Massachusetts Project on End-of-life Care for Persons With Serious Mental Illness

Massachusetts Department of Mental Health : Do It Your Way : Outreach

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This site currently offers 3 outreach resources:
  • "REAPŠ" (Readiness to Engage in Advance care PlanningŠ) uses a common behavioral change methodology to assess where a person is in contemplating the preparation of an advance care plan.
  • "Do It Your Way" is a patient guidance brochure developed to reach as many clients as possible with information about Advance Care Planning. The brochure explains the processes involved in selecting a health care agent.
  • The "Do It Your Way" HealthCare Preferences Workbook (soon to come) documents the advance care choices, attitudes, and opinions of persons with serious mental illness.

On this page:
arrow Readiness to Engage in Advance Care Planning - "REAPŠ"
arrow Do It Your Way" - Consumer Brochure
arrow Mental Health Consumer Comments and Feedback
REAPŠ - Readiness to Engage in Advance Care Planning

Included on the right are downloads for the following:
  • Description of the "stages of change" transtheoretical model of Prochaska and Diclemente and its application to changing health related behavior such as smoking, exercise, and substance abuse.
  • Application of this approach to the advance care planning process and a "short form" question to determine if a person is in the precontemplatoin, contemplation, action or maintenance phase.
  • A detailed reference list regarding "stages of change" theory and practice.

  • REAPŠ - Readiness to Engage in Advance Care Toolset
    (Three downloads available)

    "Do It Your Way" - Consumer Brochure

    Cover Inside 1
    Inside 2 Inside 3 Back

    Main Topic Areas:
  • Making your own medical and psychiatric health care decisions
  • How a Health Care Proxy can help
  • How to choose someone to make or communicate your health care decisions if you can't

  • Brochure headings:
  • Let's start with rights
  • So how do I do it?
  • What is a Health Care Proxy?
  • Why do I need a Health Care Proxy now?
  • OK, so how do I get a Health Care Proxy?
  • How do I choose my Health Care Agent?
  • What should I talk about with my Health Care Agent?
  • What if I change my mind?
  • What is the best time to complete the Health Care Proxy form?

  • Workbook headings:

  • Introduction
    • Who should be your Health Care Agent?
    • Instructions for your Health Care Agent or Guardian
    • How to fill out the Preferences Workbook and forms?
    • What you need to do when you are finished
    • When you should Review and Update your documents
  • Making Choices
    • Topic 1: About Myself
    • Topic 2: My Views, My Feelings
    • Topic 3: Preferences about My Current Mental Health
    • Topic 4: Psychiatric Hospitalization
    • Topic 5: Preventing a Crisis Situation
    • Topic 6: Exercise
    • Topic 7: Emergency Situations while Hospitalized
    • Topic 8: My Medical Hospitalization Preferences
    • Topic 9: Coma or Terminal Illness
    • Topic 10: The Quality of My Life near the End of My Life
    • Topic 11: Pain Management
    • Topic 12: At the End of My Life
  • My Checklist

  • "Do It Your Way" - Consumer Brochure
    Please Note: These files are quite large due to the art work involved in the print version.
    arrow "Do It Your Way" Consumer Brochure - Side 1 (outside)
    - PDF format - (984 Kb)
    arrow "Do It Your Way" Consumer Brochure - Side 2 (inside)
    - PDF format - (2.25 Mb - Large File - Please allow time for download.)

    We encourage you to download these patient education tools and adapt them to your programs as needed.

    If you would like hard copies mailed to you, please contact:
    Kathleen Redfern
    [email protected]

    For more information about the brochure's development contact:
    Anna Rubley, LCSW, Brochure Development Project Director
    [email protected]

    To learn more about involving consumers in similar projects, contact Pam or Steve at the MA DMH Office of Ex Patient and Consumer Affairs:
    Pam Masson
    [email protected]
    Steve Holochuck
    [email protected]

    Mental Health Consumer Comments and Feedback

    Commentary from consumer members of the brochure advisory board:

    "Mary Ellen:
    We think that the brochure is very good. The formatting, color scheme, etc. is very, very attractive and user friendly. The color scheme and photo's are very upbeat and lively (which certainly help with what can be a rather somber subject.) We think that it is great that the cover and the first section that you open to are in large font and brief and unbusy - very user friendly. The rest of the brochure contains a lot of info but it is concise. It's a nice balance. There is clarity and thoroughness about the essentials.
    Congratulations on a nice piece of work. We are glad that the Office of Consumer Affairs's 800 number can be utilized in this process"
    Steve Holochuck and Pam Mason, Office of Consumer Affairs, MA Department of Mental Health.

    Some issues consumers raised as the Brochure was in development and discussed in focus groups:

    A 35 year old woman with serious mental illness responded:

    "Yes, I read the material. I think every one should have a health care proxy in case they had a car accident or something and might be in a coma for a long time. I know I wouldn't want to be hooked up to a machine for a long time."

    Another person's response (62 year old with serious mental illness, married for 37 years, mother of three):
    " Oh, I think that it is vital for me to have a health acre proxy since I am older and I have some health issues. Certainly there is no one in my family who would be able to be my agent. Could someone else be the Agent? I have a really good friend at my Quaker meetings whom I trust, but she's in her 80's, so I might want to get an alternate. One concern that I have is that if my health care proxy has to be executed, what would happen if someone in my family disagreed with my agent? What if my Agent's interpretation of my wishes is different from how I interpret my wishes? There is an awful lot to be considered in choosing a health care proxy. I am going to have to spend a lot of time thinking about this."

    Some consumer responses to the completed brochure:

    "I have bipolar disorder and allot of medical problems and TD (tardive dyskinesia). I think about the future and what might happen and when I was last in the hospital they talked to me about a proxy. But I did not want to do it . . . Looking at this makes it seem less scary. I think I will talk to my brother about being my guy, hey . . . thanks."

    "I like the pictures, they remind me of the outdoors and my friends. You know we die early. I wonder who I should talk to about this... I have a guardian, does that mean I cannot do this? It says here about being competent. Boy, what a bummer."

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    PEELC This information is provided by the Massachusetts Department of Mental Health. End-of-Life Care for Persons with Serious Mental Illness is a multi-faceted project supported by a grant from Promoting Excellence In End-of-Life Care, A National Program Office of the Robert Wood Johnson Foundation. Visit the main Web site at