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Annex 9. Example: New Zeal<strong>and</strong> Advance Directives for Mental Health Patients ADVANCE DIRECTIVES IN MENTAL HEALTH CARE AND TREATMENT Information for mental health service users HDI Health <strong>and</strong> Disability Commissioner Te Toihau Hauora, Hauãtanga Example: An advance directive refusing ECT Manu has been sectioned under the Mental Health Act on several occasions. He was once given a series of electroconvulsive shock treatments without his consent. He does not remember much about the procedure, but did not like the fact that afterwards he experienced memory blanks. He has read a lot of material about ECT <strong>and</strong> strongly believes he does not want to take the risk of experiencing further memory blanks. He also knows from experience that other treatment, as well as family support, will help prevent disabling depression. It is now three months since Manu’s last hospitalisation <strong>and</strong>, at his next outpatient appointment, he sits down with his psychiatrist to discuss a personal crisis plan. It is agreed that Manu will prepare an advance directive stating that he does not wish to receive ECT under any circumstances. His crisis plan covers issues such as noticing early symptoms of depression <strong>and</strong> seeking help from the psychiatric team, as well as advice to his family about how best to support him. Manu is hopeful that even if he is sectioned again under the Act, the wishes he has expressed in his directive will be considered by his clinicians. What options do I have if my advance directive is not followed? If your advance directive about your future health care is not followed <strong>and</strong> you are not satisfied with the clinician’s explanation, you can complain to the Health <strong>and</strong> Disability Commissioner. What happens if I do not have an advance directive? If you have a crisis <strong>and</strong> are considered incompetent to consent to treatment (<strong>and</strong> you’re not being sectioned under the Mental Health Act), your clinician can still decide on your treatment, taking into account: · your best interests; <strong>and</strong> · your probable choice if you were competent to make it; or · the views of other people <strong>who</strong> are interested in your welfare. What about nominating someone to make decisions on my behalf? In some countries your advance directive can include a nominated person to make decisions on your behalf. However, in New Zeal<strong>and</strong> you need to appoint a person to be your Enduring Power of Attorney in relation to your personal care <strong>and</strong> welfare, through the Protection of Personal Property Rights Act 1988. If you wish, you can give this person the power to make health care decisions on your behalf when you are not competent to do so yourself. You should seek advice from a lawyer if you wish to appoint someone as your Enduring Power of Attorney. 178
What about decisions that don’t relate to my health care? There may be decisions not related to your health care that you wish to communicate in advance. One way to do this is through crisis planning. The people working in your mental health service should discuss your preferences with you in case you experience another crisis. Your crisis plan can record decisions such as <strong>who</strong> you would like to look after your children, or the names of family members you would like to be contacted while you are in hospital. You can also incorporate your advance directive into the crisis planning process. If your clinician does not involve you in any crisis planning you can simply write down your own wishes <strong>and</strong> ask for them to be put in your file. Example: An advance directive refusing a specific drug When Bill was hospitalised he was given a high dose of the drug X <strong>and</strong> had a very severe reaction to it. Bill discussed his medication with his psychiatrist <strong>and</strong> they decided that it would be better to avoid drug X altogether, especially as a suitable alternative had been found. Bill has family in different parts of New Zeal<strong>and</strong>, <strong>and</strong> often travels around. He decided it would be a good idea to carry with him an advance directive to safeguard against being given the drug if he required admission to a different mental health service that did not have his records. He also felt it would be helpful to record the names of both drug X <strong>and</strong> his current medication, as when he is unwell he sometimes gets confused <strong>and</strong> can’t remember the names. An Enduring Power of Attorney for informing family <strong>and</strong> friends John is a young gay man <strong>who</strong> currently has a partner <strong>and</strong> a wide circle of friends <strong>who</strong> were really supportive when he had a mental health crisis last year. However, when his parents came to see him during the crisis they made things worse. They disapprove of John’s lifestyle <strong>and</strong> tried to prevent his friends from seeing him. They didn’t want him to go home to his flat, which he shares with his partner <strong>and</strong> a couple of other gay men. Although John wishes his parents to be informed if he is hospitalised, he wants decisions about his care to be made by his partner. For this reason, John, with help from his lawyer, has appointed his partner as an Enduring Power of Attorney for his personal care <strong>and</strong> welfare. What is the best way to protect my wishes <strong>and</strong> interests? An advance directive will help ensure your wishes <strong>and</strong> interests are respected in a crisis, but an Enduring Power of Attorney <strong>and</strong> a crisis plan will protect your wishes <strong>and</strong> interests even more. Do you want more control over what happens in a crisis? If you do, an advance directive could be a good way for you to gain more control over the treatment <strong>and</strong> care you are given in a future episode. Past episodes will have helped you underst<strong>and</strong> what treatments <strong>and</strong> care work for you <strong>and</strong> what don’t. You have the right, under the Code of Health <strong>and</strong> Disability Services Consumers’ Rights, to use an advance directive to make your wishes known about the treatments <strong>and</strong> care you receive during a future episode. What is an advance directive? In simple terms, an advance directive is the giving or refusing of consent to treatment in the future. It is a statement to others, usually in writing, setting out your treatment preferences if you experience another episode of mental illness that leaves you unable to decide or communicate your preferences at the time. Under the New Zeal<strong>and</strong> Code, advance directives relate only to the type of health care <strong>and</strong> treatment you want. In some countries advance directives can include decisions not directly related to your health care, but in New Zeal<strong>and</strong> different processes are needed to make these wishes known. 179
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WHO RESOURCE BOOK ON MENTAL HEALTH,
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All rights reserve
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Technical contribution and<
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Nacanieli Goneyali Maria Grazia Gia
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Leen Meulenbergs Harry I. Minas Alb
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Harvey Whiteford Ray G. Xerri XIE B
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5. Rights of users of mental health
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4.1.3 Sanction, promulgation <stron
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For whom is this R
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This chapter covers five main areas
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3.2 Violations of human</st
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3.5 Promoting access to mental heal
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health legislation
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The right to health, as embodied in
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trade, torture and
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The MI Principles have also served
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8.4 The Salamanca Statement <strong
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Chapter 2 Content of mental health
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persons with mental disorders. The
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Mental disability is not synonymous
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Mental Disability Mental Incapacity
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Definition of “mental ill health
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Example: Mental health in primary c
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Another means of promoting communit
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MI Principles: Access to informatio
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Legislation (or accompanying regula
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Rights of users of mental health se
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mentally ill offender. Countries ma
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7.3 Determining incapacity
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• The presence of a major mental
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The concept of “voluntary” prec
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The key issue for mental health <st
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“separate” process from admissi
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In some cases, certain families bel
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as an inpatient or outpatient. This
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Example: Successful appeal of an ad
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8.3.7 Involuntary treatment in comm
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Figure 1. Procedure for combined in
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Emergency situations: Key issues
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10.1 Major medical and</str
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MI Principles: Seclusion an
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The MI Principles and</stro
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Authorize or prohibit intrusive <st
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• confidentiality • independent
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14.2 Responding to calls for assist
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15. Legislative provisions relating
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For minor offences, the court could
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15.4 The post-sentencing (serving s
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16. Additional substantive provisio
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• Right to work and</stro
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In countries where women are detain
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Kenya The Mental Health Act (Act No
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Figure 2. Process of mental health
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) Qualitative information from focu
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When examining another country’s
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• The process of building a conse
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Consultation should be undertaken w
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Written submissions have the advant
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The group, body or individual(s) m<
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4.1.2 Debate of draft legis
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mental health facts and</st
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Example: The National Commission ta
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5.2.4 Developing information <stron
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Human resource iss
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Rosenthal E, Sundram C (2002). Inte
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Declaration of Hawaii (1983). Appro
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Bibliography Araya R et al. (2001).
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Introduction and h
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2) Does the legislation</st
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C. Access to mental health care 1)
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3) Does the legislation</st
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Page 150 and 151: ) there is serious likelihood of ha
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Page 154 and 155: 2) Are all the criteria and
Page 156 and 157: O. Special treatments 1) Does the l
Page 158 and 159: 3) Does the law specify a restricte
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Page 162 and 163: 3) (iv) Maintain registers of accre
Page 164 and 165: • the right of patients a
Page 166 and 167: 3) Does the law allow for people <s
Page 168 and 169: 2) Does the law provide for “reas
Page 170 and 171: 3) Does the law ensure that all min
Page 172 and 173: AZ. Offences and p
Page 174 and 175: • Inter-American Convention on th
Page 176 and 177: Civil and Politica
Page 178 and 179: 5. A patient shall never be invited
Page 180 and 181: Principle 15 Admission principles 1
Page 182 and 183: Principle 20 Criminal offenders 1.
Page 184 and 185: Annex 5. Extract from the Declarati
Page 186 and 187: 5. Organ Transplantation: The role
Page 188 and 189: Restraint & Seclusion: If condition
Page 190 and 191: Rights of Recipients Summary in Eng
Page 192 and 193: PART C TAKING PERSON TO APPROVED ME
Page 194 and 195: I base my opinion on the following
Page 198 and 199: Who can make an advance directive?
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