Carers identified?

Appendix D: Advance directive for treatment

Page last updated: 2010

Courtesy of Hyson Green Calvary Private Hospital

An advanced directive is an expression of the patient's preferences of future mental health care and treatment. The directive is usually written when the patient is well and referred to when the patient is experiencing a relapse in their mental health. Thus the patient is pre-emptively able to communicate their preferences for care.

This advanced directive should be filled out in collaboration with a clinician and is a summary of an agreement between the patient, psychiatrist, hospital and any other concerned mental health professional.

It should ideally be adhered to as much as possible with the understanding that clinical needs will at all times override any preferences expressed in this document.

The Advanced Directive contains information on the following:

etc Top of page

Signatories to this document

Provide name and contact number for the following positions:
  • Patient
  • Community psychiatrist
  • Admitting Psychiatrist
  • GP
  • Community mental health team
  • Partner
  • Parent
  • Friend

Preferred treating team

Provide name and contact number for the following positions:
  • Patient
  • Community psychiatrist
  • Admitting Psychiatrist
  • GP
  • Community mental health team

Significant others to be contacted

Provide the following details for each significant other:
  • Name
  • Phone
  • Relationship
  • Special tasks
  • When notified Top of page

Those not to be contacted (or visited)

Provide name and relationship for each person.

Relapse prevention plan

Provide details of early warning signs (mild, moderate and severe) and action plan for each warning sign.

Preferred transport to the facility

Provide a list of four types of transport and reason for each.

Preferred treatment facility

Provide details of facility (mild, moderate and severe) and reason for each.

Preferred inpatient interventions

Provide list of interventions and reason for each.

Preferred other interventions

Provide list of interventions and reason for each.

Preferred medication

Provide list of medication and reason for each. Top of page

Medications not to be administered

Provide list of medication and reason for each.

Preference to not be treated by mental health professional

Provide list of professionals and reason for each.

Signature

Name:
Date:
Signature: