Stage 11: Continuity & Care Coordination
Concept 7 of 8
E11.7

Crisis Plans & Advance Directives

Patients who have been through crisis can plan for the next one. Psychiatric advance directives and crisis plans operationalize the foresight.

Encounter card
Setting
During stable periods with patients who have a history of psychiatric crisis — particularly bipolar, psychotic disorders, suicidality.
Opening move
Invite the patient to plan during stability for the next crisis. What did they learn? What worked? What didn't? Whom do they want involved? What medications? Where do they want care?
Sample language
  • "You've been through this before. What did you learn — what worked, what didn't?"
  • "I'd like to write down a plan for the next crisis, while you're thinking clearly."
  • "Some patients write psychiatric advance directives. Have you heard of those? Want to talk about it?"
Listen for
Patient's insight into their patterns. Preferences during crisis (specific medications, providers, settings). What family/supports should know.
Common pitfalls
Skipping this during stable periods. Failing to revisit after each crisis. Not respecting the directive when the moment comes.

Red flags / escalate: Patient refuses to plan because "it won't happen again" — common but concerning, often before the next episode.

Documentation
Crisis plan in chart, accessible to ED, on-call providers. Psychiatric advance directive if filed.

Real-world reality: Crisis planning and advance directive work is unbilled time in most fee-for-service settings but produces substantial safety value. Some integrated systems support this work explicitly.

The patient's well version is the best resource for their unwell version. Capture the wisdom during stability.

Warm grey-tinted clinical notebook page, soft mauve accent. Crisis planning during well periods — the patient's well self speaking to their unwell self. Margin clusters on the framework.

Crisis plans and psychiatric advance directives are the structured documents that capture, during stable periods, what the patient wants to happen during future crises. The patient's well-version is the best resource for their unwell version; planning ahead while clear-headed produces better outcomes than improvising during a crisis.

Crisis plans are informal documents collaboratively built between clinician and patient during stable periods. Specific to the patient: early warning signs they recognize in themselves, what has worked for them before, who they want involved, what medications they want to try first, what they want to avoid, what setting they prefer for care during crisis, who can speak for them when they can't speak for themselves. The plan is for the patient's next crisis; the work happens now.

Psychiatric advance directives (PADs) are formal legal documents that may carry weight during involuntary care decisions, depending on jurisdiction. The patient specifies in advance what treatment they want or don't want during periods of incapacity. PADs are particularly valuable for patients with recurrent severe mental illness — bipolar I, schizophrenia, severe recurrent depression with suicidality — where the future crisis is likely and the patient has clear preferences.

Build during stable periods. The bipolar patient who has been well for 2 years is the right candidate to build a crisis plan about their next episode. "Let's use this stable time to plan for the next episode — even though we hope there isn't one. What did you learn from prior episodes?" Patient often has substantial insight when well that's not accessible when unwell.

Honor the plan in the next crisis. When the patient becomes manic and refuses lithium, the prior crisis plan that says "I want lithium even if I refuse during episodes" matters. Both ethically and sometimes legally, the well-version's preferences carry weight against the unwell-version's refusals. Document the prior plan in the chart so it's accessible during the crisis.

Update after each crisis. What was learned? What worked? What didn't? Revise the plan based on the latest episode while it's fresh. The plan evolves over years and episodes.

Share the plan with family, with the receiving clinicians, sometimes with crisis services. The plan in the chart that no one accesses during the crisis doesn't help; the plan that's accessible to the people involved in the next crisis does.

Psychiatric advance directives — formal documents specifying treatment preferences during incapacity. State-specific. Margin notes on the legal frame.
The anchor

The patient's well-version is the best resource for their unwell version. Plan crises during stability — preferences, medications, supports, providers.

Honoring the plan in the next crisis — when the patient is unwell, the well-version document carries weight. Margin clusters on the practice.
Prove it

A patient with bipolar I and three prior manic hospitalizations is now stable for 2 years. What planning work do you do during this stability?

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