Introduction
Advance directives (ADs) allow patients to document their preferences for future medical care in case they lose the capacity to communicate. Although often associated with end-of-life planning, ADs shape care decisions well before the final stages of illness, and psychiatry frequently becomes involved when questions of capacity, insight, or informed refusal arise. This sheet reviews what ADs are, when psychiatric input is needed, and how to support patients in completing and using them.

What Are Advance Directives?

• Living will: outlines preferences for specific treatments (eg, CPR, artificial nutrition) and desired level of comfort care.
• Durable power of attorney for health care: designates a health care proxy to make medical decisions if the patient becomes incapacitated.
• Requirements vary by state, but most ADs include one or both of the components above.

Common Reasons for Psychiatric Consultation

• Delirium: a patient with delirium refuses life-sustaining treatment; the treating team assesses capacity, with psychiatric consultation when the assessment is complex, and determines whether an existing AD applies.
• Depression: a depressed, terminally ill patient refuses a potentially beneficial intervention; psychiatry evaluates whether depression, hopelessness, or suicidality is impairing the patient’s ability to understand, appreciate, reason about, and communicate the decision.
• Psychosis: a patient with longstanding delusions has an AD refusing lifesaving care; psychiatry must assess whether it was made during a lucid period and remains valid.
• If capacity is unlikely to return: decisions fall to the health care proxy, an authorized family member or other surrogate, or a court-appointed conservator, guided by the AD.

Related Medical Orders

• DNR/DNI (Do Not Resuscitate/Do Not Intubate) orders: clinician-signed orders specifying whether resuscitation or intubation should occur in an emergency.
• POLST (Physician Orders for Life-Sustaining Treatment) forms: translate treatment preferences into detailed, legally recognized orders (eg, CPR, feeding tubes); more effective than ADs alone at honoring patient wishes (Hickman SE et al, J Am Geriatr Soc 2010;58(7):1241–1248).

Psychiatric Advance Directives (PADs)

• PADs let patients with chronic mental illness document preferred medications, facilities, and use of therapies like ECT during future crises, and allow them to name a trusted decision maker.
• Evidence of benefit: PADs reduce coercive interventions (Swanson JW et al, J Ment Health 2008;17(3):255–267) and improve adherence — one study found patients prescribed a PAD-listed medication were nearly 8 times more likely to adhere over 12 months (Wilder CM et al, Psychiatr Serv 2010;61(4):380–385).
• Limits: PADs may be overridden when a patient meets criteria for danger to self, danger to others, or grave disability, but they still guide care as closely as possible.

Overcoming Barriers to AD Adoption

• Only about one-third of US adults have completed an AD (Yadav KN et al, Health Affairs 2017;36(7):1244–1251).
• Common barriers: discomfort discussing future health scenarios, equating ADs with “giving up,” cultural/religious beliefs, limited health literacy, time constraints, and inconsistent EHR integration.
• Reframe: position ADs as tools for maintaining autonomy, not surrendering control.

Tips for Talking About Advance Directives

• Normalize: make AD discussions routine for all patients, regardless of age or illness stage (“Have you thought about how you'd want your care handled if you couldn't speak for yourself?”).
• Educate: point patients to clear resources, eg, the National Institute on Aging's Advance Care Planning page.
• Address language/culture: use multilingual resources (eg, MedlinePlus) and professional interpreters as needed.
• Simplify: refer patients to state-specific forms via AARP or the National Resource Center on Psychiatric Advance Directives (nrc-pad.org).
• Integrate: work with IT to build AD/PAD prompts and templates into the EHR.

Ensuring Accessibility in Emergencies

• An AD is only useful if it can be found when needed. Encourage patients to give copies to family, health care proxies, and PCPs; upload it to their medical record; keep an accessible physical copy (eg, wallet, refrigerator); store it digitally via smartphone apps or cloud services; and, for chronic or terminal conditions, consider medical alert jewelry.
• Revisit regularly: especially after a new diagnosis, hospitalization, or other major life change.

CARLAT VERDICT
ADs and PADs are powerful tools for preserving dignity and autonomy, yet they remain underutilized. Discussing and initiating them can be challenging given patient hesitation, capacity concerns, or systemic barriers — but making these conversations a routine part of care reduces uncertainty, improves decision making, and helps ensure treatment aligns with patients' values.

Source: Nazarian A, Hendrick V. Advance Directives: Guiding Patients Toward Dignity and Autonomy. The Carlat Hospital Psychiatry Report. Oct/Nov/Dec 2025;5(7&8):1-3.