Feature Image
Title
A Real Psychiatric Advance
Directive (PAD) 2021 prompted by the Orange County Health Care Agency (OCHCA)
for Keith “Buster” Torkelson MS V Brand New Day
72 Hour Hold
We here at Mentalation Solutions
Group finish proofreading this our principal’s Keith “Buster” Torkelson MS’s
Psychiatric Advance Directive or PAD on July 23, 2021 (F). Now we will hold it for 72 Hours while we
work out our intentions. What follows is
Buster’s Beta Version or Educated PAD.
We will use some of this material when the time comes for constructing
Buster’s finished PAD. We plan to publish
this on one or more of our Blogs on Monday July 26, 2021.
Intent Taken From Be Well OC
|
- |
|
|
|
What can you do? |
Note |
|
|
- |
|
|
|
Raise Awareness |
PADs and confidentiality driven stigma |
|
|
Share Resources |
Save others time spent |
|
|
Inspire Conversations |
Already have with Buster’s family |
|
|
Share Your Story |
Lived experience through guarder disclosure |
|
|
- |
|
|
Last Reviewed: 20210728-W:
Advance Directives for Mental Health Treatment
The following is a list of Psychiatric
Advance Directive (PAD) parts that we here at Mentalation Solutions Group (MSG)
found in an on-line Commercial-off-the-shelf (COTs) instrument. The author(s) indicate: “Please refer to the
Psychiatric Advance Directives Toolkit for instructions to complete this
worksheet”. For the most part we are
creating our own “Toolkit” based on Keith “Buster” Torkelson MS’s lived
experience centered about Behavioral Health.
MSG’s motivation is the Orange County Health Care Agency (OCHCA) is
currently investing in PADs. With the
timeline they are sharing we don’t see Beta-PADs developed for more than six
months as best. There a small chance the
OCHCA’s PAD project may be abandoned. In
either case “Buster” and Mentalation Solutions Group (MSG) are shooting to get
our OCHCA driven on the virtual record first.
This report will be paired with our PAD Project Mechanics Study
(PAD-PMS). Recurrent Theme about
Buster’s PAD is: Sleep is protective.
COTS Outline for PADs
1. Symptom(s) I might experience
during a period of crisis
2. Medication instructions
3. Facility Preferences
4. Emergency Contacts in case of mental health
crisis
5. Crisis Precipitants. The following may cause me to experience a mental
health crisis
6. Protective Factors. The following may help me
avoid a mental health crisis
7. Response to Hospital. I usually respond to the hospital as follows
8. Preferences for Staff Interactions
a. Staff of the hospital or
crisis unit can help me by doing the following
b. Staff can minimize use of
restraint and seclusion by doing the following
9. I give permission for the following people to
visit me in the hospital
10. The following are my preferences about ECT
11. Other Instructions
12. Legal documentation for
Advance Directives
1. Symptom(s) I might experience during a period of crisis:
The key factors that drive a
crisis for Buster have repeatedly been not able to get adequate health
promoting sleep in the bed that he leases and resides. As of July 11, 2021 Buster has not been in
the psychiatric or physical hospital since 2012. Buster rents a bed in a local Rent a Shared
Room (RASR) facility. In the past nine
or so years he has shared his room with many severely mentally and physically ill
persons. In order to get enough nightly
sleep he more often than not faces issues.
When Buster exhausts his coping behaviors he asks for help. He tries to avoid asking “911” for help. When he needs to ask for help we here at
Mentalation Solutions Group (MSG) call it a full blown Crisis. Buster learned in his Crisis Intervention
Class at Cypress College (fall, 2011) that a Crisis = Danger and Opportunity. Once a true crisis is in effect until its’
resolution Busters symptoms have been: Worrying, impaired sleep, worsening of
the sleep problem, problems resting, move readiness by moving property from
room to his storage, panic attacks, increased risk for injury, increased risk
of accidental death, lack of motivation to help out in his volunteer capacities,
sleeping outside (practicing homelessness), wanting to call “911” on the person
keeping him up, wanting to Mace the person keeping him up, etc. Buster has practiced exceptional restraint
with regard to those interfering with his sleep.
2. Medication instructions.
A. I agree to administration of
the following medication(s):
Psychoactive Medications (+)
Brief Medication List
|
- |
|
|
|
|
|
Medication |
Note |
Detail |
Doctor(s) |
|
|
- |
|
|
|
|
|
1-Clozapine |
Current - Works |
Treats intractable sleep disorder |
Singh, Vu, Lee, Bera |
|
|
2-Ativan (PRN) |
Current - Works |
Augments Clozapine |
Rimal B Bera, Others |
|
|
3-Restoril |
Worked 2012 |
Possible in our Clozapine Contingency Plan for Buster |
Bum Soo Lee (BSL) |
|
|
Clozapine Contingency |
[SEPARATE] |
|
|
|
|
|
|
|
|
|
|
Ambilify |
Untested |
Consumers report shortfalls |
NA |
|
|
Seroquel |
SoSo |
Bizarre nightmares and restless leg syndrome a variation
of akathisia |
2003-2008 David Dobos |
|
|
Lithium |
Current No measurable benefit |
Used to track adherence |
Rimal B Bera |
|
|
Invega SR Injection |
Didn’t work |
Strongly correlated with hospitalization 2012 Previously Buster did not benefit from Risperidone which
is related to Invega |
The Daniels Experiment |
|
|
Term slow release |
Any unlikely to work |
Buster needs cyclical medications |
Discussed with Dr. BSL in 2012. BSL agreed with Buster |
|
|
- |
|
|
|
|
Last Reviewed: 20210722-W:
[SEE Comprehensive MEDICATION HISTORY AND LIST - SEPARATE]
MSGBase >
Tuesday,
July 27, 2021
Psychotropic
plus Medication History for Keith “Buster” Torkelson MS as Associated with
OCHCA prompted Psychiatric Advance Directive (PAD)
https://psychiatry4dummies.blogspot.com/2021/07/psychotropic-plus-medication-history.html
Safety – Clozapine Risks
When Buster was first stabilized
on Clozapine circa 2006 at Westminster Therapeutic Residential Center (WTRC) he
was given his whole daily dose at once by the pharm staff. Buster was finding that it made him very
dizzy. When he got up to go to the
bathroom at night he would faint and fall down.
Eventually both dizziness and falling were reduced with a lower dose of
Clozapine and breaking it up into divided doses. This is not to say that we have eliminated
nightly dizziness and risk of falling yet in recent years both are
tolerable. Buster cannot drive the car
after he has ½ or more of his nightly dose of Clozapine in his system. As we mention elsewhere Clozapine is
associated with low white blood cell (WBC-V-PMN) counts. In particular Clozapine is associated with low
neutrophil (PMN) counts (neutropenia).
We have been working on a Clozapine Contingency Plan (CCP) just in case
Buster begins to suffer neutropenia.
What Enables My Wellness?
Buster is committed to the Rent a
Shared Room (RASR) environment as a battle scar from campaigns lost. Now and henceforth Buster is overly vulnerable
to harm. At the core of his treatment
plan is Sleep. For all practical
purposes he is dependent on Clozapine for nightly sleep. Just having Clozapine in his system at night
does not completely guarantee sleep. The
RASR environment has to be conducive to Sleep (SleepAble-E). As we addressed above: Clozapine has a
glitch. Clozapine is associated with a
blood factor conversion call Neutropenia.
If this happens the doctor responds by cold turkey elimination of
Clozapine [SEE THE STORY OF SAM I AM]. A
better approach would be titrate down the Clozapine rather than eliminate it.
For mitigation efforts Buster addresses his Clozapine Contingency Plan or CCP.
[INSERT LINK CLOZAPINE - Stayed]
MSGBase >
15_Clozapine_Publications_Work_Done_21072704_Notes
Clozapine Contingency
Health Related Engagements -
Phlebotomy
We here at Mentalation Solutions
Group (MSG) have defined incidences where Buster gets out of the house for
health related ventures his Health Related Engagements (HREs). His insurer, Brand New Day, even compensates
him some of his appointments. Since 2012
Buster has very near if not perfect attendance for in-network
appointments. Buster attends to Health
Related Engagements both in network and out of network. One of his high priority HREs is his monthly
Clozapine associated CBC blood draws. He
also coordinates his medication each month.
Considering administration of Clozapine requires in the maintenance
stage monthly CBC blood draws Buster is really touchy when it comes to
phlebotomy. Considering Buster’s doctor Ravinder
P Singh started her Clozapine experiment for Buster on Buster back in 2006
Buster has had no less than 168 blood draws for Clozapine driven CBC
testing. Buster’s left arm is his
preferred arm to draw from. This keeps
his good arm, his right arm, in reserved for the future.
What works? What doesn’t and Why?
Doesn’t work
During the years since the
initial psychotropic experimentation (1989) using Haldol Buster has agreed to
more than twenty experiments using psychotropic drugs. With the major tranquilizer class of
medications Buster has been treated with conservatively around six.
Sustained release injectable(s)
Since Buster needs minimal
interference (adverse effects) during the day to carry out his activities like
driving the car he prefers no Clozapine or Ativan in his system during the
day. Since Buster requires Clozapine to
sleep he takes it in divided doses before bedtime. Note: If a consumer cannot clear the
medication from their systems every 24 hours then they are a risk for toxicity. It may take a week or even a year yet they more
often than not become toxic. Dr. Deutsch
had managing toxicities originating in the hospital at the core of his
practice. Clozapine has some annoying
side effects. Yet, after ironing out
some details for Buster Clozapine’s benefits outweigh its’ shortcomings. In 2012 Buster had been on Clozapine for
about 5 years. In 2012 Buster was
treated by Dr. Daniels at the Anaheim Lighthouse. She told Buster that with Invega she could
“put you in a place that you have never been.
Her sell worked and Buster agreed to her experiment. Dr. Daniels proceeded to cold turkey Buster
off Clozapine and began titration with her Invega SR Injectable. For three days she augmented Buster with a
Barbiturate to help with sleep. After
she removed the Barbiturate Buster was sleepless for two nights. Next Buster ended up in the psych ward at
Western Med Anaheim. That is where he
met Dr. Bum Soo Lee MD (BSL). Doctor Lee
had the choice: Maintain Buster of Invega which doesn’t work for him or resume
Clozapine which has a history of helping.
BSL chose Clozapine. At this
moment we knew Dr. Daniels experiment had failed Buster and incurred losses.
Other Treatments and Assists
Due to the fact that Buster holds
out as long as possible before he calls “911” he is very sick when he is
admitted to the psych ward. More often
than not the attending physician concludes that it is a medication issue. Circumstantially this is the case because out
of more than 10 primary psychotropic medications applied over time only three
or so were at good fit. The only time a
medication change really made a change for the better is when Dr. Ravinder P Singh
started him on Clozapine. It took three
trips to the Psych Ward before doctor Singh finally got it right. She started Buster on Clozapine asked him to
submit to Conservatorship and released him to a long term semi-lock down therapeutic
residential treatment facility: Westminster Therapeutic Residential Center
(WTRC). When Buster goes to the psych
ward it is nearly always related to sleep issues and a bed move. Quite often his immediate family steps up and
helps him with his belongings and other episodic challenges. The assist that Buster needs most is finding
a GoodBed on the way for stepping down care.
Other assists would be a sustainable treatment and services plan focused
Buster’s unmet Sleep needs. Aside: In
the hospital it would be nice to bring back “Smoke Break”. While in the psych ward, Buster likes access
to the time out room formally called to tie down room if he needs it. He only brought the muscle-staff down on
himself on one occasion. He would prefer
for managing problematic persons on the ward that they come up with a better
approach than tackle and mangle. On any
given day Dr. Ravinder P Singh would spend a minute or two with each consumer
on her caseload. We would prefer the
psych ward doctors to spend more time with their charges. In the face of Psychiatric Advance Directive
(PAD) it might be a promising practice to spend five minutes each day
discussing germane features contained in a PAD.
Assessment
A factor that helps makes Buster
different that those in his Rent a Shared Room (RASR) cohort(s) is self-assessment. Another factor that makes Buster unusual is
literacy and the skills to support literacy: Especially computing, writing and
publishing. He is also superior in his problem
solving that most of his contemporaries.
In addition, Buster is by far Mental Health Services Act (MHSA) aware. It is the language that we here at
Mentalation Solutions Group (MSG) that we fondly call Steinberg Programming
Language (SPL) that helps Buster keep the faith. Yet once again and most important is that he
places as a very high priority nightly sleep.
Back in 2006-2007 while sleeping at Westminster Therapeutic Residential
Center (WTRC) LPS Conservatorship presented problem. Buster asked the WTRC treating physician Dr.
Belman: What is the average stay? He
said two years! Buster had a family
business on the outside to help run. So to
sort things out Buster did four things: Determined his issue was anxiety,
gained approval from the service chief and staff to pursue Cognitive Behavioral
(CBT) biblio-therapy for anxiety, created a behavior assessment, and create an
anxiety management assessment. After
about three and a half months of working his program for setting things Right, Buster
presented his materials to a visiting forensic psychologist Dr. Sue Beck. She represented his case in Probate
Court. Conservatorship was ended on
Friday and Buster was out the door by Sunday.
The duration of care at WTRC was 4 months. In sum his WTRC worker Roxanne indicated that
Buster we most impressive.
Considerations when Considering
Buster finds meaning to his life
through performance. It is largely due
to performance that Buster has participated in so many experiments with
psychiatrists. [MEDICATION LIST
SEPARATE]. Buster had a most significant
other ever (MSOE) from 1998-2018 or twenty years. When a medication change was
made such as to Paxil or Zoloft what mattered to Buster's MSOE was that Buster
could be intimate. Paxil and Zoloft caused
overt impotence. Clozapine for Buster is
not associated with diminished performance.
Some of the side effects have directly influenced Busters performance. Wellbutrin enhanced Busters’ performance yet
aggravated his anxiety. Lithium’s
associated tremors can be stigmatizing.
In Vet School Buster was on Lithium for a term and the tremors
interfered with his teams surgery in Liver Physiology. The tremors also make it hard to write and
draw.
Tuesday, July 27, 2021 [DITTO]
Psychotropic
plus Medication History for Keith “Buster” Torkelson MS as Associated with
OCHCA prompted Psychiatric Advance Directive (PAD)
https://psychiatry4dummies.blogspot.com/2021/07/psychotropic-plus-medication-history.html
Performance
A few of the factors that make
Buster a bit different from others that he knows or associates that share a
history of serious and persistent behavioral illness (SPBI) are: Literacy,
completing college, drive to perform, measurement, volunteering, and for the
most part knowing what he needs for the most part. Whether well or not Buster pushes himself
hard. These factors are some of
Mentalation Solutions Group’s (MSG’s) qualities for a Professional Consumer
(ProSumer).
Autonomy
When Buster is healthier as
measured by his Activities of Daily Living (Extended) he is fairly
autonomous. Buster works hard to set
things right after a hospitalization. As
of July 17, 2021 Buster has not been in the hospital since 2012. He credits this partially with making sleep a
priority.
Side Effects
Unfortunately this is not the
place and time to discuss the costs of side effects since Buster signed on for
Behavioral Health Doctor (BHD) driven psychotropic experimentation back in
1989. Clozapine has a different sensation
profile every night. Some nights it can
be just plane miserable whereas other night it is quite un-remarkable. After Buster ingests by mouth ½ or more of
his daily dose of Clozapine he can get irritable. He does not prefer to do any complex business
after starting his nightly divided dose Clozapine titration. He takes his Lithium during the day so as not
to interfere with his perception of Clozapine.
Lithium’s costs have nearly always outweighed its’ benefits. Yet Buster takes it because his current
doctor prescribes it for an indirect indicator for Buster’s adherence. His Ativan is prescribed as needed
(PRN). Buster is lucky because other
patients that see his BHD indicate that their BHD in common prefers to not
prescribe Ativan. When indicated, Buster
only takes Ativan in the evening or nighttime.
Restoril is not only a good alternate to Ativan it is part of our
Clozapine Contingency Plan (CCP) for Buster.
Buster was tried on Seroquel yet it can interfere with his life both by causing
bizarre nightmares and restless leg syndrome.
Yet, Seroquel appears to be an alternate to Clozapine. Clozapine has helped with Buster’s anxiety
yet it is the side-effect “May cause drowsiness” that Buster leverages. Buster suffers and intractable sleep
disorder. Clozapine overtly makes Buster
sleep. As we saw with the Dr. Daniel’s
experiment without Clozapine Buster does not sleep. After about 48-72 hours without sleep Buster
deteriorates so much that he is a candidate for the psych ward.
B. I do not agree to administration of the
following medication(s):
Slow release injectable and non-generics
Tuesday, July 27, 2021 [DITTO]
Psychotropic
plus Medication History for Keith “Buster” Torkelson MS as Associated with
OCHCA prompted Psychiatric Advance Directive (PAD)
https://psychiatry4dummies.blogspot.com/2021/07/psychotropic-plus-medication-history.html
C. Other information about medications (Allergies,
side effects)
Side Effects – Clozapine – High Impact
|
- |
|
|
|
Effect |
Note |
|
|
- |
|
|
|
Dependency |
Buster is dependent on
Clozapine for sleep Note Clozapine is not Klonopin
or Clonazepam |
|
Dizziness
|
Dose and titration rate related
|
|
|
Drowsiness |
Desirable since Buster only
takes his Clozapine at night the drowsiness side effect is desirable. Since
2007 Clozapine has not caused any tolerance issues |
|
|
Falling Forward |
On one occasion Buster fell
forward and cracked a tooth |
|
|
Hyperextended Knees |
We know how normal knees bend.
On a few occasions Buster had been faced with his knees bending backwards.
Not only is the painful and scary this complication can break knees |
|
Tremors
|
Not so much Clozapine as Lithium
|
|
|
Weak Knees |
Dose related |
|
|
Weakness |
We have been trying to figure
out why Buster is weak as measured by gym performance |
|
|
|
|
|
Last Reviewed: 20210721-W:
Side Effects – Clozapine - Lower Impact & Resolved
|
|
|
|
|
|
Effect |
Note Impact |
Detail |
|
|
|
|
|
|
|
Allergy |
Low |
Some medication managers have reported that Buster may be
allergic to certain psychotropic meds |
|
|
Fainting |
Resolved |
Partially solved by reducing the nightly dose |
|
|
Falling - Backward |
Resolved |
Buster fairs better when falling backward that forward |
|
|
Stairs |
Resolved |
Had problems with stairs when the only bathrooms were on
the first floor |
|
|
Compliance |
SoSo |
Because Buster believes that Clozapine is essential he is
highly compliant |
|
|
Irritability |
SoSo |
After Buster has ½ or more of his daily dose he get
irritable |
|
|
Misery |
SoSo |
Periodically Clozapine make Buster miserable |
|
|
Trouble walking to the bathroom at night |
SoSo |
The med nurse indicates to sit on the edge of the bed for
a bit before standing up |
|
|
- |
|
|
|
Last Reviewed: 20210721-W:
Medication Management - Problem Fixes
Argument for Clozapine
All of the above effects of
Clozapine may sound like a good argument to find something better. It is not.
After some fixes here and there: Such as reducing the daily dose, dosing
4 times over 2 hours, and dosing only at night many of the risky effects have
been mitigated. Clozapine is a good if
not the best psychotropic medication that Buster has been experimented
with. For various reasons Mentalation
Solutions Group (MSG) is not a proponent of fixing a side effect by adding
another drug such as Cogentin. This
year, 2021, Buster takes five medications.
If he had to keep two they are: Clozapine and Atorovostatin. As compared to others that are disabled an
renting a shared room (RASR) only being on 5 medications is a huge achievement. Make note that when a consumer is admitted to
Orange County Jail (OCJ) you are very unlikely to get your medications as
prescribed by your doctor: Both in variety and dosage.
Require adequate Clozapine to sleep
Whether it is a bed in jail,
residential therapeutic center or the psych ward Buster needs his sleep. In order to get sleep he has been highly dependent
on nightly Clozapine since 2007 or more than fifteen years. Interruptions or inadequate doses of
Clozapine have been associated with going into the hospital.
Aside – PAD Motivation
On one occasion Buster sought out
seclusion on his own because he was having a panic attack. While in the hospital Buster has been
restrained a few times. Someone in one
of the information session indicated the PADs are a means to: “Have your voice
heard”. This is one our motivations to
release Buster’s PAD to a fairly broad public.
Minded Medication - Brief
Buster practices something we
call Minded Medication. In general
minded medication is designed to sustain the flow of Clozapine and other lesser
medications. It prevents the
accumulation of containers and medications not prescribed anymore. Have you ever heard the following message
associated with an appointment: “Please bring all of your medicines with you go
over with your doctor?” The only time
Buster brings a medication to the doctor is for his every 4 months medication
management appointment with his Behavioral Health Doctor (BHD). Buster’s Ativan is prescribed as needed (PRN). In a given month he doesn’t use all of his
Ativan. During the monthly minded
medication turn-over he flushes the remaining Ativan. Every fourth month he brings the un-used
Ativan to his BHD to turn it in. His BHD
has yet to take the extra Ativan from Buster for appropriate disposal. If Buster were to go in the hospital it may
be helpful to bring his containers with some meds in each with him. Buster has experience some discontinuity with
his meds upon release from the hospital.
Therefore, Buster prefers to leave some emergency meds with someone he
trusts such as the landlord.
A few photos
Considering this is our Psychiatric
Advance Directive (PAD) for Buster we tried to reserve photos for our other PAD
related studies such and our PAD mechanics report. Below is a photo Buster DBA Keith took while
living in a Rent a Shared Room (RASR) environment. Busters’ doctor past, Arnold P Deutsch MD,
called these mixes cocktails. The photo
shows Buster’s roommate Doug’s cocktail back around 2009. We count some odd ten (10) prescriptions. Doug has since died – Doug died too young.
Figure – Another of Dug K’s Prescription Cocktails
3.
Facility Preferences.
A. I agree to admission to the following
hospital(s):
We here at Mentalation Solutions Group (MSG) ask ourselves: Why suffer at a lower level of care? At some point a consumer such as Buster might receive high enough quality of care that one may become aware of standards for excellence for medication management and housing including beds. We here at MSG focus a good deal with “The Bed”. An example of increased awareness arrived when Buster stayed for a term in two GreatBeds at Westminster Therapeutic Residential Center (WTRC). After his 2007 release he place himself in a substandard Bed. An indicator of a substandard bed is when the consumer is short-order is right back in the hospital, has to move or chooses homelessness. Buster had to move because the facility closed. We here at MSG wants as a minimum for our Buster that crisis and changes are in order and if when needed that his new Bed is a humane one and will meet his unique needs. We here at MSG would really prefer Buster never need the psych ward again. It has been since 2012 or nine (9) years since he was last on the psych ward. We attribute this in part that Buster keeps sleep as a daily priority.
|
- |
|
|
|
|
Facility |
Note |
Detail |
|
|
- |
|
|
|
|
Western Med Anaheim |
Frequent Flyer |
Fast track releases that put Buster at greater risk Needed to agree to LPS in order to get treatment and
essential respite at WTRC |
|
|
College Hosp Cerritos |
Nightmare on Eden Street |
Released to LA county |
|
|
Royale |
First TRC Experience |
Good food Doesn’t know where he would have gone if dad had not had
him released |
|
|
Westminster Therapeutic Residential WTRC |
Standard of Excellence |
Policies and programs were rather good Inmates expected to sleep at night |
|
|
John Henry Foundation |
Hope for future |
Bed portfolio consideration Rimal Bera foundation Medical Director |
|
Preferences for
Emergency Treatment
|
Quite variable
|
Prefer to avoid
|
|
Hospitals
Psych Ward
|
Set Back
|
Not enough like real
life to prepare consumer for community living
|
|
|
SMH |
Reality Check |
Came close to referral to Napa State Mental Hospital
(1989) |
|
Jails
|
Set Back
|
Consumer getting monthly
check issue
Reduction in medications as prescribed by doctor on the
outside expected |
|
|
- |
|
|
|
Last Reviewed: 20210721-W:
As Related to Facilities
What will help? What will make things worse?
After all these hospitalizations
Buster believes he has worked out the basis about a successful
hospitalization. Plan in advance with
tools such as PADs and avoid going to the hospital in the first place. By making sleep a very high priority Buster
has not been to or in the hospital since 2012.
What makes things worse is quick release to a BadBed. Buster cannot live alone anymore. Permanent Supportive Housing (PSH) indicates
they can get consumers such as Buster into a home of their own. Due to too many episodes of panic, Buster is
dependent on the Rent a Shared Room (RASR) environment. If one of more of his roommates does not
sleep well and maintain 830pm – 830am quiet time this can acerbate Buster’s
anxiety. Dr. Ravinder P Singh (RPS-2006)
was very helpful when she tried the Clozapine Experiment with Buster. RPS got the medicine side down well yet did
not pursue the long term housing problems that Buster faced/faces. She sent him to Westminster Therapeutic
Residential Center (WTRC) and that was very almost unrealistically
helpful. WTRC staff listened better to
Buster than RPS.
B. I do not agree to admission to the following hospital(s):
At one time Buster was released
to LA County. The facility Eden Manor
was dog-eat-dog with: Drinking, drugs, prostitution, fist fights, etc. At and near Eden Manor Buster was way out of
his league away from family and his Most Significant Other Ever. We call environments such as these
“Traps”. At Eden Manor, Buster was
definitely out of his comfort zone or CZ.
Buster appealed to his family and they helped relocate him to Orange
County his County of origin. Even though
in this incidence his “911” call came from “The OC” he was transported to
College Hospital Cerritos. The placement
people never asked him his housing preferences.
They failed to help him with their uneducated placement to South
Gate. Another time he was transported to
South Laguna. After they treated him
they released him to the streets. Currently,
as Buster’s Orange County Connectedness decreases he entertains other hospital
options yet it is probably best to stay with hospitals in central Orange
County. Buster’s insurer Brand Day is in
Garden Grove.
FYI – In short – Objective
EDEN MANOR - CLOSED - 8921 California
Ave, South Gate, CA
https://m.yelp.com/biz/eden-manor-south-gate
Assisted Living Facilities
1 review of Eden Manor – “This
place is horrible! I have lived near Eden Manor for over a decade and it is…”
C. Other information about hospitalization:
Take first hospitalization in an
episode seriously
Buster needs: Rest and assurance
when he surrenders that he can be humanely taken care of. Buster has been released to some nightmarish
situations. Actually in 2012 the first
hospitalization was to South Laguna. He
was released to the streets. We here at
Mentalation Solutions Group have the impression that if the first
hospitalization were managed better he very likely would not have ended up in
Orange County Jail. He went from and
GoodBed in the hospital to a BadBed in the community, to a worse bed in Orange
County Jail.
4. Emergency Contacts in case of mental health crisis:
Guarded Disclosure – Version to Disclose
Due to the evolving nature of
emergency contact information we suggest that the consumer carry their contact
including emergency contact information on a wallet card. We left out personal contact information
because we don’t want to rile up Buster’s family. The professional contacts are current as of
July 21, 2021 (W). This part of the PAD
could be very dynamic over time thus needs to be considered differently. Buster has had more than 10 Behavioral Health
Doctors (Psychiatrists). He graduated
from his last one Bum Soo Lee MD because BSL retired. One of the reasons he picked Rimal B Bera MD
was doctor’s age parity. Both RBB and
CDM (PCP) at the present time are co-located.
Amendments
This is a good place to discuss
amending the Psychiatric Advance Directives (PADs). For the typical consumer we project 3 PADs in
order to get things right. The first two
can be amended by whatever means works.
Yet, the third or mature and notarized PAD that will be digitized and
kept in digital cloud (silo) format is best amended by appending.
Personal Contacts
Name: LAK: Address: Home Phone #: Work Phone #
Relationship to Me: (Oldest
sister and primary family helper)
Name: EAK: Address: Home Phone #:
Work Phone #
Relationship to Me: (Nephew and
successor family helper)
Professional Contacts
Psychiatrist: Rimal B Bera MD > Work Phone # 714-741-0116
For coordination purposes
Primary Care Physician: Chester D
Mojica MD > Work Phone # 714-643-7176
Case Manager/Therapist: Howard
Trazo > Work Phone # 714-741-0116
[CONSIDER - Stayed]
Insert image of BND Card
For the version we plan to submit
to the proposed OCHCA PAD data silo we would include a scan of our insurer
Brand New Day’s card. Yet it is very
likely we will not share Buster’s Medicare or Medi-Cal information.
5. Crisis Precipitants.
The following may cause me to experience a Mental Health Crisis (MHC):
Any of the items in the Crisis
Factor Summary (CFS) list below may cause a MHC crisis. There are additional factors we chose not to address
at this time. We prefer to use Behavioral
Health Crisis (BHC) rather than MHC. BHC
implies that there are corrective behaviors.
Crisis Factor Summary (CFS)
|
- |
|
|
|
Factor |
Note |
|
|
- |
|
|
|
Abandonment |
Alone and too far away from his resources |
|
|
Bed becomes un-sleepable due to outside forces |
Roommates that do not sleep well at night or do not sleep
at all Some using street drugs |
|
|
Going back to school |
From 1982-1988 school was protective for Buster. After 1989 first onset many of Buster’s
crises have been associated with school |
|
|
Lack of options to take time outs during the day in
peaceful environment |
Lack of Peace is an integral factor in Buster’s crises. Note: Currently things are better |
|
|
Lack of sleep due to unhealthy noise(s) in sleeping
environment |
This pushes Buster to his limit |
|
|
Medication problems |
At present OK |
|
|
Room becomes un-sleepable due to outside forces |
Roommate dynamics = You have a good roommate for a term
and next they become problematic |
|
|
Sleep difficulties due to host factors |
Of course Buster can do things that impair his sleep |
|
|
Troubles with Most Significant Other Ever |
At times it was exhausting working to satisfy her. Eventually she suffered ALZ symptoms and we
moved apart |
|
|
Work load too much |
At one point in his history Buster was on-call 24/7. It was too exhausting and generated
multiple crises |
|
|
- |
|
|
Last Reviewed: 20210721-W:
Crisis Intervention Management - Crisis Factors
Too traumatic and complicated to do it justice here
|
- |
|
|
|
Factor |
Note |
|
|
- |
|
|
|
Family conflict |
In hindsight Buster’s family have done the best that they
could in the face of complex circumstances |
|
|
Inappropriate medication |
Worst ever was Invega (2012) to replace Clozapine Directly associated with a hospitalization |
|
|
Neglect |
Buster has suffered much due to abusive behavior He tends to be overly vulnerable |
|
|
Unspecified panic associated with impulse |
Not even going here! Panic + Impulse may equal loss of life |
|
|
- |
|
|
Last Reviewed: 20210721-W:
6. Protective Factors. The following may help me avoid a mental health crisis:
Recurring Theme = Sleep is
Protective
|
- |
|
|
|
Protective Factor (PF) |
Note |
|
|
- |
|
|
|
1-Great sleep |
Recurrent theme |
|
|
2-This document PAD |
We see protection as one of the PAD promises |
|
|
|
|
|
|
Education College/University |
Cause and Effect double edged sword [SEPARATE] |
|
|
Education - MHSA |
Protective yet not Preventative |
|
|
Volunteerism |
Example association with the OCHCA 2009-2011 &
2013-2017 |
|
|
Empowering Rest |
Short 10 minute timeouts where you feel much better than
when you laid down |
|
|
Finances |
Having enough including subsidies for a new start Access to needed funds especially housing related |
|
|
Household matters |
Peaceful and harmonic that promotes health & healing |
|
|
If I am gone from my life |
See things to be done when I am away |
|
|
Limit Drama |
Too much drama is draining and stressful Minimizing drama about the house is protective |
|
|
Prevent Losing Rights |
Such as with LPS [SEPARATE] |
|
|
PEACE & Harmony |
The allusive Golden Goose Take them where you can find them |
|
|
Practical Matters |
Problem solving skills |
|
|
Prevent Catastrophic Losses |
[SEPARATE] |
|
|
Putting Protections in place |
Money, free up time, assemble a team, secure
transportation, link, etc. |
|
|
- |
|
|
Last Reviewed: 20210721-W:
Precipitation & Critical Control Points
Buster doesn’t deteriorate very
fast. At times from the initial
overburden that triggers a series of negative effects till hospitalization crisis
growth may take more than 1 year. One of
the negative effects and serious indicators for Buster is when Law Enforcement
and/or Crisis Personnel become involved.
Buster has never really been a problem for them. He goes away quietly. All Buster really wants is to be safe while
he sorts things out and sets things Right.
For Buster the most important Critical Control Points are centered about
his sleeping and anything that interferes with his sleep.
7. Response to Hospital. I usually respond to the hospital as follows:
|
- |
|
|
|
|
Domain |
Note |
Detail |
|
|
- |
|
|
|
|
Activation |
1/3 or more of the cohort at any given time |
More often than not Buster is activated when he get to the
psych ward [ASIDE OUR STROKE IDEA] |
|
|
Contraband |
Most of the standard list is still sound |
Smartphone should be permitted so the consumer call
coordinate treatment plan |
|
|
Covers |
Two versions |
Big one is not warm enough Small one is too small |
|
|
Dangerous roommates and people |
|
Most dangerous was at the Royale |
|
|
Eating |
Best Part |
Less wasted food when Buster is on the ward |
|
|
Escape |
Inappropriate Treatment |
Had to turn in a kid once because they offered 2
cigarettes as a reward |
|
|
Exercise |
Weak program if any |
Standard gym yoga intensity is better |
|
|
Hygiene |
Shower every other day |
Buster prefers hot baths Offered at Woodland Memorial |
|
|
Medications PRN |
Example is the sleeper |
You have to ask for it between 11pm and midnight |
|
|
Networking |
Hooking up after |
Only happened once (Robin) |
|
|
Phone |
Technology and Recovery |
Old school pay V new school smartphone separate |
|
|
Pillows |
Crunchy pillows |
On admit Buster is activated yet prefers to lay down
immediately First off he kills the crunchy pillow |
|
|
Privacy |
Give it up |
Will prepare you for the Rent A Shared Room (RASR) environment |
|
|
Release |
Huge problem |
After pampering they cannot find you a good bed (GoodBed)
> Then you revolve back again |
|
|
Smoking |
Second best part |
“SMOKE Break” |
|
|
Temperature |
A bit cool |
WMA - Buster spent about a day shutting down the majority
of the AC ducts |
|
|
Visitors |
When they bring you goodies |
Cigarettes and approved health food |
|
|
- |
|
|
|
Last Reviewed: 20210721-W:
8. Preferences for Staff Interactions.
a. Staff of the hospital or crisis unit can help me by doing the following:
For the most part psych ward
staff have been gracious to Buster. What
we ask for Buster is find him great bed (GreatBed), provide safely, medicate
immediately to stop the anxiety including panic, give him a snack, and bring
back smoking: “Smoke Break!”. We would
also like more time with the Behavioral Health Doctor that was linked with
him. When Buster’s PAD becomes effective
we would like “doctor” to take time discussing sections that apply.
b. Staff can minimize use of restraint and seclusion by doing the following:
History of restraint
Buster has been tied down or
cuffed to the bed a few times. First at
Yolo General Hospital (YGH) he was seeing other patients getting to have smoke
break and he didn’t get to have it. So in
short order he escaped to have himself a cigarette. It took about 8 hours and ten miles to catch
up to him. When returned to the psych
ward they 5-point restrained to one of the “scary” beds: “To teach him to
behave”. Almost immediately he had to go
pee. When he was in a Bakersfield hospital
for a physical health condition (broken neck) they tied him down because he
unplugged the IV machine twice. He
unplugged it because it was too noisy to get rest. He asked to be restrained in the ambulance
once because he feared the rear door flying open on the freeway and he wanted
the gurney to take the brunt of the collision.
While being serviced at Huntington Beach Hospital he had a panic attach
and made a break for the door. They told
him he could not leave. Hospital staff
used padded handcuffs restrained to the bed.
They would let him get up to go pee.
Buster has never been secluded by psych ward staff. On one occasion he asked to use the time out
room to help him with his panic.
9. I give permission for the following people to visit me in the hospital:
Only once was there a problematic visitor. This was Buster’s 1st cousin who showed up at College Hospital Cerritos to have Buster sign a Proxy. She wanted Buster to sign away his 25% voting rights for the family business. Hit a guy when he is down alright. This was only one an element in a huge family fiasco with consequences that still affect Buster’s family to this very day.
Inventory of Visitors
|
- |
|
|
|
|
Visitor |
Note |
Detail |
|
|
- |
|
|
|
|
Father |
First visitor ever and it meant a lot |
Passed |
|
|
MSOE – Joan |
When she came it made things feel better |
Succumbed to ALZ |
|
|
Candace |
Came with Joan |
She is out of geographic scope |
|
|
Joyce Maxine Brown |
Three visits |
Passed |
|
|
Warm and Fuzzy Person |
[SEPARATE] |
|
|
|
Family |
Kline picked up from Cerritos Joy visited Cerritos to have us sign a proxy |
Family Burnout |
|
|
Friends |
Never had a friend visit |
Do not expect friends visiting |
|
|
Current Landlord |
Has visited others |
Don’t expect much help |
|
|
Brand New Day Helper |
2012 Oswaldo Escalante |
Succeeded by Howard Trazo |
|
|
- |
|
|
|
Last Review: 20210720-TU:
History
To keep it short Buster would enjoy it if Buster’s Brand New Day helper
(Howard Trazo) and his Behavioral Health Doctor (BHD) Dr. Rimal B Bera to
visit. Buster has one sister living in
Orange County. It would be nice if she
and or her husband would visit if he were in the hospital.
10. The following are my preferences about ECT:
At some point Buster’s mom had lived experience during the 1940s and
1950s with associates that were treated for Behavioral Health issues with
Lobotomy and Electroconvulsive Therapy (ECT).
Apparently ECT has been in use since the 1930s. Buster’s mom was a bit traumatized with the
treatment outcomes she was witnessing. That
is why when Dr. Deutsch support pharmacologic intervention she bought into it. When Buster was in Woodland Memorial Hospital
circa 1990 he met Robin T. They spent
time together on the psych ward watching TV and holding hands. He was surprised to learn from her that she
checked herself in periodically for her routine ECT designed to relieve her major
depression. When he met Robin after the
hospital she could drive a car and intimately engage. It was Buster’s treatment that caused
interference with intimacy. By this time
Buster was off taken Haldol, the first drug, and he agreed to experimentation
with Navane. If Buster were to become so
anxious, suffering panic, with an elevated risk of becoming road kill like his
friend Mark then he might consider ECT.
This section will definitely be revised.
Some say that over-medication is a chemical lobotomy. Once while looking into ECT Buster found
interest in Transcranial magnetic stimulation (TMS) as an alternative to
ECT. He is still undecided with ECT.
ECT - Well Undecided
FYI “ECT works for many people
when drugs or psychotherapy are ineffective. There are typically fewer side
effects than with medications. ECT works quickly to relieve psychiatric
symptoms. Depression or mania may resolve after only one or two treatments.”
Additional Sections (Long term helper relationship)
MSGBase >
Brief Housing History
02_Housing_History_18012801_Table
CASAS LA SOS V2021
Housing
During one of the Psychiatric Advance
Directives (PAD) trainings and information sessions a consumer talked about her
nightmares associated with housing and how the underlying problem(s) need to be
solved. For her the presenting problem
was environmental problems that impaired her sleeping. She gave as her example: She lived on the
first floor and the people up-stairs walked around all night long. We liken it to when you get a crumby hotel
room where the floor above you is just too active to get a good night
sleep. The PAD is supposed to help with
improved and integrated care. We put
housing high on the list of integrative elements that needs solving. She also talked about not feeling safe in her
home due to many unwanted outsiders coming into her apartment. For this we really do not have a good analogy
yet we feel for her.
Employment & Education
The Psychiatric Advance
Directives (PADs) can be associated with mitigating adverse impacts of a
psychiatric hospitalization. Buster has
fallen and gotten back up several times as measured by: Employment,
volunteering, income and education. Back
around 2009 Buster links up with the OCHCA as a consumer on track for employment. Yet, he knew his personal needs and need in
the community were not quite met. To
meet his needs Buster returned to college fall semester 2011 and came out with
a semester of 4.0. Ironically, in
college one of his courses was Crisis Intervention Management (HHS-CIM). Then 2012 the year of catastrophic losses hit. Since the time Buster has decided to do the
best with what he has. Buster is
satisfied that he earned his BS degree, MS degree, made grades in Vet School,
has an Orange County multi-campus GPA of 4.0 and finished the MHSA WET funded
Consumer Training Program. With
graduation from his county volunteer role around 2015 his county supervisor was
hooking him up with either Quality Assurance or Operations. We know that if Buster were to pursue more
work such as report writing with insider information about the OCHCA he would
require unreasonable accommodations.
Trauma Triggers
The form asks about trauma, yet,
we are not positioned at this time to discuss how trauma plays into Buster’s
Behavioral Health. We do know the Buster
very likely suffers Post Traumatic Stress Disorder (PTSD) and that he has made
substantial progress on moving forward and passed trauma in his life.
FYI > TRCBase >
SCR_Trauma_11120503_PTSD_Assess V2021
Safety Plan
Safety might be defined as “the
condition of being protected from or unlikely to cause danger, risk, or injury”. The most injurious conditions that Buster has
suffered with respect to a hospitalization are more often than not: Being
placed in a harmful bed and being experimented with an ineffective medication. Losses due to medication may often exceed the
gains. Buster has only been roughed
enough to leave marks in the hospital by staff once. That is another story.
Champion of Protection including Safety
Years ago now (2017) while Buster
was taking a health respite in Fallbrook/Temecula Buster heard Judge Judy on
the Television say: “I protect those that cannot protect themselves”. Buster tries his best yet quite often he
cannot protect himself. In other words
he has been injured (Tort) by other meanie people. As Buster’s signs and symptoms of anxiety
exceeds his skills to cope with them he becomes more susceptible for harm by
others.
FYI - Tort
“A tort, in common law
jurisdiction, is a civil wrong that causes a claimant to suffer loss or harm,
resulting in legal liability for the person who commits the tortious act. It
can include intentional infliction of emotional distress, negligence, financial
losses, injuries, invasion of privacy, and many other things.”
Brief Including Torts
|
- |
|
|
|
|
Harm Factor |
Episode |
In Hospital |
|
|
- |
|
|
|
|
Dangers |
In past Buster’s greatest danger was blunt force trauma
and abandonment |
Being release before he is ready |
|
|
Risks |
If he asks for help and it is not enough the chance that
Buster will take a risk are greater |
They have placed him in unhealthy beds for which they have
no bed quality study information |
|
|
Injuries (Tort) |
In 2012 he had his nose broken twice and was punched in
the jaw |
While in the hospital one time staff roughed him up a bit This left some bruising |
|
|
- |
|
|
|
Last Review: 20210721-W:
Starting to struggle – Recurrent Theme - Moving
At what point does a struggle
begin?
FYI - Struggle is might be defined
as: “To do something with difficulty”. Another
definition for struggle is: “to try very hard to do, achieve, or deal with
something that is difficult or that causes problems”. Moving to a new bed has been wrought with
difficulty for Buster. He has a history while
moving of exhausting himself before he asks for help. At times the help he is given can make things
worse. Here, we focus on the Rent A
Shared Room (RASR) environment. Sometimes
moving from one bed to another is easier than others. It is often more simple for peoples with few
needs and little property or belongings to move. People with learned helplessness do not have
many housing demands.
History of Difficult Times –
1982-2006
Beginning as a Transitional Aged
Youth (TAY Age 23)
|
- |
|
|
|
|
|
Difficulty |
Note |
Detail |
Level |
|
|
- |
|
|
|
|
|
UC Davis Undergraduate |
Work before sleep strategy |
Incurred huge sleep debt = risk factor |
|
|
|
Vaccine Associated Adverse Event (VAE) |
1988 2 in 110 |
Impaired rest and sleep |
Crisis |
|
|
Move to new apartment |
1989 Belongings randomized |
Sorting things out overwhelmed me |
First Hospitalization |
|
|
Period of Resilience (POR*) |
1989 |
Separate |
|
|
|
Resume getting too little sleep |
1989 Fall |
Veterinary Student @ UCD |
1990 Hospitalized |
|
|
[RECORD GAP] |
|
|
|
|
|
Parents Dying |
1998 & 1999 |
Lost resources and supports |
|
|
|
Family conflict |
2003-present |
Frustrating |
|
|
|
SUD - ETOH |
2002 & 2012 |
[LEFT OUT – TOO MUCH FOR NOW] |
Crises |
|
|
Dr. starts Clozapine experiment |
2006 |
After working out the bug Clozapine is highly effective |
|
|
|
Series of terrible beds |
Separate |
Marked by roommates unable to sleep and or rest |
|
|
|
- |
|
|
|
|
Last Review: 20210721-W:
History of Difficult Times –
2007-2021
Beginning as a Transitional Aged
Youth (TAY Age 23)
RASR = Rent a Shared Room
|
- |
|
|
|
|
|
Difficulty |
Note |
Detail |
Level |
|
|
- |
|
|
|
|
|
1st Adjustment to RASR environment |
2007 |
Surrender many of the features that make life satisfying |
|
|
|
Two roommates that caused chronic fatigue |
2008-2011 |
|
Crises |
|
|
Vulnerability (**) |
Most of the time |
Buster has and is vulnerable to harm by others |
|
|
|
Catastrophic Losses of 2012 |
2012 separate |
[CLs2012*] Separate |
Hospitalized |
|
|
No Clozapine |
2012 |
Dr. takes away Clozapine to experiment with Invega |
Hospitalized |
|
|
Roommates not sleeping at night |
2014-2021 |
Separate |
Crises |
|
|
OCHCA Socials deemed un-necessary |
2020 |
Degree of social poverty |
|
|
|
Adjusting to a new RASR |
2021 |
July 2021 seems promising |
Potential Solution |
|
|
Stakeholders do not understand our housing product(s) |
2021 |
Frustrating |
|
|
|
- |
|
|
|
|
Last Review: 20210721-W:
FAQ - How has the last week been difficult?
July 11, 2021 – July 17, 2021
For the first time in quite a
while Buster can honestly say for one week nothing impaired his sleep. With ten (10) being perfect sleep, Buster has
Sleep Value Scores (SVSs) of 9.8 or greater on a scale of 0-10 for the whole
week. Buster recently switched rooms in
the same Rent a Shared Room (RASR) establishment. A Bed incumbent died on June 27, 2021
(SUN). So far his new bed seems to be a
BetterBed. What could quickly change
things is: Three consecutive nights of impaired sleep caused by either outside
forces or an interruption in his medication Clozapine.
11. Other Instructions.
a. If I am hospitalized, I want the following to be taken care of at my home:
Housing Needs
Interventions to prevent
homelessness
Loss mitigation efforts
Move away from bed of origin
Move to bed in same house
Pay rent on office
Remaining in same bed
Responding to Lose(s)
Assuming the hospitalization period(s) are lengthy exceeding one month and we are retaining the housing we have the following needs taking care of:
Avoid paying for two or more beds
Bills Paid
Food eaten
Moving Property
Oversee person(s) still back a
home
Solving legal such as
un-impounded the car
Parking the Car
Pet(s) Cared For
Rent Paid
Responding to notifications PRN
History
For Buster, ever since the
inception of severe Behavioral Health issues back in 1989 he has been in the
hospital several times. His best release
was back in 1989 when his parents took him in.
He took his medication as prescribed, received great nutrition, landed a
full-time job at a clinical diagnostic laboratory, and got plenty of
sleep. Within a year he bounced back resilient
enough for his doctor to approve his return to UC Davis School of Veterinary
Medicine. All of his other releases were
less remarkable and most always involved him being placed in unrestful
environment.
Supporter & Designate agents
For quite some time now Buster’s
designated agent has been his oldest sister LAK. Very slowly LAK, Buster, and EAK are working
on succession. We hope EAK to assume the
formal role as Buster’s designated agent in the near future. It would be a promising practice if EAK would
review Buster’s PAD with him. Everyone
in Buster’s immediate family has supported Buster in one way or another. Yet, for the most part we are working around
what we call Family Burnout. Buster’s
siblings are all in their sixties and seventies. Again, Buster has been working on a successor
to his siblings to help him out as needed (PRN).
Hospital Preferences
We went through and gave Quick
Stars Scores (Q*S) to all of the hospitals and institution caring for Buster’s
Behavioral Health needs. We found that
in Buster’s case it is not so much the hospital that matters rather the
treating physician and where they release you to. Just because one stay in a given hospital
went well as measured by housing stability and time out of the hospital doesn’t
mean the next stay will be equal or better.
Continuity of Care (COC)
Most consumers don’t know early
on in their treatment about continuity of care (COC) issues. The client usual presents in the hospital
setting. There the new consumer hooks up
with their first Behavioral Health Doctor (BHD). While in the hospital some consumer work hard
establishing rapport with their first BHD.
Then they are released and get referred or find a BHD on the
outside. In a chain of events from
doctor to doctor crazy things often occur.
The only doctor that took a super good history such as the one included
in this report for Buster was Kaiser’s Aliso Viejo Dr. David Dobos. In 2012 Buster was matched as an in-patient
with Dr. Bum Soo Lee MD (BSL). On
release and pulling a few strings Buster was matched with BSL on the outside. They enjoyed a productive partnership until
BSL Retired. This BHD centered transition
is a good example of COC.
Big Picture Dilemma
Once again this Psychiatric Advance
Directive (PAD) assignment was encouraged by the Orange County Health Care
Agency (OCHCA). Buster has attended
several Zoom presentations on selling their Mental Health Services Act (MHSA)
funded PAD initiative. During the
presentations, various consumers and providers have spoken up. They the informers hope their PADs will help
consumers get individualized, appropriate and needed: Treatment as measured by
better outcomes. About the OCHCA’s PAD
notion they ask many including community members and stakeholders to
advocate. This document is part of
Buster’s call to advocate. It looks very
likely that we will meet the deadline that Buster has set for us: Draft and publish
his PAD (Beta) by the end of July 2021.
PAD’s are both medical records and legal documents. We hope to address stigma about Behavioral
Health vis-à-vis transparently by sharing Buster’s PAD and PAD related via one
of our Blogs to the general public. We
will most likely present on PADs for Buster’s clubhouse (Wellness Center West)
and eventually at his program Brand New Day.
Comments – Reference Documents
The majority of our comments and
suggestions we will share with our Psychiatric Advance Directive (PAD) content
and mechanics reports. The following
four areas about PADs we found compelling: Comparing a PAD to the Advance
Health Care Directive (AHCD), PAD utilization, and training dedicated PAD
Specialists and the part of PADs with the Coordination of Care (COC). At its’ very core a PAD is a coordination
tool. In our preliminary (since April 1,
2021) sharing phase most of the people to which we talk think we are talking
about AHCDs. A bit of extra effort is
needed to help stakeholders and potential stakeholder differentiate PADs from
AHCDs. We found that in practice PADs
are far more complex than AHCDs. In
addition, many providers prefer that a consumer only submit one AHCD. This usually occurs somewhere around
intake. Also it will be wise to address
how Wellness Recovery Action Plans (WRAPs) and Personal Health Records (PHRs)
fit in the bigger picture of PADs. We feel that it will take the average
consumer via an iterative approach three attempts on the way to generating the
best PAD possible: Pre-educated PAD,
educated PAD and high performance PAD.
Summary
Just this year
(2021) we here at Mentalation Solutions Group (MSG) became aware of Psychiatric
Advance Directives (PADs) in their current incarnation with the Orange County
Health Care Agency (OCHCA). The county
hopes to fund its’ PAD initiative using Mental Health Services Act (MHSA)
Innovations Component monies. After a
few PAD information sessions we here at MSG decided to take the time to deliver
a Beta-PAD about our principal Keith “Buster” Torkelson MS. We have followed through with quite a bit of
work. We hope that what we share here
can save others time and money. It looks
like it may take some time before PADs in Orange County become streamlined, routine
and available from silos. Thank you for
your time and consideration (MSG-Avey).
The remainder of the report is Commercial-of-the-shelf (COTs)
Legalese. For the most part we have
retained the legalese in its’ original format.
Legalese = the formal and technical language of legal documents that is
often hard to understand.
b. I understand that the information in this document may be shared by my mental health treatment provider with any other mental health treatment provider who may serve me when necessary to provide treatment in accordance with this advance instruction. Other instructions about sharing of information are as follows:
12. Legal documentation for
Advance Directives:
Note: Considering our local PAD stakeholders
have yet to release their choices for valid PAD formats our PAD here is for
instructional purposes only.
a. Signature of Principal
By signing here, I indicate that
I am mentally alert and competent, fully informed as to the contents of this
document, and understand the full impact of having made this advance
instruction for mental health treatment.
Date:
April 9, 2021 (F) – Digital Signature
Nature of Witnesses
I hereby state that the principal
is personally known to me, that the principal signed or acknowledged the
principal’s signature on this advance instruction for mental health treatment
in my presence, that the principal appears to be of sound mind and not under
duress, fraud, or undue influence, and that I am not:
- The attending physician or mental health service
provider or an employee of the physician or mental health treatment
provider;
- An owner, operator, or employee of an owner or
operator of a health care facility in which the principal is a patient or
resident; or
- Related within the third degree to the principal or to
the principal’s spouse.
[Continued Legalese]
b. Affirmation of
Witnesses
We affirm that
the principal is personally known to us, that the principal signed or
acknowledged the principal’s signature on this advance instruction for mental
health treatment in our presence, that the principal appears to be of sound
mind and not under duress, fraud, or undue influence, and that neither of us
is: A person appointed as an attorney-in-fact by this document; The principal’s
attending physician or mental health service provider or a relative of the
physician or provider; The owner, operator, or relative of an owner or operator
of a facility in which the principal is a patient or resident; or A person
related to the principal by blood, marriage, or adoption.
Witnessed by:
Witness: ____________________________________
Date: _______________
Witness: ____________________________________
Date: _______________
From - STATE OF
NORTH CAROLINA, COUNTY OF ORANGE
Modified for:
STATE OF CALIFORNIA, COUNTY OF ORANGE
Not Valid for:
STATE OF CALIFORNIA
[Continued Legalese]
c. Certification of Notary Public
[STATE OF
CALIFORNIA, COUNTY OF ORANGE]
I,
________________________, a Notary Public for the County cited above in the
State of North Carolina [CALIFORNIA], hereby certify that
______________________________ appeared before me and swore or affirmed to me
and to the witnesses in my presence that this instrument is an advance
instruction for mental health treatment, and that he/she willingly and
voluntarily made and executed it as his/her free act and deed for the purposes
expressed in it.
I further
certify that __________________________ and ___________________________ ,
witnesses,
appeared before me and swore or affirmed that they witnessed
_____________________________ sign the attached advance instruction for mental
health treatment, believing him/her to be of sound mind; and also swore that at
the time they witnessed the signing they were not (i) the attending physician
or mental health treatment provider or an employee of the physician or mental
health treatment provider and (ii) they were not an owner, operator, or
employee of an owner or operator of a health care facility in which the
principal is a patient or resident, and (iii) they were not related within the
third degree to the principal or to the principal's spouse. I further certify
that I am satisfied as to the genuineness and due execution of the instrument.
This is the
____________ day of _________________, 20___.
Notary Public
My Commission
expires:
[Continued
Legalese]
d. Statutory
Notices
Notice to Person
Making an Instruction For Mental Health Treatment. This is an important legal document. It
creates an instruction for mental health treatment. Before signing this
document you should know these important facts: This document allows you to
make decisions in advance about certain types of mental health treatment. The
instructions you include in this declaration will be followed if a physician or
eligible psychologist determines that you are incapable of making and
communicating treatment decisions. Otherwise you will be considered capable to
give or withhold consent for the treatments. Your instructions may be
overridden if you are being held in accordance with civil commitment law.
Power of
Attorney
Under the Health
Care Power of Attorney you may also appoint a person as your health care agent
to make treatment decisions for you if you become incapable. You have the right
to revoke this document at any time you have not been determined to be
incapable.
YOU MAY NOT
REVOKE THIS ADVANCE INSTRUCTION WHEN YOU ARE FOUND INCAPABLE BY A PHYSICIAN OR
OTHER AUTHORIZED MENTAL HEALTH TREATMENT PROVIDER.
Revocation &
Notary Public
A revocation is
effective when it is communicated to your attending physician or other
provider. The physician or other provider shall note the revocation in your
medical record. To be valid, this advance instruction must be signed by two
qualified witnesses, personally known to you, who are present when you sign or
acknowledge your signature. It must also be acknowledged before a notary
public.
[Continued Legalese]
“Incapable”
Notice to
Physician or Other Mental Health Treatment Provider. Under North Carolina law, a person may use
this advance instruction to provide consent for future mental health treatment
if the person later becomes incapable of making those decisions. Under the
Health Care Power of Attorney the person may also appoint a health care agent
to make mental health treatment decisions for the person when incapable. A person
is "incapable" when in the opinion of a physician or eligible
psychologist the person currently lacks sufficient understanding or capacity to
make and communicate mental health treatment decisions.
Medical Record
This document
becomes effective upon its proper execution and remains valid unless revoked.
Upon being presented with this advance instruction, the physician or other
provider must make it a part of the person's medical record. The attending
physician or other mental health treatment provider must act in accordance with
the statements expressed in the advance instruction when the person is
determined to be incapable, unless compliance is not consistent with G.S.
122C-74(g). The physician or other mental health treatment provider shall
promptly notify the principal and, if applicable, the health care agent, and
document noncompliance with any part of an advance instruction in the
principal's medical record.
Authority
The physician or
other mental health treatment provider may rely upon the authority of a signed,
witnessed, dated, and notarized advance instruction, as provided in G.S.
122C-75. (1997-442, s. 2; 1998-198, s. 2; 1998-217, s. 53(a)(5).)
Promotions at the End
-
