Psychiatric Advanced Directives: An Underutilized Practice That Could Change Psychiatric Crisis Care
Filling a Gap: Our Work on Psychiatric Advanced Directives
Dr. Marvin Swartz is the lead of the Behavioral Health Team at the Wilson Center for Science and Justice, a Professor at Duke University School of Medicine, and Co-Director of the Services Effectiveness Research Program. Throughout his career studying mental health care across emergency departments, inpatient units, outpatient clinics, and correctional facilities, he kept encountering the same troubling pattern. When people with severe mental illness enter a crisis, they often lose decision-making capacity. The system’s default response is involuntary commitment, frequently involving law enforcement, sometimes handcuffs, and almost always confusion and fear. For many patients, the experience feels less like medical care and more like an arrest.
This pattern of crisis, lost autonomy, and coercion led Dr. Swartz to focus on a different kind of question. Instead of asking how to better manage people once they are in crisis, what if the system could honor their preferences before the crisis takes over? One promising answer is the Psychiatric Advance Directive—or PAD—a tool he and his longtime collaborator Dr. Jeffrey Swanson, Professor in Psychiatry and Behavioral Sciences at Duke University School of Medicine, have spent years researching, refining, and working to make more accessible in practice.
That research found a permanent home in the National Resource Center on Psychiatric Advance Directives (NRC-PADs), a project Dr. Swartz helped build to make the legal and practical landscape of PADs navigable for clinicians, patients, and policymakers. NRC-PADs tracks state-by-state laws and implementation resources at nrc-pad.org—but it represents something larger than a database. It’s an attempt to make PADs a real option for the people who need them most.
What is a Psychiatric Advanced Directive (PAD)?
A PAD is a legal document that allows someone, while they have decision-making capacity, to outline their preferences for future mental health treatment and to designate a trusted health care proxy to speak on their behalf if a crisis temporarily impairs their judgment. In many ways, it is the psychiatric counterpart to a medical advance directive.
Through a PAD, a person can document which medications have helped or caused harmful side effects, which hospitals they prefer or want to avoid, who should be contacted, and what de-escalation strategies tend to work best. The directive activates only if the person becomes unable to make decisions during a psychiatric emergency.
The core idea is simple: when people are well, they often understand their treatment history, triggers, and needs far better than anyone else. In the absence of that guidance, crisis care frequently defaults to coercive interventions that can damage trust and deepen trauma. PADs create a bridge between those two states, preserving autonomy, dignity, and continuity of care at the moment they are most vulnerable.
Despite being legally recognized in North Carolina since 1997, and even earlier in states like Oregon, PADs remain strikingly uncommon.
How the NRC-PADs Project Took Shape
Before their work with the Wilson Center, Drs. Swartz and Swanson concentrated on outpatient commitment, a civil court process in which a judge orders someone to comply with a treatment plan while living in the community. The policy is controversial and often criticized, but they were drawn to a practical question: can structured legal interventions reduce instability and improve outcomes?
Over time, however, their attention shifted. The more they observed how routinely crisis care defaulted to coercion, the more they became interested in approaches that strengthened autonomy rather than constrained it. PADs offered that possibility.
When PAD laws were passed in several states, they saw potential. But when their team surveyed five sites across the country, they discovered that only 2 to 3 percent of eligible individuals had completed one on their own. The demand was not the problem. Nearly two-thirds of respondents said they would complete a PAD if someone helped them. The barriers were practical. The official forms were dense and legalistic, difficult to interpret, and easy to misunderstand. Many people assumed a PAD required drafting a rigid, fully binding treatment plan, when in fact it serves as a guide to preferences, not an inflexible order.
That finding prompted a shift in focus. If people were not completing PADs independently, the work would have to center on facilitating their use and making them more accessible in everyday care.
What the Project has Accomplished
At the Wilson Center, the NRC-PADs Project has focused on hands-on facilitation paired with research on effectiveness. The process is simple but intentional. It involves sitting down with someone and asking thoughtful questions about their treatment history. What has worked? What hasn't? What would they want providers to know during the next crisis? The most common response has been striking: "No one has ever sat down and asked me that before."
This reflection process appears to create value independent of the document itself. Studies show that people who complete PADs through facilitation feel more aligned with their providers and more confident that they will receive preferred treatment in the future. The process strengthens the therapeutic relationship in ways that last beyond the session.
The project has also trained peer support specialists and chapters of the National Alliance on Mental Illness (NAMI) in Charlotte to facilitate PADs. These efforts worked locally but scaling them statewide proved difficult. Mental health advocacy organizations operate under constant pressure from funding constraints and immediate crises, leaving little capacity for preventive work.
Stay tuned later this month for the Wilson Center’s report laying out the challenges to the current NC statute governing unauthorized practice of law and how policy makers could enact changes that would make PADs more widely available.
Turning Policy into Practice and What Comes Next
Federal requirements and CMS rules acknowledge PADs, yet crisis settings routinely ignore them simply because providers often don’t know they exist. Emergency departments rarely have streamlined access to them, and there is no established infrastructure of facilitators comparable to what exists for medical advance directives.
Structural inequalities compound the problem. People with severe mental illness often lack resources, legal representation, and the capacity to self-advocate. PADs require witnesses and notarization, barriers that disproportionately affect low-income individuals. In a system where involuntary commitment offers the path of least resistance, PADs demand more deliberate effort from everyone involved.
Closing that gap is the work ahead.
The team is developing online tools and exploring AI-assisted PAD completion to make the process easier to navigate, while remaining attentive to concerns around trust, autonomy, and privacy.
Education efforts continue at the state level. In North Carolina, efforts are focused primarily on raising awareness and expanding practical use. Meanwhile, states like Washington and California are moving more actively on PAD-related reforms. There is also growing interest in elevating PADs within national mental health organizations such as NAMI.
The long-term vision is a crisis system that automatically checks for a PAD, with providers trained to honor them, fewer police-involved commitments, and more collaborative interventions. In other words, care that remembers the individual at its center.