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Psychiatric-Mental Health Nursing

11.3 Powers of Attorney and Advance Directives

Psychiatric-Mental Health Nursing11.3 Powers of Attorney and Advance Directives

Learning Objectives

By the end of this section, you will be able to:

  • Explain the purpose of a power of attorney and its application to mental health nursing
  • Outline how a proxy directive can be used in a mental health situation
  • Define psychiatric advance directives and the way in which they are utilized in mental health care

Individuals and families can make plans in advance of the need for action in mental health crisis situations. They can create an advance directive, which is a document that allows a person to make decisions when they are still capable of making them; they include three components: power of attorney, living will, and health-care proxy. These instructions allow for decision-making by designated others when a person is not capable of self-care, including making decisions on their care. It is important to become aware of the implications, limitations, and benefits of advance directives for those with mental illness.

Power of Attorney (POA)

Variable by state, a power of attorney (POA) is a written designation of authority to act for another person in specified matters (Table 11.3). It is one type of advance directive. Medical or health-care power of attorney gives the designee (agent), who must be over the age of 18, the permission to make decisions in the event the designator (principal) is incapacitated. A person living with mental illness may experience episodes of incapacity for decision-making, whether this involves psychological detachment from reality, extreme social withdrawal, or mental health crisis, including self-harm or danger to others, so it often makes sense to appoint a power of attorney in case these situations arise. Limitations of the POA are that no one can transfer authorization and no decisions can take place after the death of the principal.

Type Definition Uses
Durable May be used for persons with or without capacity for decision-making Financial affairs management
Estate planning
Springing Becomes effective upon a predetermined date or event In advance of a potential incapacity or physical absence
Special Takes effect only for selected duties When expertise may be needed, i.e., legal contracts, banking, real estate
Medical Allows medical decision-making for the person Health-care decisions, emergencies when the person may not be capable
Table 11.3 Types of Power of Attorney

Power of attorney status, in general, authorizes the agent to manage personal and business matters for a principal person. These matters may include financial, personal property, real estate, or contracts. The health-care power of attorney can speak for the person if the person cannot make their own health-care decisions. The health-care POA will follow the person’s known wishes or directions as documented in the advance directive. Agents only make decisions if the principal is unable to do so. Agents may have access to the medical record and make decisions regarding admission/discharge, treatment, and medication.

Psychiatric Advance Directives

The application of the health-care POA to mental health nursing involves psychiatric advance directives (PAD), a legal document, variable by state, created by the person for use if the person becomes unable to make their own mental health-care decisions. The PAD can specify the person’s choices regarding hospital admission, treatment, and medication in the case of a mental health emergency.

Living Will

Upon signing POA documents, the principal specifies their wishes, usually via a living will, a document that identifies acceptable medical treatment, especially at end of life. For persons living with mental illness who may have a potential need for assisted or assumed decision-making, a living will sets forth the person’s wishes while the person is stable to decide. A person’s directions specified in the living will document are intended to apply when medical care is proposed to prolong life for an uncertain time frame to prevent death.

End-of-life care and hospice care directions may be part of the living will document. These directions include treatments the person wishes to avoid, such as artificial feeding intubation, defibrillation, and so forth. If the person cannot communicate at end of life, the living will can designate what treatment is acceptable. This may include the person’s preferences about resuscitation and organ donation after death.

Issues Related to Making Life Better

Quality of life is defined by the person themselves, and loved ones may or may not agree. For a person living with mental illness, quality of life may involve aspects of treatment, personal freedoms, and a sense of personal control.

Autonomy is an ethical principle and an important factor in quality of life (Varkey, 2021). advance directive with power of attorney designation can communicate a person’s preferences for their future if the person becomes incapable of making their own decisions. The hope and belief may be that the representative decision-makers will make the “right” decision at the right time, though this is not guaranteed. Faced with medical decisions, input from others, fear, uncertainty, and financial concerns, family members may struggle with these decisions, despite knowing what the person may have wanted. A person’s autonomy can conflict with loved ones’ guilt or concerns about the need for institutional care.

The Patient Self Determination Act of 1990 in the United States required health-care facilities accepting Medicare and Medicaid to inform consumers of their rights to make preferences known. PAD can accomplish this and create a partnership between the person and systems of care, possibly balancing the person’s independence with obligations of health-care providers. Resources available for individuals and families regarding advance directives are available at:

Proxy Directives

Proxy means representative. As with all advance directives, proxy designation varies in the United States by state. A health-care proxy, also called durable medical power of attorney or health-care surrogate, is a person with legal authorization to represent a client in their health-care decisions. The proxy will decide as the person would have decided. The designated health-care proxy may have limited or broad authority, as designated by the principal, including whether any other persons may be involved in decisions. An alternative proxy can be named, should the primary proxy be unreachable at a needed time. In mental health-care situations, proxies are often involved with decisions regarding quality of life and end-of-life care.

According to Medicare Rights (2023), there are specifics to consider when planning for representation in health-care matters, such as:

  • Someone designated as health-care proxy may have access to the person’s medical record. Any limits on this access should be designated.
  • Persons should ensure the proxy is aware of their beliefs and attitudes about care during illness and end of life, as well as preferences for facilities or providers. Documents should be updated if preferences change.
  • The person may change the proxy. If so, a new document is required.

Laws and guidelines vary by state, so persons should be aware that:

  • The proxy is a decision-maker for health care; arrangements concerning health-care costs and health insurance may be categorized as financial decisions.
  • State law may designate a decision-maker in the absence of the person’s documented directives.
  • States may combine the living will and health-care proxy in the single advance directive document.

Domingues et al. (2022) advocate for the person diagnosed with a mental health disorder to outline health-care proxies and advance directives during periods of stability. A person faced with death may cycle through thoughts and reactions related to multiple emotions. These changing emotional states may not coincide with actions specified in the advance directive. In these cases, or in periods of exacerbation of psychiatric symptoms, some forms of paternalism within the health-care systems may not sanction death without intervention for a person diagnosed with a mental illness (Domingues et al., 2022). While acknowledging that medical education and research should address these concerns, Domingues et al. (2022) assert that persons’ autonomy is fundamental to health care.

In a comprehensive literature review, Wilkinson et al. (2007) describe end of life as a “value-laden issue” due to the many aspects of chronic disease and the multiple methods of prolonging and sustaining a living state. End-of-life issues also apply to those clients who may have a mental health problem. Wilkinson et al. (2007) cite the concern of significant others to those with psychiatric diagnoses and found that “facilitated discussion” was helpful. Further, this review of literature found studies to support the interest and ability of persons living with mental illness to complete advance directives for psychiatric care. Specific to end-of-life care, nearly half of older persons studied who were diagnosed with depressive disorders had “do not resuscitate” orders and more than 10 percent rejected ventilation at end of life (Wilkinson et al., 2007).

Concerning designation of proxy decision-makers, Wilkinson et al. (2007) cited a community study of those living with mental illness, which found more than 70 percent supported the idea of proxy and more than 60 percent were able to select a proxy.

Concepts for end-of-life care include:

  • safety and comfort
  • client’s self-determination
  • client may be offered a life review with a therapist
  • pain management
  • spiritual care
  • support for survivor grieving

Life-Stage Context

Considerations at End of Life

For clients nearing the end of life, nurses should self-reflect, focus on self-care, and honor their therapeutic relationship with their clients in the following ways:

  • begin by asking clients about their beliefs related to end-of-life care
  • be aware of their own personal biases that can interfere with therapeutic communication
  • convey empathy, provide information, follow the client’s cues
  • assure the client of provision of symptom relief
  • allow time for clients to express themselves and ask questions
  • reassure family members as indicated
  • perform ongoing psychosocial assessment for changing needs
  • intervene on acute distress, hopelessness, pain, or refusal of care with emotional support, stress reduction techniques, collaboration with other providers for change in plan of care

(Vazquez & Santone, 2011)

Implications of Psychiatric Advance Directives

According to the Substance Abuse Mental Health Services Administration (SAMHSA, 2023), psychiatric advance directives (PAD) must comply with the state guidelines and typically include a notarized signature page with two additional witnesses signing. Frequently, the PAD may contain a statement of the person’s intent in creating the PAD; the designation of another decision-maker if the person is adjudicated incompetent; designation of a guardian if a court appoints one; the person’s preferences for hospitalization, alternatives to hospitalization, specific medications, or the use of electroconvulsive therapy; the person’s preferences for emergency interventions, which may address the use of seclusion, restraint, and emergency medication administration; willingness to participate in experimental studies or research; people to notify upon the person’s admission to a psychiatric facility; the person’s preferences regarding visitation if hospitalized and the care of dependent family members or pets; and the person’s right to suspend or terminate an advance directive while incapacitated, as allowed by state law (SAMHSA, 2023).

When conducting client and family education with regard to PAD, nurses should discuss the following benefits and barriers to encourage informed decision-making. Collaborative care with social services and counselors is helpful. Benefits and barriers associated with PAD as defined by the Joint Commission (2023) include:

  • Benefits
    • client’s autonomy
    • improved relationships with providers
    • treatment adherence
    • less coercive interventions, especially if the person has specified certain medication
    • better follow-up after discharge
  • Barriers
    • lack of safe storage or ready access to the document
    • lack of awareness or understanding by others
    • lack of communication among treatment staff, especially emergency response teams
    • some state laws provide for court petition to overrule the PAD

Nursing Responsibility Regarding PAD

According to Chan et al. (2019), completion rate in American states for advance directives is approximately 26 percent of the general population. Because acceptance of the idea is higher than the completion rate, this creates a teaching opportunity for nurses. Especially in psychiatric-mental health nursing where nurse-client interaction is basic care, the nurse can teach and advocate for clients interested in completing a PAD. Nurses can listen to clients as they identify their values and assist them to access resources. This education may include involvement of the family or trusted others. Nurses should evaluate client understanding of the process and provide additional instruction or referral as appropriate. Nurses should also ensure that advance directives are included as a portion of the client’s care plan. They should review them with the clients in their first meeting and regularly thereafter to ensure accuracy and currency. Nurses also should document advance directives in the medical record and communicate their existence and content to all members of the interdisciplinary team.

Collaborative Care in Mental Health Advance Directives

Mental health case managers, social workers, therapists, counselors, and medical, nursing, and legal professionals should work together in assisting clients and families to create a PAD. Collaboration may be through team treatment meetings, through referrals, or in clinic-based care in community settings.


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