The Ulysses Contract: Why Your Advance Directive Isn't Enough for a Mental Health Crisis
tl;dr: The Declaration for Mental Health Treatment (DMHT)
When we build estate plans, clients usually think about worst-case physical scenarios -- car accidents, strokes, or terminal illnesses. But what happens if the crisis is psychiatric?
Your standard Oregon Advance Directive is great for general medical and end-of-life care, but it is generally blind to mental health crises. To cover that gap, Oregon law uses a highly specialized, standalone document called the Declaration for Mental Health Treatment (DMHT).
Think of the DMHT as a "Ulysses contract." Its primary purpose is to allow a client with a known psychiatric condition to lock in their treatment preferences while they are completely lucid. By doing this, they expressly prevent their future, incapacitated self from refusing necessary treatment or consenting to unwanted treatment during an acute mental health episode.
What Exactly Does a DMHT Cover?
Under ORS 127.700, the DMHT is strictly limited to four specific categories of psychiatric care. It does not cover general medical care, surgical procedures, or end-of-life decisions. Through a DMHT, you can explicitly consent to or refuse:
Psychoactive Medication: You can list specific medications you consent to, medications you absolutely refuse (e.g., due to severe side effects you've experienced in the past), and your preferred dosages.
Electroconvulsive Treatment (ECT): You can explicitly give or withhold consent for this treatment.
Admission to a Treatment Facility: You can consent to voluntary admission and retention in a health care facility specifically for mental health treatment for up to 17 days.
Outpatient Services: You can consent to or refuse specific outpatient mental health treatments and programs to stabilize a crisis without full hospitalization.
The Rulebook: DMHT vs. Standard Advance Directive
For an estate plan to actually work in Oregon, you have to treat the DMHT as a completely separate tool with its own distinct rules. Here is how it differs from your standard Advance Directive:
| Feature | Standard Advance Directive | Declaration for Mental Health (DMHT) |
|---|---|---|
| Duration of Validity | Valid indefinitely until revoked. | Expires automatically after 3 years. (Note: If you are incapacitated at the 3-year mark, it remains valid until you regain capacity). |
| Revocation Rules | Can be revoked at any time, even if your capacity is questionable in the moment. | Can ONLY be revoked when you have capacity. If you are actively in a psychiatric crisis, your protests or attempts to revoke the document are legally void. |
| Proxy Override | A health care representative generally has broad latitude to make decisions. | A representative appointed under a DMHT cannot override your written instructions regarding meds, ECT, facility admission, or outpatient services. |
The Execution Rules: Making it Legally Binding
Because the DMHT deals with a highly vulnerable client population, Oregon has strict rules on how the document must be signed to prevent coercion or fraud. Under the recently updated ORS 127.707, your DMHT is only effective if you sign it, and it is either notarized by a notary public or signed by two competent adult witnesses. If you choose to use witnesses instead of a notary, each witness must attest that you are known to them, that you signed the document in their presence, and that you appeared to be of sound mind and not under duress or fraud.
Who Cannot Be a Witness:
If you go the witness route, Oregon law strictly disqualifies certain people from signing your DMHT. To be valid, your witnesses cannot be:
Your attending physician, mental health service provider, or any of their relatives.
An owner, operator, or relative of an owner/operator of a health care facility where you are currently a patient or resident.
A person related to you by blood, marriage, or adoption.
The person you are appointing as your attorney-in-fact (your representative) in the document.
The Strategic Advantage: Protecting Your Agency
We typically build a DMHT into the estate plans of clients who navigate conditions like bipolar disorder, schizophrenia, or severe clinical depression, where an episodic loss of capacity is a known risk.
By having both a standard Advance Directive (for general physical care) and a DMHT (for psychiatric care) in your legal toolkit, you ensure your agency is protected across all medical fronts. More importantly, it gives your medical providers the clear legal cover they need to administer life-saving psychiatric treatment during an acute episode, exactly the way you wanted it.
