Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY
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ADMINISTRATIVE ORDER
No. 2022 -_(0| ]

SUBJECT: Guidelines for Informed Consent, Supported Decision Making,

Advance Directives, and Legal Representation, in relation to
Republic Act 11036, otherwise known as the Mental Health Act

RATIONALE

Informed Consent is one of the most fundamental rights of the service users
upheld by Republic Act 11036, otherwise known as Mental Health Act, in accordance
with the Philippine Constitutional Rights, the United Nations Universal Declaration of
Human Rights and the Convention on the Rights of Persons with Disabilities (CRPD),
and all other relevant international and regional human rights conventions and
declarations. A service user is therefore expected to give informed consent before
receiving treatment or
care, except in cases of psychiatric or neurologic emergency or
impairment or
temporary loss of decision-making capacity.

In the past, legal capacity has generally been conflated with mental capacity,
which the CRPD Committee defines as ‘the decision-making skills of a person’.
Generally, in psychiatric practice as well as in conditions where an individual’s
mental capacity is most likely to be compromised and their mental ability to consent
is impaired, the challenge arises as to how to elicit informed consent given such
obstacles. Service users with mental capacity must provide informed consent in
writing prior to the implementation of treatment, including physical or chemical
restraint. As for conditions where a patient’s decision-making capacity is impaired or
in a psychiatric or neurologic emergency, exceptions in obtaining informed consent
may apply, the recourse of which is usually to make use of an advance directive, if
available, or an appointment of
accordance with the law.
a
patient’s legal representative in the order provided in

As mandated by Section 13 of the RA 11036, the Department of Health

(DOH)
in coordination with the Commission on Human Rights (CHR) and other
relevant stakeholders hereby issued this Order to provide guidelines in obtaining and
documenting Informed Consent, Advance Directive, Legal Representative, and
Supported Decision Making. Standardizing informed consent as a requirement before
providing any intervention or treatment also safeguards both the service user and the
mental health professional, from possible legal liabilities that may arise.

This Order is in congruence with the principles and policies of RA No. 11223,
also known as the Universal Health Care (UHC) Act, which embodies a health care
model that provides all Filipinos access to a comprehensive, people-oriented set of
quality, and cost-effective health services that is centered on people’s needs and
well-being. Moreover, this Order provides for the enhancement of the delivery of an
integrated mental health services towards achievement of UHC.

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1108, 1111 to 13
Direct Line: 711-9502 to 03 Fax: 743-1829 @ URL: http://www.doh.gov.ph; e-mail: [email protected]
 i. OBJECTIVE

This Order is issued to provide the implementing guidelines, systems and

procedures for the operationalization of obtaining and documenting informed
consent, exceptions to informed consent, advance directive, legal representative, and
supported decision making of service users, excluding minors and special population.

Til. SCOPE OF APPLICATION

This Order shall apply to adult service users, excluding minors and special
populations, all health facilities and agencies, both public and private, all mental
health professionals and mental health service providers, and other physicians and
allied mental health professionals, and general health facilities that may encounter
patients with mental health conditions during medical consultations.

IV. DEFINITION OF TERMS

A. Advance Directive refers to a signed, dated, notarized document expressing one’s

preference for treatment, allowing a service user to make decisions in advance
about his or her preference in relation to mental health treatment, including
medications, short-term admission to inpatient treatment and electroconvulsive
therapy.

B. Impairment or Temporary Loss of Decision-Making Capacity refers to a

medically- determined inability on the part of a service user or any other person
affected by a mental health condition, to provide informed consent. Such
impairment or temporary loss of decision-making capacity may be due to such
situations, but not limited to stroke or brain injury (secondary to an accident),
mental health condition (e.g. psychosis, bipolar disorder), dementia, learning
disability, confusion, drowsiness or unconsciousness due to an illness or the
treatment for it and substance or alcohol intoxication.

C. Impropriety refers to administering treatment and care without consent; failure to

comply with recognized standards on treatment and care; consent gained using
force and coercion; and abuse and exploitation of consent given by the service
user.

D. Informed Consent refers to consent voluntarily given by a service user to plan

for treatment, after a full disclosure communicated in plain language by the
attending mental health professional, of the nature, consequences, benefits, and
risks of the proposed treatment, available alternatives as well as the consequences
of not undergoing the treatment.
KE. Internal Review Board (IRB) refers to the collegial body created pursuant to the
Mental Health Act that is mandated to conduct review, monitoring, audit,
inspection of the mental health facilities as well as investigate cases involving
service users and mental health service providers. Composition, powers, and
functions of the IRB are covered by separate guidelines.
F. Legal Representative refers to a person designated by the service user or
appointed by a court of competent jurisdiction, or authorized by RA No. 11036 or

=
 any other applicable law, to act on the service user’s behalf. The legal
representative may also be a person appointed in writing by the service user to act
on his or her behalf through an advance directive.

Mental Health Facility refers to any establishment, or any unit of an

establishment, which has, as its primary function, the provision of mental health
services.

Mental Health Services refer to psychosocial psychiatric or neurologic activities

and programs along the whole range of the mental health support services
including promotion, prevention, treatment, and aftercare, which are provided by
mental health facilities and mental health professionals, as defined in RA 11306.

Mental Health Professional refers to a medical doctor, psychologist, nurse,

social worker or any other appropriately trained and qualified person with specific
skills relevant to the provision of mental health services.

Service User refers to a person with lived experience of any mental health
condition including persons who require, or are undergoing psychiatric,
neurologic or psychosocial care.

Mental Health Service Providers refers to an entity or individual providing

mental health services whether public or private, including, but not limited to
mental health professionals and workers, social workers and counselors, informal
community caregivers, mental health advocates and their organizations, personal
ombudsmen, and persons or entities offering nonmedical alternative therapies, as
defined in RA 11306.

Psychiatric or Neurologic Emergency refers to a condition presenting a serious

and immediate threat to the health and well- being of a service user or any other
person affected by a mental health facilities and mental health condition, or any

requiring immediate medical intervention, as defined in RA 11306.

of
other person affected by a metal condition, or to the health or well-being others,

Service User refers to a person with lived experience of any mental health
condition including persons who require, or are undergoing psychiatric,
neurologic or psychosocial care.

Supported Decision Making refers to the act of assisting a service user who is
not affected by an impairment or loss of decision-making capacity, in expressing a
mental health-related preference, intention or decision. It includes all the
necessary support, safeguards and measures to ensure protection from undue
influence, coercion or abuse, as defined in RA 11036.

GENERAL GUIDELINES

A. All health facilities providing mental health services shall adopt the prescribed
guidelines on obtaining informed consent from service users. Algorithms for the
processes of obtaining informed consent shall be used for the following:

ae
=
 1. Service Users with Psychiatric or Neurologic Emergencies (Annex A);

2. Service Users without Psychiatric or Neurologic Emergencies (Annex B); and

3. Service Users with Impairment or Temporary loss of Decision-Making

Capacity (Annex C).

All service users are presumed to have capacity to give informed consent in
writing prior to the implementation by mental health professionals, workers and
other service providers of any plan or program of therapy or treatment, including
physical or chemical restraint. Service users within the scope of this policy shall
be presumed to possess legal capacity for the purposes of RA 11036 or any
applicable law, irrespective of the nature or effects of their mental health condition
or disability.

Mental health facilities shall be allowedto

draft their respective Informed Consent
to Treatment and Advance Directive in their Manual of Procedures (MOPs),
provided that they adhere to the essential elements, which are provided in the
Informed Consent template (Annex D), and shall be reviewed accordingly by their
Internal Review Boards.

Informed Consent, Advance Directive, Designation of Supporters, and Legal

Representative Forms are stand alone documents and are issued independently,
based on documents needed for particular situations.

Non-mental health professionals and other health facilities shall refer patients with
possible mental health conditions to the mental health services provider that is
most accessible to the patient, for proper guidance.

The confidentiality of personal and sensitive information, data, and concerns of

end-users covered by this Administrative Order shall be subject to the provisions
of the Data Privacy Act of 2012, and its Implementing Rules and Regulations
(IRR).

G. Informed consent to treatment and advance directive forms shall be translated to

the dialect common topatients catered by the health facilities.

VI. SPECIFIC GUIDELINES

A. Obtaining Informed Consent (ANNEX D)

1. A service user’s written informed consent shall be obtained prior to the

implementation of any therapy or treatment, including physical or chemical
restraint, subject to exemptions in accordance with the Mental Health Act.

2. All written informed consent to treatment shall incorporate the following

important principles:
a. Voluntarism, indicating that consent is given without threat or coercion,
undue influence, or manipulation;
 b. Competency, indicating that the service user can understand information
about a decision, understand the potential consequences of the decision, and
communicate the decision;
c. Disclosure, indicating that the mental health professional has adequately
disclosed information on the treatment plan including the possible benefits
and negative effects/ risks of the proposed treatment; possible alternatives
to the proposed treatment; the possible benefits and risks of not accepting
the proposed treatment and/or of choosing one of the alternatives;
d. Understanding, indicating that the service user possesses the capacity to
understand information relevant to the specific circumstances and
appreciate the foreseeable consequences of making (or failing to make) a
decision;
e. Decision, indicating that the service user is authorizing and allowing the
mental health professional, workers, and other service providers to execute
the proposed treatment plan which is consistent with their authentic
preferences or advance directives.

B. Exceptions to Informed Consent

L, In case of psychiatric or neurologic emergencies, or when there is impairment

or temporary loss of decision making capacity, the informed consent may be
temporarily waived prior to the administration of treatment, restraint, or
confinement. The proposed management shall be administered pursuant to the
following safeguards and conditions:
a. In compliance with the service user’s advance directives, if available,
unless doing so would pose an immediate risk of serious harm to the
patient or another person;
b. Only to the extent that such treatment or restraint is necessary, and
only while a psychiatric or neurologic emergency, or impairment or
temporary loss of capacity exists, or persists; and
c. Such involuntary treatment or restraint shall be in strict accordance
with the guidelines approved by appropriate authorities.

In cases wherein the service user was unable to provide informed consent prior
to the administration of treatment, restraint, or confinement, mental health
professionals shall assess the service user’s capacity to provide informed
consent, based on clinical assessment, within fifteen (15) days from start of
administration of treatment plan, restraint or confinement without Informed
Consent, and every 15 days thereafter while the treatment, restraint, or
confinement continues.

C. Issuing Advance Directive (ANNEX E)

1. At the instant that the service user regains his/her capacity for
decision-making as assessed by the attending mental health professional,
creation of a comprehensive advance directive and appointment of a legal
representative shall be highly encouraged.

The advance directive, including the appointment for a legal representative,

shall be accomplished by the service user. A notarized copy of the said
 documents shall be filed to the service user’s clinical record, so as to use
potential cases of psychiatric and neurologic emergency or impairment or
it
in

temporary loss of decision-making capacity of the service user.

All mental health facilities shall honor the advance directive, provided that it
must be signed, dated and notarized. An advance directive may be revoked by
the most recent and notarized advance directive.

A service user may carry a copy of his/her advance directive and present it to
any mental health facility where he/she may be treated/managed. The Advance
Directive shall be attached to the individual patient chart and shall be filed
accordingly in the records section of the facility.

Relatives, referring medical personnel, supporters, or legal representatives

may present these documents to the attending physician for execution,
especially in cases of emergency or impairment of decision-making capacity.

D. Designating Legal Representation

1. All mental health facilities shall ensure the following in appointing a legal
representative:
a. A service user may designate or appoint a person of legal age to act as his
or her legal representative through the Mental Health Advance Directive
Form.
b. The appointment of a legal representative may be revoked by the
designation of a new legal representative or by a notarized revocation.
c. Appointed legal representatives shall provide a copy of one (1) valid
identification card for validation purposes.

Declining an Appointment
a. Persons appointed as legal representative may decline to act as a service
user’s legal representative.
b. A person who declines to continue being a service user’s legal
representative must take reasonable steps to inform the service user, as
well as the service user’s attending mental health professional or worker,
of such a decision.

Failure to Appoint — If the service user fails to appoint a legal representative,

the following persons shall act as the service user’s legal representative in the
order provided below:
a. The spouse, if any, unless permanently separated from the service user by
a decree issued by a court of competent jurisdiction, or unless such spouse
has abandoned or been abandoned by the service user for any period which
has not yet cometo an end;
b. Children of service users 18 years old and above;
c. Chief, administrator or medical director of the mental health facility where
the service user is confined or treated; or
d. A person appointed by the court.

ae
 i. Petition for the appointment of a legal representative shall be filed with
the proper court by a hospital or professional social worker. In their
absence, the court social worker shall file the said petition.
ii. In the absence of a social worker, the request shall be filed by the
service user’s relative, or a person with established ties with the service
user.
iii. In the absence of such a relative, or person, the Secretary of Health or
the Secretary of Social Welfare and Development, as the case may
shall file the petition through the Office of the Solicitor General.
be,
E. Supported Decision-Making

1. A service user may designate up to three (3) persons, including his/her legal
representative, for purposes of supported decision-making. Service users have
the liberty to choose and are not limited to designating family members only.

2. Those designated as “supporters” shall have the authority to:

a. access the service user's medical information;
b. consult with the service user vis-a-vis any proposed treatment
and
or
therapy;

c. be present during service user's appointments and consultations with a

mental health service provider during the course of treatment or therapy.

F. Monitoring and Evaluation

Monitoring of the compliance of facilities with this Order may be conducted by

their
respective IRBs without prior notice, subject to pertinent laws and guidelines.

Vil. ROLES AND RESPONSIBILITIES

A. Institutional Roles

1. Department of Health, through the Mental Health Division of the Disease

Prevention and Control Bureau shall:
a. Oversee the implementation of this policy in both public and private
mental health facilities;
b. Provide technical assistance and capacity building, as needed; and
c. Facilitate stakeholder consultations and policy cascade in coordination
with Centers for Health and Development.

2. Philippine Council for Mental Health shall:

a. Provide technical guidance on matters concerning policy implementation
and evaluation;
b. Provide Technical Assistance as needed; and
c. Recommend policy amendments, as needed.

3. DOH Health Facilities and Services Regulatory Bureau shall:

a. Ensure that all mental health facilities comply with the DOH licensing
standard.
 4. Internal Review Board of mental health facilities shall:
a. Conduct regular review, monitoring, and audit of all cases involving the
treatment, confinement orrestraint of service users within its jurisdiction;
b. Inspect mental health facilities, under their jurisdiction, to ensure that
service users therein are not being subjected to cruel, inhumane, or
degrading conditions or treatment and are in compliance with the
guidelines.
Review complaints and elevate to appropriate agencies for action.
Inspect forms if they conform with the standards provided in the law and
articulated in this guideline.

5. Commission on Human Rights shall:

a. Establish mechanisms to investigate, address, and act upon complaints of
impropriety and abuse in the treatment and care received by service users,
particularly when such treatment or care is administered or implemented
involuntarily;
Inspect mental health facilities to ensure their compliance with the
guidelines.

6. National Center for Mental Health shall:

a. Provide recommendations as as
to the operationalization of the guidelines,
the National Specialty Center for Mental Health;
b. Develop a centralized electronic database for monitoring and research
purposes, compliant toexisting data privacy laws and other policies; and
Provide technical assistance to mental mental health facilities, as needed.

7. DOH Centers for Health Development shall:

a. Cascade policy to all public and private health facilities;
b. Monitor and supervise the implementation and adoption of the guidelines
to facilities, both public and private, providing mental health services
under their regional offices; and
Report implementation updates and assessments to the DOH Central
Office through the Mental Health Division.

B. Individual Roles

1. Service User/Family and other Care and Support Groups shall:

a. Report any violation to the responsible mental health facility or through
the IRB; and
b. Proactively consult with mental health professionals should there be
inquiries and concerns on provision of informed consent, advance
directive, appointment of legal representative, and designation of support
groups.

2. Mental Health Professionals shall:

a. Provide every service user, whether admitted for voluntary treatment, with
complete information regarding the plan of treatment to be implemented;
b. Ensure that informed consent is obtained from service users prior to
implementation of regarding any medical procedure or plan of treatment or
care, except during psychiatric or neurologic emergencies or when the
 service user has impairment or temporary loss of decision-making
capacity.
c. Inform and educate service users of the rights and ensure compliance to
the guidelines; and
d. Inform and educate legal representatives with respect to any treatment or
therapy received by the
service user.

3. Legal Representative shall:

a. Provide the service user with support and help, represent his or her
interests, and receive medical information about the service user (specific
purpose and specific duration);
b. Act as a substitute decision maker when the service user has been assessed
by a mental health professional to have temporary impairment of
decision-making capacity; and
c. Assist the service user vis-a-vis any right provided under R.A. No. 11036.

4. Social Worker shall:

a. Ensure that a petition for the appointment of a
legal representative shall be
filed with the proper court for service users that failed to appoint their
legal representative.

Vil. PENALTY CLAUSE

Any violation of this Order shall be sanctioned in accordance with Section 44

of RA 11036 and Section 45 of its IRR, as well as other applicable laws.

IX. SEPARABILITY CLAUSE

If any clause, sentence, or provision of this Order shall be declared invalid or

unconstitutional, the other provisions not affected thereby shall remain valid and
effective.

REPEALING CLAUSE

Any orders, issuances, rules and regulations inconsistent with or contrary to

this AO shall be repealed, amended or modified accordingly.

XI. EFFECTIVITY CLAUSE

This Order shall take effect fifteen (15) days after its publication in a newspaper of
general circulation and upon filing with the University of the Philippines Law Center
of three (3) certified copies of this Order.

fer FRANCISCO T. DU
ecretary of Health
IIL, MD, MSc
 ANNEX A. ALGORITHM FOR GETTING THE INFORMED CONSENT
(link to digital copy: https://bit.ly/3EgoXgN)

A.1. SERVICE USERS WITH PSYCHIATRIC OR NEUROLOGIC EMERGENCIES

C 5 sta RT

Service User Encounter

>ig eel
Criteria for Psychiatric/Neurologic
Emergency: (all must apply}
Presence of Serious or is there a NO Proceed to Annex A.2.
immediate threat Psychiatric/Neurologic
Affects health and Emeergencycy?
well-being of the Service User
or other persans
Requires immediate
medical intervention

REASSESSMENT

Exception to informed
Consent
Css there an Advance Directive?
Proceed to TREATMENT
~
{See Section C at the
Specitic Guidelines)
\e

Does the Advanoe Directive caver NO

Paychiatric ano Neurologic
Emenpencins?

Follow
ADVANCE DIRECTIVE

i >
Lee
Cm od —— —
—_
 ANNEX B. ALGORITHM FOR GETTING THE INFORMED CONSENT
(link to digital copy: https://bit.ly/3EqoXgN)

A.2. SERVICE USERS WITHOUT PSYCHIATRIC OR NEUROLOGIC

EMERGENCIES

Criteria for presence of decision

making capacity: fall must apply)
C smart)
al ,

Service User Encounter

(Service User without
Psychiatric or Neurologic
(1) Understand information
concerning the nature of a mental Emergencies)
health condition;

(2) Understand the consequences

of one's decisions and actions on
one's life or health, or the life or
health of others;

(3) Understand information about

the nature of the treatment Is there capacity for
proposed, including methodology, decision-making? Proceed to Annex A.3.
direct effects, and possible side
effects; and

(4) Effectively communicate

consent voluntarily given by a
service user to a plan for
treatment or hospitalization, or
information regarding one’s own
condition;

NO
Are there supporters ?

¥
YES
Obtain
INFORMED CONSENT

Supported Decision-Making (See Section B of the

Specific Guidelines)
 ANNEX C. ALGORITHM FOR GETTING THE INFORMED CONSENT

__
(link to digital copy: https://bit.ly/3EgoXgN)

A.3. SERVICE USERS WITH IMPAIRMENT OR TEMPORARY LOSS OF

DECISION-MAKING CAPACITY

START)

i
—_
Service User Encounter
(Service User with Impairment or
Temporary Loss of Decision-
Making Capacity)
i

Criteria for valid | Exception to Informed Consent

RENEE CrOCEe Is there Follow the Advance Directive, wee

Signed...
YES
;
‘ - + as applicable, unless doing so co END
7
Dated Advance
*
Notarized Nirective |
would pose an immediate risk
of serious harm to the service . ae | ,

. Latest user or to another person

(NO
Criteria for valid ¢
appointment of legal
representative:
. Signed
° Dated is there a
legal YES
° Notarized a snueey
>
Legal age of representa
appointee tive?
° Latest
. Accepted by
appointee

NO

i
|

Designation of legal

| a
!

representative, in
order:
. Spouse 4
B
° Non —minor
children Assignment of Legal |
The legalrepresentative |
al
. Either performs his/her END
Representative functions. if with
parent
*
Chief, supporters, they are eee
administrat included in the process
or or
medical :
director of a f
——

mental Functions
health * Provide the service user with support and
help, represent his or her interests, and
receive medical information about the service
As for appointment by court, a petition for the user (specific purpose and specific duration).
Act a5 a substitute decision maker when the
appointment of legal representative shall be filed
with the proper court by a social worker. In the i
service user has been assessed by a mental
absence of social worker, the request shall be filed health professional to have temporary
by the service user's relative or friend. in the impairment of decision making capacity;
absence of a service user's relative or frend, the Assist the service user vis-@ vis any right
Secretary of the Department of Health or the provided under R.A. No. 11036;
Be consulted with respect to any treatment or
Secretary of the Department of Social Welfare and
Development, as the case maybe, through the |
therapy received by the service user
Office of the Solicitor General shall file the petition.
 ANNEX D. MODEL INFORMED CONSENT TO TREATMENT FORM
(link to digital copy: https://bit.ly/3EqoXgN)

PATIENT INFORMATION
Patient Name: Hospital No: Sex M/F Age

Part 1: Physician’s Declaration ( to be completed by clinician obtaining the consent)

Tick the boxes
stated procedure:
or
cross out and initial any changes or
information not appropriate to the

Oo have informed the patient of the treatment options available, and the likely
|

outcomes of each treatment option, including known benefits and possible

complications.
oO | have recommended the treatment/procedures/investigations that | have ticked
and countersigned below on this form.

a I
have explained the treatment/procedures/investigations, identified below, and
what is entailed for the patient.
oO have provided the patient with information specific to the treatment/ procedure/
|

investigations identified. The patient has been asked to read information provided and
ask the doctor questions about anything that is unclear. An identifiable copy of the
information | have provided to the patient has been kept on the patient’s medical
record.
Oo | have given the opportunity to discuss the proposed
patient an
treatment/procedure/ investigations, benefits and risks, both general and specific and
the risk of not having the procedure.
c | have provided the patient with information regarding his/her rights as enumerated
in RA 11036 sec. 5
Part 2: List of Treatments/Diagnostics/Procedures
TREATMENTS DIAGNOSTICS PROCEDURES

0 Medications: cj Laboratory Procedures 0 Outpatient Treatment

Specify:
ciPsychopharmacology O Inpatient
c Psychologic Testing
oO
Adjunct Medications 3 Psychosocial Rehabilitation
o Others: Ppaeram
a Other medications
Specify: a Others:
c Psychotherapy:
co Somatic Modalities:

oElectroconvulsive
Therapy
oTranscranial Magnetic
Stimulation
 coOthers:

c Others:

A specialist/ mental health professional/ mental health worker may be requested to explain
specific benefits and risks that may arise from treatment/procedure/investigations as deemed
appropriate by the physician

Part 3: Disclosure of Material Risks

Material risks or specific risks particular to this patient that have arisen as a result of our
discussions are:

Part 4: Signature of Physician

Full Name (in print): Position/Title:
Signature: Date:

Part 5: Service User’s Declaration

Material risks or specific risks particular to this patient that have arisen as a result of our
discussions are:
Please read the information carefully and tick the following to indicate you have understood
and agree with the information provided to you. Any specific concerns should be discussed
with your doctor in
charge prior to signing the consent form.
oO The doctor has explained my medical condition and prognosis to me. The doctor
also explained the relevant diagnostic/ treatment options that are available to me and
associated risks, including the risks of not having the procedure.

O The risks of the procedure have been explained to me, including the risks that are
specific to me and the likely outcomes. | have had an opportunity to discuss and
clarify any concerns with the doctor.
O understand that the result/outcome of the treatment/procedure cannot be
|

guaranteed.
O | understand that if | am treated as a public patient, no guarantee can be provided
that a particular doctor will perform the procedure, and that the doctor performing
the procedure may be undergoing training.
O understand that tissue samples and blood removed as part of the procedure or
|

treatment will be used for diagnosis and common pathology practices (which may
include audit, training, test development and research), and will be stored or disposed
of sensitively by the hospital.

‘)
 staff member is exposed to my blood,
consent to a sample of blood being

|
O If a |

collected and tested for infectious diseases. | understand that will be informed if the
sample is
tested, and that | will be given the results of the tests.
O | agree for my medical record to be accessed by staff involved in my clinical care and
for it to be used for approved quality assurance activities, including clinical audit.
O | understand that if immediate life-threatening events happen during the procedure,
| will be treated accordingly.
g | understand that |have the right to change my mind at any time before the
procedure is undertaken, including after | have signed this form.
Ol understand that | must inform my doctor if this occurs.
al consent to undergo the procedure/s or treatment/s that | have chosen below.

0 | consent to a blood transfusion, if needed o Yes © No

(tick appropriate box)

Part 6: List of Treatments/Diagnostics/Procedures

TREATMENTS DIAGNOSTICS PROCEDURES

c Medications: c Laboratory Procedures 0 Outpatient Treatment

Specify:
cPsychopharmacology c Inpatient
;
Oo
Psychologic Testing
a Adjunct Medications c Psychosocial Rehabilitation
Oo Others: Engg ram
0 Other medications
Specify: co Others:

© Psychotherapy:

0 Somatic Modalities:

oElectroconvulsive
Therapy
oTranscranial Magnetic
Stimulation
oOthers:
oO Others:
Part 7: Service User’s Signature
the Legal Representative with or without supporters
(If Service User, may sign this form)
O By
signature, | confirm that my consent is voluntarily given and | completely
affixing my
understand the benefits and risks of the treatment plan which was discussed with my
physician in charge.
Patient’s full name: Date and Time:
Patient’s signature:
0 By
affixing my is
signature, | confirm that my consent voluntarily given and | completely

|
understand the benefits and risks of the treatment plan which was discussed with my service
user’s physician in charge and that will act conscientiously and reflect the service user’s
wishes faithfully upon consultation with any supporters that may have been designated
Patient’s full name: Date/Time
Patient’s signature:

0 That my cooperation is
voluntarily given and | completely understand the benefits and risks
of the treatment plan which was discussed with my physician in charge and act to the benefit
of the patient
Date/ Time
Supporter #1 full name:
Supporter #1 signature:

Supporter #2 full name:

Supporter #2 signature:

Supporter #3 full name:

Supporter #3 signature:
 ANNEX E. MODEL MENTAL HEALTH ADVANCE DIRECTIVE FORM
(link to digital copy: https://bit.ly/3 EqgoXgN)

NOTICE TO PERSONS CREATING A MENTAL HEALTH ADVANCE DIRECTIVE

This is an important legal document. It creates an advance directive for mental health treatment.
Before signing this document, you should know these important facts:
(1) This document iscalled an advance directive and allows you to make decisions in advance about
your mental health treatment, including medications, short-term admission to inpatient treatment
and electroconvulsive therapy.

THIS FORM WILL NOT TAKE EFFECT UNLESS SIGNED.

SIGNING OF ADVANCE DIRECTIVE IS NOT MANDATORY.

If you choose to complete and sign this document, please do not leave any blanks, otherwise write
“not applicable” or “N/A” on the part of the form that is optional or not applicable to you.
(2) You have the right to appoint a person as your legal representative to make treatment decisions
for you. You must notify your legal representative that you have appointed him or her
representative. The has to act with wishes made
as a legal
known
person you appoint a duty consistently your
by you.If your legal representative does not know what your wishes are, he or she has a duty to
act
in your best interest. Your legal representative has the right to withdraw from the appointment at
any time.
(3) The instructions you include with this advance directive and the authority you give your legal
representative to act will only become effective under the conditions you select in this document.
You may choose to limit this directive and your legal representative's authority to times when you
are incapacitated or to times when you are exhibiting symptoms or behavior that you specify. You
may also this
make directive effective immediately. No matter when you choose to make this
directive effective, your treatment providers must still seek your informed consent at all times that
you have capacity give
to informed consent.
(4) You have the right to revoke this document in writing at any time you have capacity.

YOU MAY NOT

REVOKE THIS DIRECTIVE WHEN YOU HAVE BEEN FOUND TO
BE INCAPACITATED UNLESS YOU HAVE SPECIFICALLY STATED IN THIS
DIRECTIVE THAT YOU WANT IT
TO BE REVOCABLE WHEN YOU ARE
INCAPACITATED.

it
(5) This directive will stay in effect until you revoke unless you specify an expiration date. If you
specify an expiration date and you are incapacitated at the time it expires, it will remain in effect
until you have capacity to make treatment decisions
(6) If there is anything in this directive that you do not understand, you should ask a lawyer, your
legal representatives, or supporters to explain and help you understand the terms.
(7) You should be aware that there are some circumstances where your provider may not have to
follow your directive.
(8) You should discuss any treatment decisions in your directive with your provider.
(9) You may ask the court to rule on the validity of your directive.

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 PART I.
STATEMENT OF INTENT TO CREATE A MENTAL HEALTH ADVANCE
DIRECTIVE

lL, being a person with capacity, willfully and voluntarily execute

this mental health advance directive so that my choices regarding my mental health care will be
carried out in circumstances when I am unable to express my instructions and preferences regarding
my mental health care. If a legal representative is appointed by a court to make mental health
decisions for me, I intend this document to take precedence over all other means of ascertaining my
intent.
I intend that all completed sections be followed. If I have not expressed a choice,
my legal
representative should make thedecision that he or she determines is in my
best interest. I intend

this directive to take precedence over any other directives have previously executed, to the extent
I

that they are inconsistent with this document, or unless I expressly state otherwise in either
document.
I understand that I
may revoke this directive in whole or in part if I am a person with capacity. I
understand that I cannot revoke this directive if a court, two health care providers, or one mental
health professional and one health care provider find that I am an incapacitated person.
I understand that, except as otherwise provided in law, revocation must be in writing. I understand

that nothing in this directive, or in my refusal of treatment to which I consent in this directive,
authorizes any health care provider, professional person, health care facility, or legal representative
appointed in this directive to use or threaten to use abuse, neglect, financial exploitation, or
abandonment to
carry out my directive.
I understand that there are some circumstances where
my provider may not have to follow my
directive.
PART
II. EFFECTIVE
WHEN THIS DIRECTIVE IS
YOU MUST COMPLETE THIS PART FOR YOUR DIRECTIVE TO BE VALID.
I intend that this directive become effective (YOU MUST CHOOSE ONLY ONE):
Immediately upon my signing of this directive.
If I become incapacitated.
When the following circumstances, symptoms, or behaviors occur:

PART III.
DURATION OF THIS DIRECTIVE

YOU MUST COMPLETE THIS PART FOR YOUR DIRECTIVE TO BE VALID.

I want thisdirective to (YOU MUST CHOOSE ONLY ONE):
Remain valid and in effect for an indefinite period of time.
Automatically expire years from the date it was created.

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 PART V.
PREFERENCES AND INSTRUCTIONS ABOUT TREATMENT, FACILITIES, AND
PHYSICIANS
A. Preferences and Instructions About Physician(s) to be Involved in My Treatment
I would like the physician(s) named below

Dr.
to
be involved in my treatment decisions:
Contact information:
Dr. Contact information:
I do not wish to be treated by Dr.
Preferences and Instructions About Other Providers
I
B.
Iam receiving other treatment or care from providers who feel has an impact on my mental health
care. I would like the following treatment provider(s) to be contacted when this directive is
effective:
Name Profession Contact
information Name
Profession Contact
information

C. Preferences and Instructions About Medications for Psychiatric Treatment

(initial and complete all
that apply)
I consent, and authorize
my legal representative (if appointed) to consent, to the
following medications:

I do not consent, and I do not authorize

my legal representative (if appointed) to consent,
to the administration of the following medications:

am willing to take the medications excluded above if my only reason for excluding them
I

is the side effects which include and these side

effects can be eliminated by dosage adjustment or other means.
I am willing to try
any other medication the hospital doctor recommends.
I am willing to try
any other medications my outpatient doctor recommends.
I do not want
to
try any other medications.

Medication Allergies

I have allergies to, or severe side effects from, the following:

Other Medication Preferences or Instructions

I have the following other preferences or instructions about medications

Preferences and Instructions About Hospitalization and Alternatives

(initial all that apply and, if

desired, rank "1" for first choice, "2" for second choice, and so on)
In the event my psychiatric condition is serious enough to require 24-hour care and I have
no physical conditions that require immediate access to emergency medical care, I prefer to receive
this care in programs/facilities designed as alternatives to psychiatric hospitalizations.
I would also like the interventions below to be tried before hospitalization is considered:
Calling someone or having someone call me when needed.
Name: Telephone: oe
Staying overnight with someone.
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Name: Telephone:
Having a mental health service provider come to see me.
Going
to
a crisis triage center or emergency room.
Staying overnight at a crisis respite (temporary) bed.
Seeing a service provider for help with psychiatric medications.
Other, specify:

Authority to Consent to Inpatient Treatment

I consent, and authorize my Legal Representative (if appointed) to consent, to voluntary admission
to inpatient mental health treatment for days (not to exceed 15 days)
(Sign one):
If deemed appropriate by my Legal Representative (if appointed) and treating physician.

(Signature)
or
Under the following circumstances (specify symptoms, behaviors, or circumstances that
indicate the need for hospitalization)

(Signature)
or
I do not consent, or authorize
my Legal Representative (if appointed) to consent, to
inpatient treatment.

(Signature)

Hospital Preferences and Instructions

If hospitalization is required, I prefer the following hospitals:

I do not consent to be admitted to the following hospitals:

D. Preferences and Instructions About Pre-emergency

I would like the interventions below to be tried before use of seclusion or restraint is considered
(initial all that apply):
"Talk me down" one-on-one
More medication
Time out/privacy
Show of authority/force
Shift my attention to something else
Set firm limits on my behavior
Help me to discuss/vent feelings
Decrease stimulation
Offer to have neutral person settle dispute
Other, specify

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E. Preferences and Instructions About Seclusion, Restraint, and Emergency Medications

If it is determined that I am engaging in behavior that requires seclusion, physical restraint, and/or
emergency use of medication, I prefer these interventions in the order I have chosen (choose "J"
for first choice, "2" for second choice, and so on):
Seclusion
Seclusion and physical restraint (combined)
Medication by injection
in
Medication pill or liquid form
In the event that my attending physician decides to use medication in response to an
emergency situation after due consideration of my preferences and instructions for
emergency treatments stated above, I expect the choice of medication to reflect any
in
preferences and instructions I have expressed Part III C of this form. The preferences and
instructions I express in this section regarding medication in emergency situations do not
constitute consent to use of the medication for non- emergency treatment. In this case
seclusion is a medical procedure meant to protect me or others from my untoward behavior
and should not be misconstrued as “solitary confinement”.

F. Preferences and Instructions About Electroconvulsive Therapy (ECT or Shock Therapy)

My wishes regarding electroconvulsive therapy are (sign one):

do not consent, nor authorize my legal representative (if appointed) to consent, to the
I

administration of electroconvulsive therapy.

(Signature)
I consent, and authorize representative (if appointed) to consent, to the
my legal
administration of electroconvulsive therapy

(Signature)

Iconsent, and authorize my legal representative (if appointed) to consent, to the

administration of electroconvulsive therapy, but only under the following conditions:

(Signature)

G. Preferences and Instructions About Who is Permitted to Visit

If I have been admitted to a mental health treatment facility, the following people are not
permitted to visit me there:
Name:
Name:
Name:
I understand that persons not listed above
may be permitted to visit me.

H. Additional Instructions About My Mental Health Care

Other instructions about my mental health care:

In case of emergency, please contact: Coe

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Name: Address: Work
telephone: Home telephone:
Physician: Address:
Telephone:
The following may help me to avoid a hospitalization:

I generally react to being hospitalized as follows:

Staff of the hospital or crisis unit can help me by doing the following:

I. Refusal of Treatment
I do not consent to any mental health treatment.

(Signature)

PART VI.
DURABLE POWER OF ATTORNEY (APPOINTMENT OF MY LEGAL
REPRESENTATIVE)

(Fill out this part only ifyou wish to appoint a Legal Representative or nominate a supporter.)
I authorize a Legal Representative to make mental health treatment decisions on my behalf. The
authority granted to my Legal Representative includes the right to consent, refuse consent, or
withdraw consent to any mental health care, treatment, service, or procedure, consistent with any
instructions and/or limitations I have set forth in this directive. I intend that those decisions should
be made in accordance with my expressed wishes as set forth in this document. If I have not
expressed a choice in this document and my Legal Representative does not otherwise know my
wishes, I authorize my Legal Representative to make the decision that my Legal Representative
determines is in my best interest. This agency shall not be affected by my incapacity. Unless state
otherwise in this durable power ofattorney, I may revoke itunless prohibited by other state law.
I
A. Designation of a Legal Representative

I appoint the following person as my Legal Representative to make mental health treatment
decisions for me as authorized in this document and request that this person be notified
immediately when this directive becomes effective:
Name: Address: Work
telephone: Home telephone: Relationship:

B. Designation of Alternate Legal Representative

If the person named above

or I revoke that
is
unavailable, unable, or refuses to serve as my Legal Representative,
person's authority to serve as my Legal Representative, I hereby appoint the
following person as my alternate Legal Representative and request that this person be notified
immediately whenthis directive becomes effective or when my original Legal Representative is no
longer my Legal Representative:
Name: Address: Work
telephone: Home telephone: Relationship:

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C. When My Spouse is My Legal Representative (initial if desired):

If my spouse is my Legal Representative, that person shall remain my Legal Representative

even if we become legally separated or our marriage is dissolved, unless there is a court order to
the contrary or I have remarried.

D. Limitations on My Legal Representative’s Authority

I do not grant my legal representative the authority to consent on my behalf to the following:

E. Limitations on My Ability to Revoke this Durable Power of Attorney

I choose to limit my ability to revoke this durable power of attorney as follows:

F. Preference as to Court-Appointed Legal Representative

In the event a court appoints a Legal Representative who will make decisions regarding my
mental health treatment, I nominate the following person as my guardian:
Name: Address: Work
telephone: Home telephone: Relationship:

The appointment of a Legal Representative of my estate or my person or any other decision maker
shall not give the Legal Representative or decision maker the power to
revoke, suspend, or terminate
this directive or the powers of my legal representative, except as authorized by law.

(Signature required if nomination is made)

PART VII. OTHER DOCUMENTS

(Initial all that apply)

I have executed the following documents that include the power to make decisions regarding
health care services for myself:
Health care power of attorney
"Living will"
I have appointed more than one Legal Representative. I understand that the most

recently appointed legal representative controls except as stated below:

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 PART VIII.
NOTIFICATION OF OTHERS AND CARE OF PERSONAL AFFAIRS

(Fill out this part only if you wish to provide non-treatment instructions.)
I understand the preferences and instructions in this part are NOT the responsibility of my
treatment provider and that no treatment provider is required to act on them.

A. Who Should Be Notified

I desire my Legal Representative to notify the following individuals as soon as possible when this
directive becomes effective:
Name: Address: Day
telephone: Evening telephone:
Name: Address: Day
telephone: Evening telephone:

B. Preferences or Instructions About Personal Affairs |

Ihave the following preferences or instructions about my personal affairs (e.g., care of
dependents, pets, household) if I am admitted to a mental health treatment facility:

C. Additional Preferences and Instructions:

PART IX. SIGNATURE

By
signing here, I indicate that I understand the purpose and effect of this document and that I am
giving my informed consent to the treatments and/or admission to which I have consented or
authorized my Legal Representative to consent in this directive. I intend that my consent in this
directive be construed as being consistent with the elements of informed consent.
Signature: Date:
Printed Name:
This directive was signed and declared by the "Principal," to be his or her directive, in our presence
who, athis or her request, has signed our names below as witnesses. We declare that, at the time of
the creation of this instrument, the Principal is personally known to us and, according to our best
to
knowledge and belief, has capacity at this time and does not appear be acting under duress, undue
influence, or fraud. We further declare that none of usis:
(A) A person designated to make medical decisions on the principal's behalf;
(B) A health care provider or professional person directly involved with the provision of
care to the principal at the time the directive is executed;
(C) An owner, operator, employee, or relative of an owner or of
operator a health care
facility or long-term care facility in which the principal is a patient or resident (unless in
accordance with the provisions in the guidelines regarding failure to assign legal
representative);
(D) A person who is related by blood, marriage, or adoption to the person, or with whom
a
the principal has dating relationship;
(E) An incapacitated person;
(F) A person who would benefit financially if the principal undergoes mental health
treatment; or

one
i
(G) A minor.

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Witness 1: Signature: Date: Printed

Name: Telephone
Address
Witness 2: Signature: Date: Printed
Name: Telephone
Address

PART X. RECORD OF DIRECTIVE

I have given a copy of this directive to the following persons:

DO NOT FILL OUT AND SIGN THIS PART UNLESS YOU INTEND TO REVOKE THIS
DIRECTIVE IN PART OR IN WHOLE

PART XI. REVOCATION OF THIS DIRECTIVE

(Initial any that applies):

I am revoking the following part(s) of this directive (specify):

am revoking this entire directive.

I
By
I
signing here, indicate that I understand the purpose and effect of my revocation and that no
person is bound by any revoked provision(s). I intend this revocation to
be interpreted as if I had
never completed the revoked provision(s).
Signature: Date: Printed
Name:

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