“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.” Read More PAD Stories...

About PADs

  • A psychiatric advance directive (PAD) is a legal document that documents a person’s preferences for future mental health treatment, and allows appointment of a health proxy to interpret those preferences during a crisis.
  • PADs may be drafted when a person is well enough to consider preferences for future mental health treatment.
  • PADs are used when a person becomes unable to make decisions during a mental health crisis.


The glossary sets out definitions of terms relevant to PADs.  Different states may use different terms for the same concepts.  Where possible, the authors of this resource have tried to use the terms below consistently and to indicate where other terms are equivalent to those below.

Advance Directive (AD):  a legal document allowing a person to direct his or her healthcare in the event that he or she becomes unable to make or communicate healthcare decisions.  State laws on ADs typically make no reference to psychiatric treatment specifically but in general ADs can be used to make advance psychiatric decisions.  All states have passed laws allowing ADs, but the exact rules vary from state to state.

Advance instructions are decisions made in an AD or PAD about future treatment.  The part of the AD or PAD containing advanced instructions is sometimes known as the instructional directive.

Agent: a person appointed by a consumer to make decisions for him/her in the event that he/she becomes incompetent to make those decisions.  The part of the AD or PAD naming an agent is sometimes known as the proxy directive, or proxy.

Best interests: some states require an agent to act in the consumer’s “best interests” when the agent makes decisions on the consumer’s behalf.  Other states require an agent to use substituted judgment (see below) when making decisions.

Competence is a legal term meaning the capacity to understand, appreciate, reason and make choices in the context of a specific activity or decision.  A consumer may be competent to make one decision but not another.  For example, a consumer may be competent to appoint an agent but incompetent to make a decision about medication.

End of Life Decisions: decisions about medical treatment when death is near, for example whether or not a consumer wants to be treated using an artificial ventilator. ADs – but not PADs – typically include a section for end of life decisions.

Involuntary commitment: The process whereby a consumer may be required to receive psychiatric treatment, either in hospital or in the community (involuntary outpatient commitment), if he/she presents a danger to him/herself or others.  This may include treatment by force.  The exact rules on involuntary commitment vary from state to state.  When a consumer does present a danger to him/herself or others, healthcare professionals may ignore the PAD as necessary to allay the danger.  However, the PAD may still play an important role in how that person is cared for, by offering useful strategies and options.  Creating a PAD may also avoid the need for involuntary commitment altogether.

Power of attorney, or durable power of attorney is the legal term for the power an agent has to make decisions on the consumer’s behalf.

Psychiatric Advance Directive (PAD): a legal document allowing a consumer to direct his or her psychiatric treatment in the event that he or she becomes unable to make or communicate decisions about that treatment.  .  In many states, there is a specific form for a PAD.  In states without such provisions, a consumer may create a PAD using the state’s AD provisions.

Substituted judgment means that a consumer’s agent arrives at the decision he or she thinks the consumer would make, were the consumer competent to make it.  Many states require agents to use substituted judgment when they make decisions.  Other states require instead that the agent act in the consumer’s best interests (see above).

Statute: a written law passed, or enacted, by a legislature.  The law on PADs is generally found in the statutes of the individual states. However, the law may be shaped by the US Constitution; by federal law, including the Americans with Disabilities Act; and by decided cases.