Mental Health Advance Directive in Washington State

More Than End-of-Life Planning

When most people hear "advance directive," they think of end-of-life care — living wills, DNR orders, decisions about ventilators. Washington has those, governed by RCW 70.122. But the state also has a separate, less well-known tool: the Mental Health Advance Directive under RCW 71.32, designed specifically for psychiatric and behavioral health decisions.

For families navigating the turning-18 transition with a young adult who has mental health conditions, this directive fills a gap that neither a healthcare power of attorney nor a guardianship was built to address.

What RCW 71.32 Covers

A Mental Health Advance Directive allows any adult (including a newly turned-18 young adult) to document their preferences for psychiatric treatment in advance of a crisis. The directive can specify:

• Preferred and refused medications — naming specific psychiatric medications the person consents to or refuses, including dosage ranges
• Hospitalization preferences — which facilities the person prefers or refuses for inpatient psychiatric care
• Electroconvulsive therapy (ECT) — explicit consent or refusal
• Restraint and seclusion preferences — what interventions the person will accept during a behavioral crisis
• Preferred treatment providers — naming specific psychiatrists, therapists, or crisis teams
• An appointed agent — designating someone (typically a parent) to make psychiatric treatment decisions if the person becomes incapacitated

This last point is key. The Mental Health Advance Directive can function as a psychiatric-specific power of attorney, giving a designated agent authority over behavioral health decisions without touching medical, financial, or educational domains.

How It Differs from a Healthcare DPOA

A standard Durable Power of Attorney for Healthcare covers medical decisions broadly — surgery, medication, hospitalization, end-of-life care. It does not specifically address the unique dynamics of psychiatric treatment, where the individual may have strong preferences about medication side effects, involuntary commitment, or specific therapeutic approaches.

The Mental Health Advance Directive fills that gap with granular, treatment-specific instructions that clinicians and crisis responders can follow during a psychiatric emergency. It speaks the language of behavioral health — naming medications by class, specifying preferred de-escalation techniques, documenting which inpatient units have worked well in the past.

A young adult can have both documents: a healthcare DPOA for general medical decisions and a Mental Health Advance Directive for psychiatric care. They do not conflict; they complement each other.

Execution Requirements

To be valid under RCW 71.32, the directive must be:

• In writing, dated, and signed by the adult
• Signed with the signature acknowledged before a notary public, or witnessed by two adults who personally know the person. Witnesses cannot be the appointed agent, a provider directly involved in the person's care, an owner/operator/employee of a facility where the person is a patient or resident, anyone related to the person by blood, marriage, or adoption, or anyone who would benefit financially from the person undergoing mental health treatment
• The person must have capacity at the time of signing — the directive cannot be created during a period of incapacity. The document must also state whether the person wants to be able to revoke it during a future period of incapacity

This competency requirement creates a timing consideration for families. If the young adult has episodic mental health conditions with periods of clear functioning, the directive should be drafted and signed during a stable period. Waiting until a crisis hits is too late.

When the Directive Activates

The directive takes effect when two conditions are met: the situation requires a decision about psychiatric treatment, and the individual lacks capacity to make that decision at the moment. Two qualified professionals — one mental health professional plus one health care provider, or two health care providers — or a court must determine that the person is currently incapacitated before the directive's instructions or the appointed agent's authority kicks in.

Once the person regains capacity, the directive returns to standby mode. The individual resumes making their own psychiatric treatment decisions.

Revocation

The person who created the directive can revoke it at any time while they have capacity, by a written statement. During a period of incapacity, revocation is possible only if the person chose that option when signing the directive. This is a critical protection — the directive cannot be weaponized to override the person's current, competent wishes.

Why This Matters for Guardianship Planning

Many families pursue guardianship primarily because they fear losing the ability to intervene during a psychiatric crisis. If a young adult with bipolar disorder, schizophrenia, or severe anxiety has a documented Mental Health Advance Directive naming their parent as agent, the parent already has legal authority to make psychiatric treatment decisions during a crisis — without a court order.

This does not eliminate every reason a family might consider guardianship, but it removes one of the most common drivers. Combined with a healthcare DPOA and a Supported Decision-Making agreement, a Mental Health Advance Directive can cover the gap that pushes families toward court intervention.

Getting Started

The Washington Adult Guardianship & Alternatives Guide includes the Mental Health Advance Directive in its out-of-court toolkit, alongside DPOA templates and SDM agreement blueprints. For families whose primary concern is psychiatric treatment authority, this directive may be the most important document in the entire turning-18 planning process.

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