Advance Decisions to Refuse Treatment in England and Wales

An Advance Decision to Refuse Treatment (ADRT) allows someone aged 18 or over to refuse specified medical treatment in advance, in case they later lack the mental capacity to make that particular decision.

ADRT is the legal term used under the Mental Capacity Act 2005 in England and Wales. You may also hear an ADRT called an “advance decision” or “living will.”

A valid and applicable ADRT has the same legal effect as a refusal made by a person who currently has capacity. Healthcare professionals must follow it, even if they believe the proposed treatment would be in the person’s best interests.

A quick Scotland note

The Mental Capacity Act 2005 does not apply in Scotland.

In Scotland, these decisions are usually called advance directives. They operate through common law alongside the principles of the Adults with Incapacity (Scotland) Act 2000. Scottish Government guidance describes advance directives that refuse particular treatments as potentially binding, but their legal framework is not identical to the statutory ADRT system in England and Wales.

This distinction matters on placement: always check which nation’s law and local policy apply.

What an ADRT actually does

An ADRT allows someone to say:

“If I lack capacity and these particular circumstances arise, I refuse this specified treatment.”

It might cover:

• mechanical ventilation
• clinically assisted nutrition and hydration
• cardiopulmonary resuscitation (CPR)
• blood transfusion
• another clearly specified medical treatment

The person must identify the treatment being refused and the circumstances in which the refusal should apply. Vague statements may be difficult to apply safely.

An ADRT cannot be used to:

• demand a particular treatment
• require healthcare professionals to provide clinically inappropriate treatment
• refuse basic care intended to keep someone comfortable
• nominate somebody to make decisions on the person’s behalf

It only becomes operative when the person lacks capacity to make the relevant treatment decision.

Why advance decisions matter

Advance decisions protect autonomy. They allow a person’s refusal to remain effective even when illness or injury prevents them from making or communicating the decision at the time.

If an ADRT is valid and applicable, healthcare professionals do not make a best-interests decision about whether to provide the refused treatment. The person has already made that decision while they had capacity.

When is an ADRT legally binding?

Under the Mental Capacity Act 2005, the person must have been aged 18 or over and had capacity when the advance decision was made.

The decision must also:

• identify the treatment being refused
• apply to the circumstances that have arisen
• not have been withdrawn
• not have been replaced or affected by a later Health and Welfare Lasting Power of Attorney
• not have been contradicted by later actions clearly suggesting that the person changed their mind

Refusing life-sustaining treatment

Additional safeguards apply when the ADRT refuses life-sustaining treatment.

The decision must:

• be in writing
• be signed by the person, or signed on their behalf at their direction
• be witnessed
• include a clear statement that the refusal applies even if life is at risk

“Life-sustaining treatment” means treatment which the healthcare professional providing it considers necessary to sustain life. Whether a treatment is life-sustaining can depend on the person’s clinical circumstances.

ADRT versus an advance statement

These are easily confused, but they do different jobs.

Advance Decision to Refuse Treatment

• Refuses specified medical treatment.
• Can be legally binding in England and Wales.
• Applies when the person lacks capacity to make the relevant decision.
• Cannot be used to demand treatment.

Advance statement

• Records wishes, feelings, beliefs and care preferences.
• Might include cultural or religious needs, preferred routines or preferred place of care.
• Is not legally binding under the Mental Capacity Act.
• Must still be considered carefully when a best-interests decision is made.

ADRT versus a Lasting Power of Attorney

The timing and wording of the documents matter.

If someone makes an ADRT and later creates a Health and Welfare Lasting Power of Attorney (LPA) giving the attorney authority over the same treatment, the earlier ADRT will no longer be valid for decisions covered by that authority.

If the person makes the ADRT after creating the LPA, the attorney cannot consent to treatment that the later valid and applicable ADRT refuses.

An attorney can make decisions about life-sustaining treatment only when the registered LPA expressly grants that authority.

If there is uncertainty about the documents or the extent of the attorney’s authority, the healthcare team should seek senior and legal advice rather than making assumptions.

ADRT and DNACPR are not the same

A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) record is a clinical decision specifically about whether CPR should be attempted if the person experiences cardiac or respiratory arrest.

An ADRT is a decision made by the person and may refuse CPR or other specified treatments. A valid and applicable ADRT refusing CPR must be followed.

A DNACPR record does not mean that other treatment, nursing care, symptom relief or escalation should be withheld.

What student nurses might see on placement

Student nurses may encounter ADRTs during:

• advance care planning
• end-of-life care
• treatment-escalation discussions
• reviews of CPR decisions
• capacity assessments
• best-interests meetings

The team may check for:

• an ADRT or advance directive
• a DNACPR record or ReSPECT plan
• a Health and Welfare LPA
• an advance statement
• relevant documentation within the clinical record

As a student nurse, you would not decide independently whether an ADRT is valid or applicable. If a patient, relative or document indicates that an advance refusal exists, inform the registered nurse and appropriate medical team promptly, document according to local policy and avoid giving assurances about its legal effect.

If there is genuine uncertainty during an emergency, clinicians may provide treatment necessary to prevent death or serious deterioration while the existence, validity or applicability of the advance decision is established.

What to remember

Advance decisions help people retain control over their healthcare if they later lose capacity. For student nurses, the important lesson is not to interpret legal documents independently, but to recognise them, understand why they matter and escalate them promptly.

And remember: ADRT is the Mental Capacity Act term for England and Wales. Scotland has a different legal framework.

References

• Great Britain. Mental Capacity Act 2005, ss.24–26. Available at: legislation.gov.uk.
• Department for Constitutional Affairs (2007) Mental Capacity Act 2005 Code of Practice. Available at: GOV.UK.
• National Institute for Health and Care Excellence (2018) Decision-making and mental capacity (NG108). Available at: NICE.
• Scottish Government (2010) Adults with Incapacity (Scotland) Act 2000: Code of Practice for practitioners authorised to carry out medical treatment or research under Part 5 of the Act. Available at: Scottish Government.