Psychiatric Advance Directives

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Psychiatric advance directives (PADs) are legal documents that enable individuals with serious mental illness (SMI), such as major depression or schizophrenia, to state their treatment preferences for future mental health crises.

In 2020 and 2021, seven California counties began collaborating on an initiative funded by the state’s Mental Health Services Act. The purpose of the PADs Innovation Project is to increase the availability and uptake of PADs among persons with mental health needs. In this first phase, the participating counties were Contra Costa, Fresno, Mariposa, Monterey, Orange, Shasta, and Tri-City.^[1] A RAND team evaluated the initiative, examining implementation challenges and assessing outcomes.

What Is the Current State of Knowledge about PADs?

In conjunction with the evaluation, the RAND team reviewed the scholarly literature to summarize current knowledge about PADs. The review found the following:

• Many U.S. states and other countries legally recognize PADs.
• PADs can improve autonomy in decisionmaking, reduce coercion in crisis interventions, and lower involuntary hospitalization rates.
• Barriers to integrating PADs into crisis planning and care include inconsistent legal recognition across states and jurisdictions, limited provider knowledge and training, and low awareness among individuals with psychiatric conditions.
• Promising practices for PAD implementation include offering clinician training and awareness programs, facilitating PADs with peer worker or clinician support, and implementing clear legal mandates and frameworks.

Evaluating California’s PADs Innovation Project

The PADs Innovation Project created a universal PAD template for Californians, incorporating input from stakeholders, including individuals with lived experience and advocates. The project also funded the development of a web-based platform for creating, storing, updating, and sharing PADs. Participating counties beta tested the platform with small, defined groups of priority populations (e.g., individuals receiving services through a given program). The long-term goal is to facilitate access to this platform by first responders and staff in a variety of care settings and uptake by a wider population of Californians. The project also developed a standardized curriculum to train peer workers (e.g., Peer Support Specialists) as PAD facilitators. Facilitators engage priority populations, promoting PADs and guiding individuals through the completion process.

The RAND team’s evaluation of the PADs Innovation Project focused on three areas:

• post-training outcomes and experiences with real-world PADs facilitation, using surveys and interviews with peer workers
• PAD creation rates and outcomes across the participating counties, using a combination of metadata from the PAD platform, a brief user survey contained within the PAD platform, and a follow-up interview and survey with individuals who created a PAD
• the perspectives of county implementation staff, who reflected on the implementation of beta testing through interviews.

Post-Training Outcomes and Experiences

• After completing standardized facilitator training, individuals reported high readiness for facilitating PADs, with significant improvements in PADspecific skills and knowledge (see Figure 1).
• Overall, feedback on the PAD training experience was positive regarding its delivery, the training team, and the achievement of the training’s stated goals. However, some trainees and county implementers reported that the three-day training was too long and too focused on basic peer worker skills that many attendees already possessed.
• PAD facilitators desired standardized guidance on the legal enforceability of PADs and how to communicate this information to individuals completing PADs, along with clearer information on plans to make PADs accessible to first responders and care providers.

• Purpose and potential benefits of a PAD^*
  • Post-training: 100% agree or strongly agree
  • Pre-training: 65% agree or strongly agree
• How to use a digital PAD platform^*
  • Post-training: 97% agree or strongly agree
  • Pre-training: 32% agree or strongly agree
• Identify and use appropriate resources for PADS^*
  • Post-training: 91% agree or strongly agree
  • Pre-training: 35% agree or strongly agree

NOTE: An asterisk indicates that the pre-training versus post-training difference was statistically significant at p < 0.05.

PAD Creation Rates and Outcomes

• More than 150 PADs were initiated during the beta testing phase.
• Half of the individuals who engaged with the platform fully completed their crisis directive, and a third completed their treatment directive (see Table 1).
• The number of PADs created and feedback from various perspectives offer preliminary evidence that digital, facilitated PADs are both feasible and acceptable for individuals with SMI and peer workers.
• Individuals who created a PAD reported satisfaction with the process, highlighting its ease, helpful guidance, privacy, cultural respect, and sense of control. Benefits included a sense of empowerment, better communication with providers, and peace of mind.

Perspectives of County Implementation Staff

• County staff highlighted the pivotal role of peer workers in implementing beta testing and engaging individuals served.
• Beta testing provided early evidence that peer worker– facilitated digital PADs are feasible and acceptable to facilitators and individuals served.
• Beta testing also highlighted barriers to PADs, including limited awareness among providers, access challenges for first responders and hospitals, and unclear legal enforceability; these barriers can be addressed to promote the successful rollout of PADs more broadly in the future.

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Recommendations and Next Steps

Drawing on the evaluation findings, with added insights from the literature review, the evaluation team offered the following recommendations for future PAD implementation.

Training

• Offer a streamlined or modular version of the PAD facilitator training to decrease training burden and increase usefulness. Future trainings could use a tiered or prerequisite approach, such that a 101-level introductory training could focus on general peer skills and knowledge, and a 201-level training could focus on PADs and the platform more specifically.
• Evaluate future iterations of the training program, with continued attention to facilitator readiness and feedback on the training experience. Post-training evaluation can also assess whether trainees feel that they have adequate information to address questions about legal enforceability and integration with first-responder and hospital systems.

Implementation

• Continue implementing the peer worker model for PAD facilitation. Involve peer workers in implementation design and consider increasing leadership opportunities for peer workers.
• Provide clear, ongoing guidance to facilitators and individuals served on the legal enforceability of PADs and timelines for first-responder and hospital system integration as these systems evolve. These were two primary barriers to engaging populations during beta testing and are likely to persist in facilitators’ conversations with clients.
• In future implementations of PAD initiatives, prioritize training health care teams to understand the legal status of PADs and effectively integrate PADs into care practices. This will help teams become more comfortable with implementing PADs.

Conclusion

A literature review and an early evaluation of the PADs Innovation Project suggest that PAD training is effective, PADs are successfully facilitated by trained peer workers, PADs are well received by individuals served, and PADs have potential near-term benefits, such as improved communication with individuals’ health care teams and sense of empowerment.

Note

• [1] Tri-City is a Mental Health Authority serving three California cities: Claremont, La Verne, and Pomona.

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Topics

• Advance Directives
• California
• Health Care Education and Training
• Mental Health Treatment