An Advance Decision to Refuse Treatment allows you to record medical treatments that you would not want to receive in the future if you later lacked the mental capacity to decide for yourself.
It is sometimes called an Advance Decision, an ADRT or a living will. In England and Wales, a valid and applicable Advance Decision can be legally binding on healthcare professionals.
It is not a request for particular treatment, a general statement about care preferences or a way to appoint another person to make decisions. Those matters are dealt with differently.
This guide explains what an Advance Decision can cover, how to make one, the special requirements for refusing life-sustaining treatment and how it may interact with a Health and Welfare Lasting Power of Attorney.
What is an Advance Decision to Refuse Treatment?
An Advance Decision to Refuse Treatment is a decision made by an adult with mental capacity to refuse one or more specified medical treatments in circumstances described in advance.
It only applies if, at the relevant time, the person lacks capacity to consent to or refuse the treatment themselves.
If the person still has capacity, they make the decision at that time. Their current decision takes priority over anything written previously.
Why might someone make an Advance Decision?
People make Advance Decisions for different personal reasons.
For example, someone may want to:
- refuse a particular treatment because of its likely effects or burdens;
- record wishes arising from a serious or progressive medical condition;
- make their views clear before an operation or period of treatment;
- avoid uncertainty for family members and healthcare professionals;
- ensure that religious, ethical or personal beliefs are respected; or
- plan ahead in case illness or injury affects their ability to communicate.
Making an Advance Decision is a personal choice. It should be based on informed consideration rather than pressure from other people.
Who can make an Advance Decision?
An Advance Decision can be made by a person aged 18 or over who has mental capacity to make that decision.
Mental capacity is specific to the decision and the time it is made. A diagnosis of dementia, a neurological condition or another illness does not automatically mean that someone lacks capacity.
The person must be able to understand, retain and use or weigh the relevant information and communicate their decision.
What treatment can be refused?
An Advance Decision can refuse specified medical treatment.
Depending on the individual circumstances, this might include:
- cardiopulmonary resuscitation;
- artificial ventilation;
- clinically assisted nutrition or hydration;
- antibiotics for a particular condition;
- surgery;
- blood transfusions;
- dialysis;
- chemotherapy; or
- other medical interventions.
The treatment must be identified clearly enough for healthcare professionals to understand what is being refused.
The document should also explain the circumstances in which the refusal is intended to apply.
What can an Advance Decision not do?
An Advance Decision cannot:
- request or require a particular treatment;
- require clinicians to provide treatment they consider clinically inappropriate;
- appoint somebody to make decisions for you;
- refuse basic comfort care, such as appropriate warmth, hygiene and relief from pain;
- require another person to help end your life;
- authorise euthanasia or assisted suicide;
- deal with financial or property matters; or
- replace a will.
It records refusals of treatment. Broader wishes about care should normally be recorded separately in an advance statement or other care-planning document.
Does an Advance Decision have to be in writing?
An Advance Decision refusing treatment that is not life-sustaining can sometimes be made verbally.
However, putting it in writing is usually much clearer. A written record reduces the risk of disagreement about what was said, which treatment was refused and the circumstances in which the refusal applies.
A written Advance Decision should normally include:
- your full name;
- your date of birth;
- your address;
- the treatment or treatments being refused;
- the circumstances in which each refusal should apply;
- the date it was made;
- your signature; and
- details of anyone who should be contacted.
What are the rules for refusing life-sustaining treatment?
Additional formal requirements apply if the Advance Decision refuses treatment that may be necessary to sustain life.
It must:
- be in writing;
- be signed by the person making it, or by another person at their direction and in their presence;
- be witnessed;
- include a statement that the refusal applies even if life is at risk; and
- identify the treatment and circumstances clearly enough to be applied.
The witness should sign in the presence of the person making the Advance Decision.
Because treatment and circumstances can be medically complex, discussing the wording with a healthcare professional is strongly advisable.
What counts as life-sustaining treatment?
Life-sustaining treatment is treatment that the healthcare professional providing care considers necessary to sustain life.
Whether a treatment is life-sustaining depends on the circumstances.
For example, antibiotics may be routine treatment for one person but life-sustaining for another person with a severe infection. Artificial ventilation, clinically assisted nutrition and hydration, major surgery or cardiopulmonary resuscitation may also be life-sustaining in particular situations.
When is an Advance Decision legally binding?
An Advance Decision is legally binding when it is both valid and applicable to the treatment and circumstances in question.
Broadly, healthcare professionals will need to consider whether:
- the person had capacity when making it;
- the person was aged 18 or over;
- the decision has not been withdrawn;
- the person has not later done something clearly inconsistent with it;
- a later Health and Welfare LPA has not given an attorney authority over the same treatment;
- the treatment being proposed is the treatment that was refused;
- the circumstances match those described; and
- the special requirements for life-sustaining treatment have been met.
Where these requirements are satisfied, the Advance Decision has the same effect as a refusal made by a person with capacity at the time.
What does “valid and applicable” mean?
Valid
Validity concerns whether the Advance Decision still represents the person’s decision.
It may not be valid if the person:
- withdrew it while they had capacity;
- later created a Health and Welfare LPA giving an attorney authority over the same treatment; or
- later acted in a way that was clearly inconsistent with the Advance Decision remaining their settled wish.
Applicable
Applicability concerns whether the document covers the treatment and circumstances that have actually arisen.
It may not apply if:
- the proposed treatment is different from the treatment refused;
- the circumstances are materially different from those described;
- the wording is too vague to interpret safely;
- the person still has capacity to decide; or
- there are reasonable grounds to believe the person would have changed their decision if they had known about circumstances that were not anticipated.
Can healthcare professionals ignore an Advance Decision?
Healthcare professionals must follow an Advance Decision when they are satisfied that it is valid and applicable.
If there is genuine uncertainty, they may provide treatment that is immediately necessary to sustain life or prevent a serious deterioration while the position is clarified.
Disputes about validity, applicability or the person’s best interests may require senior clinical input, specialist advice or an application to the Court of Protection.
Can an Advance Decision ask for treatment?
No. It can only refuse treatment.
You may record treatment preferences, care wishes, beliefs and values in an advance statement. Healthcare professionals should take relevant wishes into account when making a best-interests decision, but an advance statement is not legally binding in the same way as a valid and applicable Advance Decision.
What is the difference between an Advance Decision and an advance statement?
An Advance Decision refuses specified medical treatment and can be legally binding.
An advance statement records broader wishes and preferences, such as:
- where you would prefer to be cared for;
- religious or cultural beliefs;
- dietary preferences;
- important routines;
- people you would like consulted;
- your views about personal care; or
- what makes you feel comfortable or reassured.
An advance statement helps people understand what matters to you but does not compel clinicians to provide particular treatment.
How is an Advance Decision different from a Health and Welfare LPA?
An Advance Decision records your own refusal of specified treatment.
A Health and Welfare LPA appoints one or more attorneys to make authorised health and care decisions after you lose capacity for the particular decision.
An LPA may cover:
- medical treatment;
- care arrangements;
- where you live;
- day-to-day welfare; and
- life-sustaining treatment, if you expressly give the attorneys that authority.
Read our guide to a Health and Welfare LPA for more detail.
Can you have both an Advance Decision and an LPA?
Yes, but the documents must be carefully coordinated.
The order in which they are made and the authority given to the attorneys can affect which document applies.
A later Health and Welfare LPA may override an earlier Advance Decision where the attorney is expressly given authority to decide about the same treatment.
A later Advance Decision may restrict an attorney’s authority in relation to the treatment it validly and clearly refuses.
Conflicting documents can create uncertainty at a difficult time. They should be reviewed together and each relevant person should know that both exist.
Does an Advance Decision cover emergency treatment?
It can cover treatment provided in an emergency if the document is valid, applicable and available to the healthcare team.
In an immediate emergency, clinicians may not know that the document exists. This makes communication and accessibility important.
Consider:
- giving a copy to your GP;
- giving copies to relevant specialists;
- telling close family members and attorneys;
- keeping a copy with important medical information;
- using an appropriate alert card; and
- asking for the decision to be recorded in relevant care or medical records.
Is an Advance Decision the same as a DNACPR form?
No.
A DNACPR recommendation concerns cardiopulmonary resuscitation if the heart or breathing stops. It is a clinical recommendation recorded by healthcare professionals.
An Advance Decision is made by the individual and may refuse CPR or other specified treatments in defined circumstances.
The two documents have different purposes and processes, although both may be relevant to the same care plan.
Does an Advance Decision apply during pregnancy?
A person can state whether an Advance Decision is intended to apply during pregnancy.
This is a sensitive and medically complex area. Anyone who wants their Advance Decision to address pregnancy should seek individual medical and legal guidance so that the wording is clear and informed.
Can an Advance Decision be changed or withdrawn?
Yes, while the person has mental capacity.
An Advance Decision can be changed or withdrawn at any time. Withdrawal does not always have to be in writing, even where the original decision concerned life-sustaining treatment.
However, written confirmation is strongly advisable. Copies of the old document should be marked as withdrawn or destroyed, and everyone holding a copy should be told promptly.
Where only part of the decision is being changed, preparing a new complete document is often clearer than making handwritten amendments.
How often should an Advance Decision be reviewed?
There is no fixed expiry date, but regular review helps show that it continues to reflect your wishes.
Review it:
- every few years;
- after a new diagnosis;
- when treatment options change;
- after a hospital admission;
- after making or changing a Health and Welfare LPA;
- following a significant change in personal beliefs or circumstances; or
- when contact details change.
Sign and date a record of the review, even if no changes are required.
Should you speak to a doctor?
Yes, particularly where the Advance Decision concerns complex treatment, a known medical condition or life-sustaining treatment.
A healthcare professional can help explain:
- which treatments may become relevant;
- how those treatments work;
- their likely benefits and burdens;
- the circumstances in which they may be offered;
- alternative treatments; and
- the consequences of refusing them.
This can help make the document precise and medically informed.
Who should receive a copy?
Copies may be given to:
- your GP;
- hospital consultants or specialist teams;
- your Health and Welfare attorneys;
- close relatives or trusted friends;
- care providers;
- anyone responsible for your care plan; and
- the person storing your important documents.
The original should be kept safely but remain accessible. A document that nobody can find may not be available when a decision must be made.
Common mistakes when making an Advance Decision
Using vague wording
Statements such as “I do not want heroic treatment” may be too unclear to apply safely. Name the treatment and describe the circumstances.
Trying to request treatment
An Advance Decision can refuse treatment but cannot require clinicians to provide a particular intervention.
Missing the life-sustaining treatment statement
A refusal of life-sustaining treatment must clearly state that it applies even if life is at risk.
Failing to obtain a witness
The signature must be witnessed where life-sustaining treatment is refused.
Creating conflicting documents
An Advance Decision and Health and Welfare LPA should be reviewed together to avoid contradictory authority or instructions.
Keeping the document secret
The people who may need to rely on it should know that it exists and where to find it.
Never reviewing it
Treatment options and personal wishes can change. Regular review provides useful evidence that the decision remains current.
Questions to consider before making an Advance Decision
- Which treatment am I considering refusing?
- In exactly which circumstances should the refusal apply?
- Have I discussed the medical consequences with an appropriate clinician?
- Could the treatment be life-sustaining?
- Does the document meet the additional formal requirements?
- Do I also have or need a Health and Welfare LPA?
- Do the documents work together?
- Who should receive a copy?
- How will healthcare professionals find it in an emergency?
- When will I review it?
Advance Decision guidance in Dorset
Brooks Wills supports individuals and families across Poole, Bournemouth, Christchurch, wider Dorset and West Hampshire with clear information about Advance Decisions and their place within wider later-life planning.
We explain the distinction between an Advance Decision, an advance statement and a Health and Welfare LPA, helping you understand the documents that may be relevant to your wishes.
Medical advice should come from an appropriate healthcare professional, particularly where the decision concerns a diagnosis, proposed treatment or life-sustaining treatment.
Learn more about our Advance Decisions to Refuse Treatment service.
Brooks Wills is a member of the Institute of Professional Willwriters and the Society of Will Writers.
Call, message or book a consultation to discuss how an Advance Decision may fit alongside your Health and Welfare LPA and wider planning.
Simplifying legacies, securing tomorrow.
This article provides general information for England and Wales. It is not legal or medical advice. The validity and applicability of an Advance Decision depend on its wording, the circumstances and the law applying at the relevant time.
Frequently asked questions
Is an Advance Decision legally binding?
Yes, if it is valid and applicable to the treatment and circumstances. Healthcare professionals must follow a valid and applicable Advance Decision.
Can an Advance Decision refuse life-sustaining treatment?
Yes, but it must be written, signed and witnessed and must clearly state that the refusal applies even if life is at risk.
Can I use an Advance Decision to request treatment?
No. It can refuse specified treatment but cannot require healthcare professionals to provide treatment that they do not consider clinically appropriate.
Is an Advance Decision the same as a Health and Welfare LPA?
No. An Advance Decision records your own refusal of treatment. A Health and Welfare LPA appoints attorneys to make authorised decisions after you lose capacity.
Can I have both an Advance Decision and a Health and Welfare LPA?
Yes, but the documents should be coordinated carefully. Their dates and the authority granted to attorneys can determine which document applies to a particular treatment.
Does an Advance Decision expire?
It does not have a fixed expiry date, but regular review is advisable. A recently reviewed document can help demonstrate that it still represents your wishes.
