Statutes, codes, and regulations
Wyoming Administrative Code
Agency 048 - Health, Department ofSubagency 0039 - Mental Health Division
Chapter 1 - PSYCHIATRIC ADVANCE DIRECTIVES & PAD FORM
Section 1-5 - Procedure

048-1 Wyo. Code R. § 1-5

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Current through April 27, 2019
Section 1-5 - Procedure

(a) Persons admitted to psychiatric health care facilities such as hospitals, group homes, or long-term care facilities must be offered information about psychiatric advance directives and how to complete such directives.

(b) A mental health professional will review this material with the individual and his/her desires regarding execution of a psychiatric advance directive.

(c) If the person desires to create a psychiatric advance directive, assistance will be offered by a mental health professional in completing the directive.

(d) The Division shall prepare a standard form for use by those wishing to prepare and execute a psychiatric advance directive. The Division shall provide the form to anyone requesting a copy. Such forms shall be kept at the Mental Health Division, the Wyoming State Hospital, and the Division shall make copies available to community mental health centers and other health care facilities, at their request.

  • i. Any form for a psychiatric advance directive must include the following data:
    • A. The person's name, date of birth, and sex.
    • B The person's eye and hair color.
    • C. The person's race or ethnic background.
    • D. The person's social security number.
    • E. The name of the current and last treating facility.
    • F. The name, address and telephone number of the persons attending physician and/or primary mental health professional(s).
    • G. The person's signature or mark, or, if applicable, the signature of a person authorized by law to execute a psychiatric advance directive.
    • H. The date on which the psychiatric advance directive was signed.
    • I. The person's directive concerning the administration or refusal of psychiatric restabilization measures, countersigned by the persons attending physician or mental health professional.
    • J. The name, address and telephone number of the person designated as an agent, if applicable, to consent to or refuse psychiatric restabilization measures for the person who has executed a psychiatric advance directive and the signature of that person indicating acceptance of this appointment.
    • K. Information that a psychiatric advance directive may be revoked at any time by the person who is the subject of the directive unless he/she is mentally incapacitated, as attested to by two mental health professionals, one of whom is the persons attending physician; or at any time by any other person who is, pursuant to state law, authorized to consent to or refuse psychiatric restabilization measures on behalf of the person who is the subject of the directive.
    • L. Completed advance directives will be witnessed by two persons who are not family members or employees of the psychiatric facility where the person is being treated.

(e) The "agent" identified in the psychiatric advance directive may not make mental illness treatment decisions unless the subject of the directive lacks capacity as attested to be two mental health professionals (one of whom is the attending physician) or by a court of law.

(f) Except to the extent that the right is limited by the declaration of any federal law, an agent has the same right as the declarant to receive information regarding the proposed mental illness treatment, and to receive, review, and consent to disclosure of medical records relating to that treatment.

(g) An agent may withdraw by giving notice to the declarant. If the declarant is incompetent at the time of the withdrawal, the agent may withdraw by giving notice to the attending physician or mental health professional. That person shall note the withdrawal in the medical record and on the psychiatric advance directive form. This person may rescind their withdrawal by executing an acceptance after the date of withdrawal reaffirming their acceptance of this responsibility. The agent will again give notice to the patient and attending physician or mental health professional.

(h) Mental health professionals shall comply with the psychiatric advance directive to the extent medically indicated under the direction of the attending physician or psychiatrist.

(i) Mental health professionals who in good faith comply with a psychiatrist advance directive shall not be subject to civil or criminal liability or regulatory sanction for such compliance.

(j) Compliance with a psychiatric advance directive shall not affect the criminal prosecution of any person otherwise charged with the commission of a criminal act.

(k) In the absence of a psychiatric advance directive, a persons consent to psychiatric restabilization measures shall not be presumed.

(l) A psychiatric advance directive for any person admitted to a psychiatric health care facility shall be implemented as directed by the psychiatric advance directive, pending further physician's orders. The psychiatric advance directive shall be deviated from only with the consent of the admitted person, his/her agent, the district court or when adherence to the directive threatens permanent physical injury.

(m) Neither a psychiatric advance directive nor the failure of a person to execute one shall affect, impair or modify any contract of life or health insurance or any annuity or be the basis for any delay in issuing or refusing to issue an annuity or policy of health insurance or any increase or premium thereof.

(n) A psychiatric advance directive may be revoked at any time by the person who is the subject of the directive unless he is mentally incapacitated or at any time by any other person who is, pursuant to the laws of this state or any other state, authorized to consent to or refuse psychiatric restabilization measures on behalf of the person who is the subject of the directive.

(o) A psychiatric advance directive shall be valid for a period not to exceed two (2) years from the date of execution unless reaffirmed by the person who executed the directive, in which case it shall be valid for two (2) more years from the date of reaffirmation.

(p) When a mental health professional is not willing to follow a person's advance directive, he/she is obligated to transfer patient care to a mental health professional who can and will follow the advance directive.

(q) Psychiatric health care facilities shall provide education for their staff and volunteers on issues regarding psychiatric advance directives.

(r) Revocation may be accomplished by:

  • i. written revocation signed by the person or legal designate;
  • ii. by verbal expression in the presence of an adult witness who signs and dates a written confirmation of the person's or legal designates verbal expression to revoke the advance directive;
  • iii. by verbal expression over the telephone with a witness who signs and dates a written confirmation of the verbal expression to revoke the psychiatric advance directive.

PSYCHIATRIC ADVANCE DIRECTIVE DECLARATION

TO MY FAMILY, MY PHYSICIAN, MY LAWYER

AND ALL OTHERS WHOM IT MAY CONCERN

Declaration made this_______ day of, ________________ 20____ .

I, being of sound mind, willfully and voluntarily make known my desires for mental health treatment(s) to be followed should it be determined by two physicians, one of whom is my attending physician, that my ability to receive and evaluate information effectively or communicate decision is impaired to such an extent that I lack the capacity to refuse or consent to mental health treatment. I understand that any treatments would be toward the goal of psychiatric restabilization as a way of restoring my capacity and optimal mental health functioning. I further understand that psychiatric restabilization may include administration of prescribed liquid medication by mouth or injection, administration of prescribed medication orally, physical restraint, seclusion or crisis psychiatric counseling and that in the statements below I may give or refuse consent to any of these or other treatment options to which I stipulate.

I understand that I may revoke this declaration at any time unless I have been declared to lack capacity to give or withhold treatment by two physicians, one of whom is my attending physician.

I understand that I may become incapable of giving or withholding informed consent for mental health treatment due to symptoms of a diagnosed mental disorder. The symptoms may include the following:

If I become incapable of giving or withholding informed consent for mental health treatment, my wishes regarding medications are as follows:

_______I consent to the administration of medications.

___ I consent to the administration of the following medications:_______________________

I do not give consent to the administration of medications.

I do not give consent to the administration of the following medications:___________________________

Conditions or limitations:___________________

Should I become incapable of giving or withholding informed consent for mental health treatment due to the symptoms of a diagnosed mental disorder and my behaviors become dangerous to myself or others, or should I become incapable of providing for my basic need. In this case I would give consent for the following treatment(s):

_______ Physical Restraint _______ Seclusion _______ Crisis Psychiatric Counseling

Other:_______

In this case I would not give consent for:

Physical Restraint Seclusion Crisis Psychiatric Counseling

Other:_______

Should I become incapable of giving or withholding informed consent for mental health treatment due to the symptoms of a diagnosed mental disorder I hereby appoint:

Name Address_____________________________________

Telephone Number(s)_____________________ to act as my agent in making decisions regarding my mental health treatment. I understand that this person will gain this appointment only if I am declared to lack capacity by two physicians, one of whom will be my attending physician.

My agent is authorized to make decisions that are consistent with the wishes I have expressed in this declaration, or, if not expressed, as are otherwise known to my agent. If my wishes are not expressed and are not otherwise known by my agent that person is to act in what he or she believes to be in my best interest.

ACCEPTANCE OF APPOINTMENT AS AGENT

I accept this appointment and agree to serve as the agent to make decisions about mental health treatment for, . I understand I have a duty to act consistent with the desires of this individual as expressed in this appointment. I understand this document gives me the authority to make decisions about mental health treatment only while this person is incapable as determined by a court or two physicians. I understand that he or she may revoke this declaration in whole or in part at any time and in any manner when he or she has capacity to make decisions.

________________________________ Signature of Agent Date

This document has significant medical, legal and possible ethical implications and effects. Before you sign this document, you should become completely familiar with these implications and effects. The operation, effects, and implications of this document may be discussed with a physician, a lawyer, and a clergyman of your choice.

Signed Date _________________________ Address __________________________________________________________

City, County, and State of Residence

The declarant has been made personally known to me and I believe him or her to be of sound mind. I did not sign the declarants signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care.

_________________________Witness Date

Witness Date

MENTAL HEALTH PROFESSIONAL STATEMENT REGARDING CAPACITY

It is my professional opinion at this time that this person has the capacity to make this declaration:

_______ Yes _______ No

Signature of Psychiatrist/Mental Health Professional Date

Name of Provider/Institution Telephone Number of Provider/Institution

____________________________________________________ Name, Address, and Telephone Number of Attending Physician/Psychiatrist

Please complete the following information to assist your physician and other psychiatric personnel to rapidly identify you as the declarant of this Psychiatric Advance Directive:

Date of Birth ____________ Sex _____ Eye Color _________ Hair Color

Racial or Ethnic Background _______ Social Security Number

Copies of this document are in the following places (i.e., family members, doctors office, hospitals, mental health centers....)

048-1 Wyo. Code R. § 1-5