PAD Stories

"This time, with a PAD, I did not receive any treatments that I did not want. They were very respectful.  I really felt like the hospital took better care of me because I had my PAD. In fact, I think it's the best care that I've ever received."

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Where did PADs come from historically?

[excerpted from Swanson, Swartz, Elbogen et al., (2006) Effectively Implementing Psychiatric Advance Directives, unpublished grant application, “Background & Significance” section]:  

Historically, PADs are a variation of medical advance directives (ADs), legal instruments that typically offer three types of self-directed planning of one's own health care in anticipation of a later time of decisional incapacity: (1) a competent individual's informed consent to future treatment; (2) a statement of personal values and general preferences to guide future health care decisions; and (3) the entrusting of someone to act as a proxy decision maker for future treatment.  Beginning with California in 1976, all states enacted advance directive statutes of some sort, including either living wills (containing instructions about particular treatments and medical conditions), durable powers of attorney (appointing a surrogate decision maker), or both (Meisel & Cerminara, 2005).  The federal Patient Self-Determination Act of 1990 (PSDA) was later enacted to promote the use of written ADs after the U.S. Supreme Court, in the Cruzan case, permitted states to apply a strict evidentiary standard of “clear and convincing evidence” to oral statements by patients who had not completed written directives (Cruzan v. Missouri Department of Health, 1990). The PSDA requires hospitals and other health care organizations to inform patients of their rights under state law to prepare an AD, to inquire and document whether patients have executed ADs, to ensure compliance with state laws by respecting advance directives, and to educate health care providers regarding these legal instruments (Omnibus Budget Reconciliation Act of 1990, 1990). 
In the wake of the PSDA, mental health advocates appropriated some of the ideals of ADs and applied them to the context of consumers with psychiatric disorders, who were seen to be particularly vulnerable to loss of autonomy and at risk of receiving unwanted interventions (Backlar, 1995).  Advocates hoped that PADs would give persons with severe mental illness greater autonomy and control over their own lives – both directly, during time of crisis, and perhaps indirectly, by improving continuity of care and working alliance with mental health professionals, and thus decreasing the need for involuntary treatment (Appelbaum, 1991; Backlar, 1995; Swanson, Tepper, Backlar, & Swartz, 2000; Winick, 1996).