Advance decision to refuse treatment

An advance decision to refuse treatment (ADRT) is a statement of your wishes to refuse a certain treatment. It is a way of making sure everyone knows what treatments you do not want to have, if you become unable to make your own decisions. It will only be used if you cannot make or communicate a decision for yourself. 

It is also called an advance decision or living will. In Scotland, it is called an advance directives.

Although you can usually make advance decisions to refuse treatment by speaking to your healthcare team, it is better to write it down. This helps avoid confusion later.

An ADRT must be in writing if it states that you refuse treatment to keep you alive.

It can include the situations in which you wish to refuse the treatment. For example, if:

• you become very unwell after having all possible treatments, and you do not want to be kept alive by having a feeding tube or drip 
• your condition and quality of life is getting worse, and you do not want to continue having a feeding tube or drip
• you are very ill and you do not want to be given antibiotics for an infection.

We have an example below of how some of this information could be written in an ADRT document.

It is important to be as clear as possible about:

• the treatment you would like to refuse
• the situations when you would like your ADRT to apply.

You should include as much detail as possible to make your wishes clear to anyone reading the document. In England and Wales, an ADRT is legally binding if it meets the requirements set out in the Mental Capacity Act 2005. This means if your healthcare team know about it, they must follow it.

You cannot insist on being given specific treatments, or request to have your life ended. You can request a treatment, but doctors will decide the most appropriate medical treatment for your condition.

If you refuse a certain treatment, you will still have the best possible care and support, and medicines to help control your symptoms.

An ADRT must be a written statement if it states that you refuse treatment to keep you alive.

You must write down your wishes if you do not want:

• the medical team to try to restart your heart and breathing if they have stopped suddenly (cardiopulmonary resuscitation or CPR)
• to be put on a breathing machine (ventilator).

It must say exactly what treatment you want to refuse and in which situation. This is because you may want to refuse a treatment in one situation, but not in another.

In these situations, an ADRT must also be signed:

• by you, or someone else who was with you at the time of it being written
• in the presence of a witness
• by the witness, with the date – this must happen while you, or the person signing for you, are there.

If an ADRT is not about treatment that will keep someone alive, the law does not state what must be included. However, it is helpful to include the following:

• Your name, date of birth, address and any obvious distinguishing features you have – for example, a birthmark. This is in case you are unconscious or unable to communicate. It will help healthcare professionals identify you.
• The name, address and phone number of your GP, and whether they have a copy of your ADRT.
• A statement saying that the ADRT should be used if you cannot make or communicate a decision for yourself.
• A statement with the exact treatment or treatments to be refused and the circumstances when your decision would apply. This is because you may want to refuse a treatment in 1 situation, but not in another.
• The date your ADRT was created.
• Your signature and a dated signature of at least 1 witness, if it is a written statement.
• If it is a decision to refuse treatment that would keep you alive, your ADRT must also include the statement, ‘I refuse this treatment even if my life is at risk as a result’.

You might wish to refuse a specific treatment in all situations, rather than in just 1 specific situation.

For example, you may want to refuse a specific medication if you:

• have an allergy
• do not want the medication for religious reasons.

If you want to make a statement about refusing a treatment in all circumstances, you should talk with a healthcare professional first. They will make sure that your ADRT is clear for any healthcare professionals who may need to use it in the future.

If you wish to refuse a treatment that is, or may be, life-sustaining (could keep you alive), you must state in the box: ‘I refuse this treatment even if my life is at risk as a result.'

If you have made an advance decision to refuse treatment (ADRT) and a health and welfare lasting power of attorney (LPA), one may make the other invalid. The document you made most recently takes priority over the other. Whenever possible try to make sure your wishes match in documents.

You should tell any doctors, nurses, family or friends who will be involved in your care what you have done. It is important to keep written records of when you made decisions and what they were. Make sure you tell everyone who may need to make decisions for you in the future where to find all your documents.