a psychiatrist. I would like for there to be an enforceable psychiatric advance directive in my state as I would not ever want any forced psychiatric treatment under any circumstance. That has been tried before, and it made things considerably worse.

I thought about creating a medical power of attorney, and having an attorney add something about how I have always opposed forced psychiatric treatment and would not want it should I become incompetent. But, again I cannot ensure that this would be followed.

What is interesting is that I read online how some family members argue that psychotropic drugs returned their adult son/daughter to sanity, but strangely it never removed their anosognosia and the person still never believed they were ill, during their period of sanity could not be coaxed into signing a document giving this concerned family member medical power of attorney, and stopped their medications. They can't have it both ways. Either the drugs worked and restored them to sanity in which case the decisions the psychiatric patients make, even if family finds them disagreeable, were made when the patient was legally competent and should therefore be respected or the drugs didn't work nearly as well as they are arguing.

I voluntarily take psychiatric medications, but if and when I decide the risks outweigh the benefits, I will be the one who decides what happens next. It is my body, my decision. It is a shame that even though I am legally competent to make decisions, I work full time, I support myself, etc I have no way to ensure that my wish for no forced psychiatric intervention be respected, should I become incompetent. That's wrong.

ClinkShrink said...

Certainly better minds than mine have thought about this issue and I'm sure I'm repeating old ideas, but bear with me for a bit.

Assume for a minute you lived in a world where what you wrote down was followed to the letter. If you didn't want medicine you didn't have to take it. No one would take you to the hospital unless you wanted to go. What would happen then? Would you need or want help at home? Would you just be quietly miserable every day? Would your physical health deteriorate? Would you get kicked out of your living situation? How likely would it be that you would die from your condition, either through lack of self-care or direct injury? Would you ever want someone to do something to prevent that? If not hospitalization, then someone to sit with you continuously at home? You've made it clear what you wouldn't want, but what WOULD you want?

Yes, as Jesse said there is the funding question and no, I don't know who would pay for sitters or home nursing care but I think sometimes a good idea has to start out as a loss leader until the system catches on that it's a good idea.

I can imagine if I were confronted between a choices of restraints and/or seclusion I would have the same reaction, particularly if I had never been violent before ever in my life. I know that I would never want to hurt someone else though, so if I was delirious in the hospital and took a swing at a nurse I would want somebody to do something (and I'd feel badly about it when I got better).

I've interviewed a lot of people who have done some pretty awful things when ill, and often they feel horribly when they get well enough to realize what happened. They would look at the seclusion/restraint item and pick one without hesitation rather than risk harm to someone else.

I know, that's an extremely skewed and small sample group, and our blog readers don't belong to that group (although I could be wrong, I guess we could have an insanity acquittee reader).

So what could someone do to help, separate from hospitalization and meds?

notsonutsastheysay said...

You make sense except that I can tell you that despite never having taken a swing at anyone, I have been forcibly restrained, both chem and physically. I have been secluded in terrible little rooms. Why? I was psychotic. I wasn't dangerous. I needed help, not more trauma. I have had some very limited experience with an different sort of intervention that did not rely on force. It's called compassion and a calm voice and the presence of some soothing entity who might be a total stranger but who can see that beneath my psychosis, I am still human. I will not say that I do not take psych meds. I do. I hate them but I function better on them than off. Still, when the insanity breaks through, the last thing I need is force. It makes me crazier and I do not consider the options of isolation or restraint of any kind to be treatment. It would cost a lot of money to have the trained staff to deal with people who are not well but who can be stabilized without resort to state sanctioned violence upon their person.
I would never have an advance directive allowing anyone to but off my cell phone etc. I have not met anyone, ever who was able to see my good mood as a good mood. It must be mania. My sad times must be pathologized too. I am not allowed, as a psych pt to experience a normal range of emotions.Anything that is not blunted is cause for concern. I would not ever have access to my phone or my car if I had an advance directive because it would be abused due to ignorance and the fear that accompanies any emotional expression on the part of someone with a MI, at least in my experience. SO had a bad day? SO can take a few drinks to chill. If I had a bad day? Off to hospital for you!!

catlover said...

I spent a lot of time writing my advance directive. The way that I handled unforseeable circumstances was that I wrote a couple of long paragraphs about what my values are and what I want from treatment, then gave a great deal of power to my power of attorney to make decisions. I have verbally told him many times not to be cowed by the doctors. I had my psychiatrist as one of my witnesses, so my competence couldn't be questioned. I then refused virtually all medications in my directive, unless there was some horribly dire circumstance that will never happen, like if I was attacking people or something. I explained why I was refusing all of these medications, in an addendum (listed each medication and why I didn't want it, in many cases because it didn't work before). I nixed all antipsychotics no matter what, and referred back to my little essay on what I value in life.

The first time I used it, I had to wave it in the nurses faces while yelling, and they relented and followed it. I then wrote letters and met with the administrator of the hospital, and I noticed that staff were well trained on these directives the next time (or maybe there was just a nasty note in my medical records by administration). I just stay the hell away from the hospital now, and glad I found out why I was unable to control my behaviors (drug side effects).

My parents had someone from the hospital help them with their medical directives (not psychiatric ones). It was a free service. I wonder if that's an option to end up with a psychiatric directive that is more likely to be followed? I figured if I put the WHYs in mine, and some medical history, it was much likelier it would be honored.

catlover said...

Notsonuts, it helps to complain. When I was inpatient and saw people being forcibly restrained when they were not a risk of harm to self or others, I threatened to report to the accreditation agency(JAACO? I forget) and Medicare and Medicaid. I took notes to document what I saw. I provided de-escalation materials to the hospital administrator and staff were trained some more, supposedly. I didn't file the complaint, because it did seem that changes were made, and my worker said hospital stays were going better for other patients. I really don't know. It was a hell of a thing meeting with the administrator when I was terrified of an involuntary commitment. I've mentioned some of this on this blog before. Hospital administrators don't get many complaints from mental patients, and maybe that has to change.

jesse said...
This comment has been removed by the author.
jesse said...

Earlier this week I passed one of the many homeless people in Baltimore. He was filthy and seemed to be talking to himself. It was twenty degrees outside. No one was making him do anything.

Perhaps he had gone off his medication, lost his job and then his home.

Years ago I once had a patient who did that, and years later thought I saw him on a street in the city, homeless.

February 23, 2013

Anonymous said...


1. I would want an enforceable psychiatric advance directive with my opposition to forced psychiatric treatment respected.
2. Were I incompetent to make decisions, I would want my sister called, as she knows and loves me and although she does not have a mental illness she shares my opposition to forced psychiatric treatment.
3. I would want medical staff to treat me with compassion and kindness, rather than with threats and ultimatums.
4. I would want staff to back off when I tell them I need to be by myself.
5. I would want staff to see my desire for family and friends to visit me as a sign of progress and encourage the contact, rather than telling me I broke some arbitrary rule I didn't even know existed and treat me like a naughty patient.
6. Move the therapy outdoors. More time out in the sun and fresh air rather than in depressing room with stale air listening to a bunch of depressing stories that leave you feeling like you've been run over by a truck.
7. I am an introvert, being chummy with large groups of people does not make me feel better, it makes me feel worse. Recognize and respect this.
8. If I were in bad shape offer medication and offer hospitalization, but do not stomp off in a huff if I decline and do not force it. Re-read my psychiatric advance directive and realize that I value my autonomy. 9. If I agree to hospitalization, I want to be on a floor that is unlocked, I am not a criminal. I would want to be able to have my sister by my side at all times in the hospital just as I could if I were in the hospital for pyleonephritis. Medical staff tend to be more respectful when family is there. My sister would be able to help ensure my wishes were respected if I were unable to communicate that.
10. I would want to be treated with the same respect as I was treated when I was hospitalized for pyelonephritis. No nurse came in and flipped of the t.v when I was awake at 3:00 in the morning, miserable and unable to sleep. She offered me something to drink and asked if I needed anything.
11. Ask how you can help, rather than tell me how it's going to be.
12. Treat me like an adult, rather than a naughty child.

Liz said...

i love what the person said who posted before me.

personally, were i to become constantly suicidal, i'd be potentially willing to consent to hospitalization at a certain unit of a certain hospital, with certain doctors, so long as they understood i would not consent to any medication. this couldn't happen, though, because all the hospital seems to do is provide a few days worth of meds and that's it... i'm just not sure how being hospitalized for three days in the midst of a long term debilitating depression would help me.

i like clink's idea of discussing with family/friends how they can help if the situation arises again. in fact, i'm going to consider doing that.

Liz said...

oh-- and i would NEVER consent to being restrained. i've never been a risk to anyone else. i was restrained to prevent self harm. i NEVER harm myself in front of anyone else. so all the "restraint" i'd need is for someone to sit with me, and my family would be willing to do that any time a crisis necessitated it. i don't see why family isn't more involved in more of these situations anyway, in particular when a client WANTS such involvement.

Anonymous said...

Jesse, I wonder if anyone offered this gentleman a place to sleep? Food to eat? Offer him coffee? Offer him a coat and gloves? Or did they only forcibly medicate him and then throw him back out on the street?

I am a psychiatric patient but I have also worked in hospitals for many years. One thing that I noticed is that people who are homeless and hospitalized for a non-psychiatric reason but who have psychiatric issues rarely tried to leave the hospital before they were ready, mostly it was hard to get them to leave once they were stable. Yet, the reverse is often true in psychiatric hospitals. Adults recognize when they are not being treated like adults, they recognize force, threats and coercion, even those who are psychotic. As has been mentioned in many of the comments here, some are grateful for it, some are not. It makes good sense that an adult, even someone with a mental illness, would avoid situations that have been threatening and/or caused them pain in the past. I have done the same. It took years for me to agree to see another psychiatrist, because i did not want to put myself in a situation where someone could do that to me again.

Does it have to be homeless on the streets or forced treatment? Is there some middle ground here? I know that even when psychotic I was much more receptive to kindness than threats of force. It takes time, but I would bet if time was actually spent meeting the physical needs in a respectful way, gaining trust, and treating them like adults, many would eventually agree to take medication.

jesse said...

@Anonymous - perhaps he was offered those things many times - I don't know, but he was not medicated forcibly as far as I know, either.

There are a lot of good ideas in the comments here, yet the ones that seem most useful are those encouraging patients to write up thoughtful and clear information on what has worked best in the past, what might be misinterpreted, how best to handle certain difficult situations, and so on. Essentially this is the careful past history which helps every clinician faced with a difficult new patient, often under stressful circumstances.

It would help everyone to have such a history available - one never knows when there will be an accident leading to arriving unconscious in an emergency room.

In my experience with many clinicians, though, this information does not need to be in the form of legal directives. If there is no power or finances with which to carry them out they are useless. Ultimately all of us in those circumstances need to be in the hands of caring and expert professionals who have authority to do what is best. There is always a point in life where we no longer have control, and that fact is often difficult and painful to accept...

ClinkShrink said...

Thank you, everybody, and keep the comments coming.

Catlover, I think your experience with the hospital is a clear indication that we need to do more to make treatment staff and facilities aware of PADs and what they mean. It must have been incredibly frustrating to put so much time and thought into a document only to have it ignored. (Off topic, but I'm a catlover too. Allergic too, unfortunately.)

I also like the comment about looking for a middle ground between no treatment and forced treatment. Right now our state is thinking about expanding the basis for civil commitment and adding a 'grave disability' standard. Inability to care for self, or dangerousness, could lead to commitment. The saving grace is that the judge hearing the commitment must also consider the 'least restrictive alternative'; in other words, other ways of caring for the patient rather than hospitalization.

If a PAD can offer a solid at-home care plan, that may be enough to avoid a civil commitment. This is why this topic is worth bringing up again. It might be worthwhile using the blog to throw together some ideas for a sample home care plan "just in case."

Still just thinking out loud...

ClinkShrink said...

While I'm on a roll here, I think it's very strange that every hospital is required to offer newly admitted medical patients a chance to sign a living will but psychiatric facilities don't routinely offer newly admitted patients a chance to write up a PAD. In the early '90's the Feds passed the Patient Self-Determination Act to require the living will offer, but that was only for medical decision making. Psych patients not considered, once again.

Anonymous said...


In my opinion, the least restrictive environment issue means zilch as many people have been forced to have outpatient ECT and take meds against their will.

Again, I think you're missing the point. As long as people with mental illness are thought of as folks to be controlled and not dealt with in a humane manner, things will never change.

Sorry, I don't mean to keep being pessimistic but I honestly don't think you all truly understand the issues. You say you do but actions speak louder than words and so far, you have never stepped outside the psychiatric box on this blog.

Liz said...

anonymous: i agree about the least restrictive environment. i find the fact that someone can be forced to ingest medication or submit to ect tragic. and i believe one day we will look back in shame on this, and other mental health travesties. if they tried to force me to take medication again, or if they tried to inject me with that nastiness, I would go on a hunger strike.... ugh!

Dinah said...

I think this is a really good idea.

While there may be a reason not to respect someone's wishes, I think many doctors would be fine with the idea. Often there are uncertainties and we wonder what someone might want in another state, or there are multiple options for treatment, then knowing what the patient wants is good.

Our state does not allow forced ECT, I don't think many do.

Even for non-psych issues, advance directives are not fully binding. If you have a Do Not Resuscitate order, make sure that when you dying, you're relatives don't call 911, they will do CPR and try to revive you. And you can have a "no machines," etc document in place, but they will only be honored if you you're able to speak, or if you're coming from a place of terminal illness. So a perfectly healthy person who has stated they don't want interventions will still get them during a car accident, and if you go to the hospital for an elective procedure and your heart stops, they will still revive you. Do Not Resuscitate orders are only allowed if you have a terminal condition. Now if you've had this order, and they get you back but you're in a permanent vegetative state, then people will know not to leave you on machines forever

CatLover said...

My father was moving his papers around a few days before he died, and my mom had to frantically look for his DNR paperwork while the paramedics were shocking my dad. I guess my mom didn't realize she could just not call 911 (? I wouldn't know what to do). So for these emergency documents, there has to be a good spot that everyone knows where to get it right away.

I did that for my psychiatric directive, but I just realized I goofed, because I moved it when I was putting new carpet in a room and didn't put it back. I have to update that sucker anyway.

I guess my psychiatric directive reads a LOT like a WRAP. I strongly suspect when someone has all these details worked out, it makes psychiatrists more confident that you can handle things well with your support system, even if you are having serious problems. So the patient would be more likely to get what they want.

It is true that the main reason I put so much effort into the advance directive was to avoid involuntary commitment. My personal values writings were also a hidden appeal to a judge, if needed, with discussions of self-determination, quality of life, and the like.

Anonymous said...

If you are old and get admitted to hospital, you can have a DNR order signed and followed even if your only terminal condition is life.

jesse said...

CatLover wrote "I strongly suspect when someone has all these details worked out, it makes psychiatrists more confident that you can handle things well with your support system, even if you are having serious problems. So the patient would be more likely to get what they want."

I think that is exactly true. Much of the time the treating personnel do not know the very best thing to do, and they themselves have supervisers who expect them to follow certain procedures. So the more any patient can supply information, whether from a friend, relative, or written directive, that creates trust in the treating team and helps them understand the rationale being requested, the greater the chance that they will work with the patient and all in the end will be better off.

Dinah said...

Anon: Really? What's the age cut-off?

Anonymous said...

Dinah, I do not know the age cut off but I am not kidding. My relative was admitted to hospital, aged 84, no known health issues other than need for post surgical rehab. Had a DNR sign at the foot of the bed. Found out it is very common for older people not to be propped up, walked etc as often as they should be for max benefits of rehab. DNR probably put in anticipation of known effects of being elderly and bed ridden. Yes, died in hospital. If you are 60 and too much trouble to get out of bed, short of staff, ask family, pt for DNR consent. Way to free a bed. 45 years old? Not sure what would happen. I doubt you would see a DNR order but I wouldn't doubt the elevator might break down if you had a heart attack and needed the doc there to resuscitate. But thanks for the snark.

Dinah said...

Anon, I was not being snarky, I don't think. I was really thinking about this, like at 75 you can't get a DNR but at 76 you can?

I may make my advance directives a blog post. We'll see.

ClinkShrink said...

Can I write your advance directives? I promise it will involve chocolate.

Anonymous said...

Dinah, why do you say that EMS won't honor a DNR order? It does have to be a valid EMS DNR order (not just a piece of an advance directive) but EMS is definitely bound by the order unless the patient specifically rescinds it.

Anonymous said...

The psychiatric advance directive still isn't going to mean much if it's not legally enforceable. That's why it needs to be legally enforceable in all states. In my state if you knowingly ignore an advance directive it's a criminal offense, unless it's a psychiatric advance directive and then that's ok.

Others have mentioned that it's good that there is an alternative plan in the psychiatric advance directive, but that should not matter. What matters is that a person who is legally competent gets to say what does and does not happen in an emergency and have that respected, regardless of the outcome, regardless of whatever plans are in place in lieu of hospitalization, chemical restraint, etc. We don't pick up and hospitalize by force people who eat fast food after their triple bypass. It's their right to not have a safe, healthy plan in place even if the outcome is death, and the same should apply to any other person legally competent to make decisions.

I am curious about the rationale for not making psychiatric advance directives legally enforceable. It's blatant discrimination against people with mental illness.

Sarebear said...

I haven't read much here in the last week, been wrestling with going in and out of altered (to some degree) states of mind/mania and back to "normal".

Because I found myself almost doing what I swore I'd kill myself for if I ever got close again, and I don't (in my current, "normal", state of mind) understand why/how I could consider such things. I'm disgusted with myself.

Anyway, so I've been doing some things online, and in my apartment, and in my marriage, with the eye of keeping my altered self out of trouble, sort of like parents of toddlers putting up safety gates and electrical outlet covers and such. My husband is an incredible man for sticking with me, and further, for working with me on this as partners, to set some things up, in case my judgement becomes impaired to the point where he needs to intervene . . . I've given him a couple kinds of things to tell me, then, although in that state I may not particularly care. However, most often I am not taken so far from myself when altered that these things would be meaningless; sometimes I am though.

Anyway, it struck me reading this post that I'm trying to do advance directives of a kind, in trying to work with my husband to come up with how to handle things should my mania push me too far.

I haven't ever looked into PADs before, but as clear as my differing states of mind have been and are to me lately as I shift between them, the importance of doing so becomes painfully clear, and the importance of figuring out how my state handles such things, and other stuff.

Being able to FEEL how harsh the difference can be, between being in your right, responsible mind, and being in an altered, reckless, brash, and risk-seeking state of mind, makes me feel like I've been like an ostrich with my head in the sand about this issue of PADs.

Dinah said...

Clink: no you can't write my advance directives, you'd knock me off in a flash.

Anon: apparently I'm not up on laws about EMS and advance directives.

Sarebare: Glad you're here!