Virginia’s Pioneering Psychiatric Advance Directive Law Getting Slow Uptake


Virginia is the first US state to try to implement psychiatric advance directives statewide, and there is much to be learned from examining what has been happening there, according to a paper in Psychiatric Services by University of Virginia School of Law researchers.

Advance directives are documents that instruct physicians and others ahead of time about what sort of treatment a person does or does not want if the person is ever deemed incapable of making his or her own decisions. “The project began with consensus building among stakeholders (2007–2009), followed by revisions to Virginia’s Health Care Decisions Act (2009–2010) and designation of five of the state’s 40 Community Services Boards as demonstration sites for facilitation efforts,” the researchers explained. “Early implementation efforts quickly showed that psychiatric advance directives are not self-executing innovations.”

The researchers noted that “(d)espite the positive outcomes associated with psychiatric advance directives, the number of consumers completing these documents remains low.” They pointed to surveys indicating that 66−77% of patients wanted a psychiatric advance directive, while only 4−13% actually completed one. In addition, even when the directives existed, they weren’t often being followed.

Consequently, efforts in Virginia have been focusing on ways to increase the awareness and use of advance directives for mental health care in both patients and physicians. In their paper, the authors reviewed such efforts as providing professional support in completing the directives and building oversight mechanisms for implementation. “The first three years of efforts underscored the centrality of these components, and it is our impression that commitment to these components is beginning to translate into noticeable gains in implementation across the state,” the authors wrote. “Virginia’s purposeful and strategic effort to translate psychiatric advance directive legislation into actual use of these empowering tools can serve as a model for other states that wish to undertake a similar effort.”

Another article on the topic of advance directives in the journal by the same authors examined challenges particularly with respect to those people with “serious mental illness.”

(Full text) Advance Directives for Mental Health Care: Innovation in Law, Policy, and Practice (Zelle, Heather et al. Psychiatric Services. January 1, 2015. DOI: 10.1176/

(Abstract) Embedding Advance Directives in Routine Care for Persons With Serious Mental Illness: Implementation Challenges (Zelle, Heather et al. Psychiatric Services. January 1, 2015. DOI: 10.1176/


  1. Advanced directives have been taken over by the forced druggers anyway. Enraged me to learn that in my state of michigan they are only being used by means of coercing patients to have to sign one to leave the hospital and then the directive states they can force drug them without a court order anytime after that. You can find these obscene documents on mich gov health sites.

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    • “increase the awareness and use of advance directives for mental health care in both patients and physicians”
      I have a good idea how to “increase awareness and use” for the physicians – penalize them every time they fail to follow a directive. First offense is a fine, second offense may be criminal if you forced someone on meds against his/her will. I bet that would teach them really fast. I thought that ignorance of the law does not absolve one from the consequences of breaking it but I should not make the mistake of thinking that laws apply to psychiatrists.

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    • Don’t be so quick to assume that these people have good intentions. Something like this happened in 2007/2008 where I am and like I said in my comment above, you can google search for michigan psychiatric advanced directives and see just what an obscene forced drugging weapon they had been working on all along.

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  2. To my way of thinking, Advance Directives are almost passe’ from the start. From what I was seeing with the Virginia Supreme Court commission on mental health reform, lawyers and doctors like them because, in a sense, they are “uncontroversial”. Patients think they are having their rights protected while they aren’t having their rights protected. The state is still not going to let involuntarily committed hospital patients refuse psych drugs, but here’s something deceptively making it looks like your rights are being protected. If you think people are going to be protected by Advance Directives from unwanted shocks and drugs, think again. Force is still the Cardinal principal in mental health treatment, even if in places it is more subtly applied than ever before.

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  3. I am guessing that the two facts are related – few people fill them out because they know that most of the time, they will be ignored. It says a lot about our lack of respect for the so-called “mentally ill” that we can’t even respect their clearly stated wishes in writing. Most discouraging.

    ==== Steve

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  4. A psychiatric advanced directive is only as good as the psychiatrist you get for your case, at least that’s the way it is in the state where I live. Hardly anyone knows about them and those that do and fill them out are not usually aware that they are not legally binding on the psychiatrist or the treatment you get. The psychiatrist is always the one who decides what will be done with and about psychiatric directives. So, for the most part we are just playing games with all this and pretending to give people some choice about what happens to them.

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    • If they are not legally binding they can very well not exist. It’s a joke and it’s a joke on us.
      In some European countries there is an institution of “psychiatric testament” and that is supposedly binding (though I have no idea what are the consequences should the psychiatrist ignore it). The downside it’s quite hard to get one: you have to pay a notary to make one for you.

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