Advance Decisions and Living Wills

An Advance Decision to Refuse Treatment allows you to refuse specific medical treatments in specific circumstances in advance. If valid and applicable, it must be followed by healthcare professionals — they cannot override it, even if they believe treatment would benefit you, unless the ADRT is not valid or not applicable to the current situation.

Examples of what an ADRT can cover include: refusing cardiopulmonary resuscitation (CPR); refusing artificial ventilation; refusing artificial nutrition and hydration (by tube or drip); refusing blood transfusions; or refusing specific medications or procedures.

An ADRT cannot: demand treatment that a doctor does not consider clinically appropriate; request anything that is illegal (such as assisted dying, which is not legal in England); or appoint someone to make decisions on your behalf — that is the role of a Lasting Power of Attorney for Health and Welfare. An ADRT operates even without an LPA in place.

For an ADRT to be legally binding, it must be valid and applicable to the treatment proposed:

• You must be 18 or over and have capacity when making it;
• It must be specific — broad statements such as "I do not want aggressive treatment" are not an ADRT. You must specify the treatment(s) you are refusing and the circumstances in which you are refusing them;
• For life-sustaining treatment — the ADRT must be in writing, signed by you (or by someone at your direction if you cannot write), and signed and witnessed by another person who confirms you had capacity when making it. It must include a statement that the ADRT applies even if life is at risk;
• For other treatment — an oral ADRT may be binding, but a written one is strongly recommended to prevent disputes about what was said.

An ADRT is invalidated if: you have since consented to the treatment specified; you have done anything inconsistent with the ADRT (such as discussing a wish to have the treatment); or you have subsequently made an LPA for Health and Welfare granting the attorney authority over the treatment specified.

An ADRT that no one knows about may not be found when it is needed. To make your ADRT effective:

• Give a copy to your GP to be included in your medical records;
• Give a copy to any hospital you attend regularly;
• Keep a copy at home where it can easily be found by family or emergency responders;
• Tell family members and close friends that it exists and where it is kept;
• If you receive regular care at home, ensure your care team know about it.

There is no central register for ADRTs in England — responsibility for ensuring it is known rests with you and your family. Some people wear a medical alert bracelet referencing their ADRT. Review and update your ADRT regularly to ensure it still reflects your wishes — an outdated ADRT may raise questions about whether it still represents your current views.

An Advance Decision to Refuse Treatment exists within the broader framework of the Mental Capacity Act 2005 and its statutory Code of Practice. Understanding the five core principles of the MCA helps clarify both how your ADRT will be applied and how decisions will be made if it does not cover a specific situation.

The five principles of the MCA are:

1. A person must be assumed to have capacity unless it is established that they lack it. Healthcare professionals cannot simply assume you lack capacity because of age, diagnosis, or disability.
2. A person must not be treated as unable to make a decision unless all practicable steps to help them have been taken. This means providing information in accessible formats, finding the right time and environment, and using communication support if needed.
3. A person has the right to make unwise decisions. Making an unusual or risky choice does not by itself demonstrate lack of capacity. An ADRT that appears unwise to a clinician may still be valid if made with capacity.
4. Any act or decision made for someone who lacks capacity must be done in their best interests. Where an ADRT does not cover the specific situation, best-interests principles govern what happens.
5. Any act or decision must be the least restrictive of the person's rights and freedoms. Clinicians cannot override an ADRT by arguing that treatment would be beneficial — the ADRT represents your autonomous choice.

The MCA Code of Practice (published by the government under section 42 of the MCA) provides detailed guidance on how these principles apply in practice. It has statutory weight — professionals in regulated roles who fail to have regard to the Code can be called to account. If you believe a healthcare professional has ignored your ADRT or failed to apply the MCA principles correctly, you can raise a complaint with the hospital or NHS trust, and ultimately with the Parliamentary and Health Service Ombudsman (PHSO).