MENTAL HEALTH ADVANCED DIRECTIVES

1 Instructions and FormsMENTAL HEALTHADVANCED DIRECTIVESFOR PENNSYLVANIANSMENTAL HEALTH ADVANCE DIRECTIVEI, _____,have executed an advance directive specifying mydecisions about my MENTAL HEALTH care. My MENTAL HealthCare Agent is I am hospitalized, my Agent should be immediatelycontacted at _____ - _____ - the hospital has questions about its legalresponsibilities to honor my decisions,it should contactPennsylvania Protection and Advocacyat:1-800-692-7443 Table ofContentsI. 4II. FREQUENTLY ASKED 5 III. COMBINED MENTAL HEALTHDECLARATION/POWER OF 9 InstructionsIV. MENTAL HEALTH 14 InstructionsV. MENTAL HEALTH POWER OF 18 InstructionsVI. GLOSSARY OF 23 VII. 24 Combined (p. 25) Declaration (p. 33) Power of Attorney (p. 39)I. INTRODUCTIONOn November 3, 2004, Governor Rendell signed House Bill 2036 into lawmaking it Act 194 of 2004.

2 By allowing you to create a MENTAL HealthAdvance Directive which can include a Declaration and/or a MentalHealth Power of Attorney this new law promotes planning ahead for themental HEALTH services and supports that you might want to receiveduring a crisis if you are unable to make 194 became effective on January 29, 2005. The passage of thislegislation is largelythe result of collaboration between advocacyorganizations, county governments, professional associations and thestate government. A MENTAL HEALTH Care Advance Directive is a tool thatfocuses on wellness and recovery planning. Pennsylvania is pleased tojoin the national trend of promoting the use of this tool as a mentalhealth is important to understand how to make this new law work for you including how to createan Advance Directive and/or appoint an agent foryour MENTAL HEALTH Power of booklet has been developed to assist you.

3 It includes forms andinstructions that you can use to create your advance directive andanswers to frequently asked questions. If you have additional questionsor need assistance with completing a form, contact any one of thefollowing organizations: Pennsylvania MENTAL HEALTH Consumers' Association 1-800-88 PMHCA Pennsylvania Protection & Advocacy / Disabilities Law Project 1-800-692-7443 717-236-8110 1-877-375-7139 (TDD/TTY) MENTAL HEALTH Association in Pennsylvania 1-866-578-3659 717-346-0549 FREQUENTLY ASKED QUESTIONSWhat is a MENTAL HEALTH Advance Directive?A MENTAL HEALTH Advance Directive is a documentthat allows you to make your choices knownregarding MENTAL HEALTH treatment in the event thatyour MENTAL illness makes you unable to makedecisions. In effect, you are making decisionsabout treatment before the time that you will needit.

4 This allows you to make more informed decisionsand to make your wishes clearly known. Anew law was passed in Pennsylvania, effectiveJanuary 28, 2005, that makes it possible for you touse a MENTAL HEALTH Advance decisions may need to be made for you ifyou have a MENTAL HEALTH crisis or are involuntarilycommitted and become unable to make treatmentdecisions. For example, the choice of hospital,types of treatment, and who should be notified aredecisions that may be made for you. Unfortunately,at the time of crisis, you may not be able to makeyour wishes known, and therefore you may end upwith others making decisions that you would notmake. One way to be sure that your doctor,relatives, and friends understand your feelings is toprepare a MENTAL HEALTH Advance Directive beforeyou become unable to make law allows you to make a MentalHealth Advance Directive that is a declaration, apower of attorney, or a combination of is a Declaration?

5 A Declaration contains instructions to doctors, hos-pitals, and other MENTAL HEALTH care providers aboutyour treatment in the event that you become unableto communicate your wishes. A Declaration usuallydeals with specific situations and does not allowmuch flexibility for changes that come up after thedocument is written, such as a new type of medicalcrisis, new kinds of medication, or differenttreatment is a MENTAL HEALTH Power of Attorney?A MENTAL HEALTH Power of Attorney allows you todesignate someone else, called an agent, to maketreatment decisions for you in the event of a mentalhealth crisis. A MENTAL HEALTH Power of Attorneyprovides flexibility to deal with a situation as itoccurs rather than attempting to anticipate everypossible situation in using a MENTAL HEALTH Power of Attorney it isvery important to choose someone you trust asyour agent and to spend time with that personexplaining your feelings about treatment doctor or his/her employee, or an owner,operator, or employee of a residential facilitywhere you are living cannot serve as an is a Combined MENTAL HEALTH Declaration andPower of Attorney?

6 Pennsylvania's law also allows you to make acombined MENTAL HEALTH Declaration and Power ofAttorney. This lets you make decisions about somethings, but also lets you give an agent power tomake other decisions for you. You choose the deci-sions that you want your agent to make for you, asmany or as few as you like. This makes yourMental HEALTH Advance Directive more flexible indealing with future situations, such as new treat-ment options, that you would have no way ofknowing about agent should be someone you trust, and youshould be sure to discuss with your agent your feel-ings about different treatment choices so that youragent can make decisions that will be most like theones you would have made for makes a MENTAL HEALTH Care AdvanceDirective valid?There is no specific form that must be used, butyour MENTAL HEALTH Advance Directive must meetthe following must be at least 18 years of must not have been declared incapacitat-ed by a court and had a guardian appointed orcurrently be under an MENTAL HEALTH Advance Directive mustbe signed, witnessed and dated.

7 Witnessesmust be at least 18 years old. If you cannotphysically sign the document, another personmay sign for you, but the person signing maynot also be a witness. Your doctor or his/heremployee, or an owner, operator, or employeeof a residential facility where you are livingcannot serve as an MENTAL HEALTH Advance Directive mustcontain your choices about beginning, continuing,or refusing MENTAL HEALTH treatment. The MentalHealth Advance Directive also can include choicesabout other things, such as who you want to beyour agent or guardian, who you want to care foryour children or pets, who you want notifiedabout your condition, and/or your dietary orreligious your MENTAL HEALTH Advance Directive is aPower of Attorney, then you must name theperson you want to be your agent and say thatyou are authorizing them to make whateverdecisions you want them to MENTAL HEALTH Advance Directive is valid fortwo years from the date you sign it unless one ofthe following happens revoke the entire MENTAL HealthAdvance Directive, make a new MENTAL HEALTH you do not have capacity to make treatmentdecisions at the time the MENTAL HEALTH AdvanceDirective will end, the Advance Directive will stay inplace until you are able to make treatment is Capacity?

8 Capacity is the basic ability to understand yourdiagnosis and to understand the risks, benefits, andalternative treatments of your MENTAL HEALTH care. Italso includes the ability to understand what mayhappen if you do not receive I need to include proof of my capacity with thedocument?No, unless you have a guardian or are currentlyunder an involuntary commitment, you are presumedto have capacity when you make a MENTAL HealthAdvance Directive. However, at a later time it ispossible for someone to challenge whether you hadcapacity. If you want to be very sure that no onecan challenge your MENTAL HEALTH Advance Directivelater, you can include a letter from your treatingdoctor from the same time period that you madeyour directive stating that you had capacity at would my MENTAL HEALTH Advance Directivetake effect?You can write in your MENTAL HEALTH AdvanceDirective when you want the directive to takeeffect, for example, when involuntary commitmentoccurs, or when a psychiatrist and another mentalhealth treatment professional states you no longerhave capacity to make MENTAL HEALTH will determine that I don't have capacity tomake MENTAL HEALTH decisions?

9 For the purpose of your MENTAL HEALTH AdvanceDirective, incapacity will be determined after youare examined by a psychiatrist and one of the fol-lowing: another psychiatrist, psychologist, familyphysician, attending physician, or MENTAL healthtreatment professional. Whenever possible, one ofthe decision makers will be one of your currenttreating if a court appoints a guardian after I haveappointed an agent to make my MENTAL HEALTH caredecisions?In your Advance Directive you can name someoneyou want the court to choose as your court will appoint the person you choose,unless there is a good reason not to. In manycases your agent and the person you would want tobe your guardian would be the same , you may want one person to make yourmental HEALTH care decisions, and someone else tomake other decisions for you. If the court-appointed guardian and your agent are differentpeople, the court will allow your agent to makemental HEALTH care decisions, unless you say other-wise in your MENTAL HEALTH Advance Directive.

10 Ifthe court decides to grant the powers that you gaveto an agent to the guardian, the guardian wouldstill have to make decisions as written in yourAdvance I make changes to my MENTAL HEALTH AdvanceDirective?You may change your MENTAL HEALTH AdvanceDirective in writing at any time, as long as youhave capacity. If you make significant changes,you should make a new document so that there areno conflicts or misunderstandings. Remember thatyour changes or a new directive must be witnessedby two individuals, at least 18 years of age, andyou should give new copies to your provider,agent, and other support I revoke my MENTAL HEALTH Advance Directive?You may revoke, or in other words, cancel, a partor the whole MENTAL HEALTH Advance Directive atany time, as long as you have capacity. This maybe done either orally or in writing. It is effective assoon as you tell your provider.