Advanced Directives & Mental Health Treatment Directives

A guide for Connected Care Community Health Workers supporting older adults in Oregon through end-of-life planning conversations.
45 min • CEU eligible (MACBO) • Rod Harwood, OABHI • Updated June 2026

About This Training

This training was developed by Rod Harwood, an Older Adult Behavioral Health Specialist and Coordinator with Oregon’s Older Adult Behavioral Health Initiative (OABHI). Rod brings over 30 years of experience as a hospital, hospice, and mental health chaplain, as well as expertise as a certified dementia educator and consultant through Positive Approach to Care.
The OABHI was established in 2015 in response to Oregon’s rapidly growing older adult population. Today, there are more adults over 65 than there are children under 18 in the United States — with 11,000 people turning 65 every single day. The initiative promotes collaboration and coordination of services for older adults and people with disabilities.
📋 Note for CHWs: Add CEU callout block here (see build guide Step 4 → Section 1)

Why Advanced Directives Matter

An advanced directive is a legal document that allows a person to express their wishes for end-of-life care and to designate someone they trust to make healthcare decisions on their behalf if they become unable to do so.

Key reasons to complete an advanced directive

  • It ensures healthcare wishes are honored — whether that means taking every possible action or allowing a natural death.
  • It removes the burden of heart-wrenching decisions from family members who may not know what their loved one would have wanted.
  • It prevents family conflict that can arise when wishes have never been discussed.
  • It reduces depression in surviving family members. Research shows depression rates are significantly lower six months after a loss when families have had the conversation ahead of time.
📋 Add here: Pull quote block (Dr. Gawande) → Video embed (ABC News) → CHW callout (see build guide)
As a CHW, frame the advanced directive as a gift to their loved ones — not a document about dying. This often lowers the emotional barrier to getting started. Older adults themselves often want to have this conversation; it is frequently the people around them who avoid it.

When Should Someone Have an Advanced Directive?

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People often assume advanced directives are only for the elderly or terminally ill. In reality, a medical crisis can happen at any age — a car accident, a sudden illness, an unexpected diagnosis. The advanced directive is a tool for any adult who wants their wishes to be known.

Common trigger points for the conversation

  • Turning 18 — for the first time, a person is legally responsible for their own healthcare decisions
  • A major trip or travel abroad
  • A new or serious medical diagnosis
  • A significant birthday (40, 50, 60, 70)
  • The illness or death of a family member or close friend
  • Marriage, divorce, or a change in family structure
As a CHW, you don’t need to wait for a crisis to raise the topic. Any of the moments above can serve as a natural, compassionate entry point.
📋 Add here: Reminder callout block — see build guide

How to Start the Conversation

One of the most common barriers to completing an advanced directive isn’t lack of interest — it’s not knowing how to bring it up.
Video preview
📋 Add here: Video embed (Rod — Football Game and Ice Cream — timestamped webinar URL)

Conversation starters to share with clients

  • “I need your help with something…”
  • “Can you and I have a conversation about…?”
  • “Remember what happened to [person we both knew]? I don’t want that for you.”
  • “Will you help me make plans for my future?”
  • “I’ve been answering some questions on the Oregon Advanced Directive about things that matter to me. I’d like to talk to you about it.”
Notice that asking for help — rather than announcing a serious topic — tends to lower the other person’s defenses. Most people are wired to want to help when someone they care about asks for it.

What Does a Healthcare Representative Do?

A healthcare representative (also called a healthcare proxy or agent) is the person named in an advanced directive to make medical decisions on someone’s behalf if they become unable to do so themselves.

Responsibilities

  • Knows and respects the person’s healthcare wishes — not just their name on a form, but through real conversations about values, limits, and preferences.
  • Communicates with healthcare providers if the person cannot speak for themselves — whether due to a coma, loss of consciousness, or advanced illness such as Alzheimer’s disease.
  • Acts as an advocate in medical settings, ensuring the person’s wishes are followed.

Important limits to know

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Clients should understand: you do not have to be terminally ill or near death for your healthcare representative to step in. What matters is your capacity to make decisions at that moment.
📋 Add here: Video embed (Rod — Healthcare Proxy Humor Clip — timestamped webinar URL)

Choosing the Right Healthcare Representative

Many people default to choosing the family member with a medical background, or the eldest child, or whoever lives closest. These may seem like logical choices — but they are not always the right ones.
📋 Add here: Pull quote block (Rod Harwood on logical vs. right choice)
📋 Add here: Video embed (How to Choose a Care Proxy — https://www.youtube.com/watch?v=OTFyfwWziPM)

Questions to help clients choose

  • Who do you trust to make decisions for you if you cannot speak for yourself?
  • Would this person be able to honor your wishes — even if they personally disagree with them?
  • Would this person know what medical treatments you do or don’t want?
  • Is this person able to be present and available during a medical crisis?
  • Would you want to place any limits on what this person can decide?

Thinking beyond family

For many older adults — particularly those who are isolated, rural, or estranged from family — the right representative may not be a blood relative at all. A close friend, neighbor, faith community member, or trusted colleague may be a much better fit.
“Strangers are family you have yet to get to know.” — Mitch Albom
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The Oregon Advanced Directive

The Oregon Advanced Directive is available as a free, fillable document online through the Oregon state website. It is available in multiple languages and can be completed digitally or printed and filled out by hand.

What the document covers

  • Whether to prolong life through medical intervention
  • Decisions related to living with dementia
  • Use of breathing machines and ventilators
  • Receiving food and water through a tube
  • Cardiopulmonary resuscitation (CPR)
  • Pain management preferences
  • Hospice care
  • Organ and tissue donation
Beyond these medical decisions, clients can also include personal wishes — who they want in the room, what music they want playing, or any other details that matter to them.

Steps to complete the document

  1. Review the Oregon Advanced Directive booklet and worksheet.
  1. Discuss your wishes with your chosen healthcare representative and important people in your life.
  1. Use the worksheet to clarify your values and preferences before completing the form.
  1. Complete the official Oregon Advanced Directive form.
  1. Sign the document with your healthcare representative and two witnesses present.
  1. Keep the original in a safe, accessible location. Give copies to your healthcare representative, key family members, and your primary care doctor.
📋 Add here: Online resource callout + bookmark link (Oregon AD form) — see build guide

Understanding DNR vs. Allow Natural Death

When working with clients and families around end-of-life decisions, the language we use matters enormously. Two terms you will encounter frequently are DNR and AND — and understanding the difference can change how a family responds in a critical moment.
📋 Add here: Two-column comparison table (DNR vs AND) — see build guide
📋 Add here: Video embed (Rod — CCU Family Story — timestamped webinar URL)
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When to Revisit an Advanced Directive — The 5 D’s

An advanced directive is not a one-time document. Life changes, and wishes can change with it. The 5 D’s (from Dr. Jodi Ready, Internal Medicine, Providence) are a helpful framework for knowing when to encourage a client to update theirs.
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Decade — It has been 10 or more years since the document was completed or last reviewed.
Death — A close friend, family member, or the named healthcare representative has died.
Divorce — A significant relationship has ended, including marriage or domestic partnership.
Disagreement — There has been a significant fracture in the relationship with the named healthcare representative or a close family member.
Diagnosis — A new or serious medical diagnosis has been received that may change end-of-life wishes.
As a general rule, encourage clients to review their advanced directive every two to three years — even if none of the 5 D’s apply.
📋 Reminder callout: An advanced directive can be changed or revoked at any time as long as the person retains decision-making capacity. There is no penalty for updating it.

Supporting Clients — The Care Partner Perspective

As community health workers, you are not just information providers — you are care partners. A caregiver gives. A care partner exchanges. The people you work with have things to offer you, too.
📋 Add here: Video embed (Rod — Father’s Prayer — timestamped webinar URL)
📋 Add here: Video embed (Rod — Talking to Father About Meaning — timestamped webinar URL)
After watching: think about clients you’ve worked with who expressed feeling like a burden, or who felt they no longer had anything to contribute. How might this reframe — that they can still give a profound gift — change the conversation you have with them?

The Oregon Declaration for Mental Health Treatment

In addition to the standard advanced directive, Oregon offers a separate legal document specifically for mental health care: the Oregon Declaration for Mental Health Treatment, sometimes referred to as a Psychiatric Advanced Directive (PAD).
This document is particularly relevant for clients who have a history of mental health crises, psychiatric hospitalizations, or diagnoses that may affect their decision-making capacity during acute episodes.
📋 Add here: Video embed (PAD Explainer — https://www.youtube.com/watch?v=0Sc2zdkQ5jI)

What the document covers

  • Which medications they consent to — and which they do not want — during a mental health crisis
  • Preferred hospitals or treatment facilities, and those they wish to avoid
  • Who should be contacted during a crisis
  • Who should care for their children or dependents
  • Who should care for their pets
  • Any other personal or health information relevant to their care

When is it used?

The declaration is only activated during a mental health crisis, when the person is unable to understand and make decisions about their own treatment. It cannot be used as long as the person retains decision-making capacity — even if they are struggling.

Key requirements

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For people living with serious mental illness, a psychiatric crisis can feel chaotic and disempowering. This declaration gives them a voice in their own care even when they cannot speak for themselves — a way of saying, “Even in my hardest moments, here is what I need.”
📋 Add here: How to access callout + OHA bookmark — see build guide

Before You Finish — A Personal Reflection

📋 Add here: Video embed (Lindsay Miller — Going Through This Ourselves — timestamped webinar URL)
📋 Add here: Pull quote blocks (Rod Harwood 27:46 + Lindsay Miller 1:00:42) — see build guide
📋 Add here: Reflection callout block with four questions — see build guide
📋 Add here: Homework callout block + Oregon AD bookmark — see build guide
These reflection prompts are for your own thinking — your responses are private. Bring anything that came up for you to your next supervision session.
📋 Add here: Completion callout block + PSU evaluation bookmark — see build guide