An Advance Directive Form — formally known as an Advance Decision to Refuse Treatment — is a legally binding document that allows any adult aged 18 or over in England and Wales to record in advance their decision to refuse specific medical treatments in specific circumstances, in the event that they later lose the mental capacity to make or communicate those decisions themselves. It is sometimes called a living will, though this term is not used in English statute.

The legal foundation for advance decisions in England and Wales is the Mental Capacity Act 2005 (MCA 2005), specifically sections 24 to 26. The Act placed on a statutory footing a right that had previously been recognised at common law — the right of every competent adult to refuse medical treatment, even where that refusal may result in their death. This principle was established through a series of landmark cases in the English courts, including Re T (Adult: Refusal of Treatment) [1992] 4 All ER 649, in which the Court of Appeal confirmed that a competent adult patient has the right to refuse medical treatment for any reason, and Airedale NHS Trust v Bland [1993] AC 789, in which the House of Lords addressed the circumstances in which life-sustaining treatment could lawfully be withdrawn.

Under section 26(1) of the MCA 2005, a valid and applicable advance decision has the same legal effect as a contemporaneous refusal by a person with capacity: the treatment specified must not be carried out or continued. A healthcare professional who provides treatment in the face of a valid and applicable advance decision could face a civil claim for battery or trespass to the person, and potentially a criminal prosecution. This makes an advance decision one of the most powerful legal tools available to an individual for controlling their medical care.

The Act draws a distinction between two categories of advance decision. A basic advance decision refuses treatments that are not life-sustaining and need not satisfy any particular formality requirements, though best practice strongly recommends that it be in writing. A more formal advance decision that includes refusal of life-sustaining treatment must comply with the additional requirements set out in section 25(5): it must be in writing, signed by the maker (or by another person at their direction), witnessed and signed by a third party in the maker's presence, and must expressly state that the decision applies even if the maker's life is at risk. Life-sustaining treatment is defined in section 4(10) of the Act as any treatment that a person providing healthcare considers necessary to sustain life.

An Advance Directive Form is needed whenever you wish to ensure that your specific wishes about medical treatment will be respected if you later lose the mental capacity to communicate them yourself. It is a proactive measure that protects your bodily autonomy and ensures that healthcare professionals are legally bound to follow your clearly expressed wishes.

The most common circumstances in which people choose to make an advance decision include: a diagnosis of a progressive or degenerative condition such as dementia, motor neurone disease, multiple sclerosis, or Parkinson's disease, where the person anticipates a gradual loss of capacity to communicate; before or after major surgery, particularly where there is a risk of post-operative cognitive impairment, prolonged unconsciousness, or a poor prognosis; as part of advance care planning at any stage of life, prompted by a desire to plan ahead while fully fit and well; where a person holds strong personal, religious, or philosophical views about specific treatments — for example, Jehovah's Witnesses who wish to refuse blood transfusions in all circumstances; and following the death of a loved one, which often prompts people to reflect on and document their own end-of-life wishes.

It is critically important to make an advance decision while you have the mental capacity to do so. Mental capacity is assessed at the time a decision is made, not in retrospect. Once you have lost the capacity to make or communicate decisions about your medical treatment, it is too late to create a valid advance decision. The decision-making process will then be governed by the best interests framework in section 4 of the MCA 2005, which requires healthcare professionals and any relevant attorneys or deputies to make decisions based on what they reasonably believe would be in your best interests — a less certain and more subjective process than a clearly documented advance decision.

The NHS strongly encourages advance care planning conversations, particularly for patients with long-term or life-limiting conditions. Having a written advance decision on file with your GP and in your NHS records ensures that your wishes can be identified and respected across different care settings — including hospitals, ambulance services, care homes, and hospices.

A well-drafted Advance Directive Form for England and Wales should address several essential elements to ensure that it is valid, applicable, and likely to be respected by healthcare professionals.

Clear personal identification is the starting point. The document must include the maker's full legal name, date of birth, and current residential address. Including the NHS number is strongly recommended: it allows healthcare professionals to quickly match the advance decision to the maker's medical records, which is particularly important in emergency situations where speed is critical.

Specification of treatments to be refused is the substantive heart of the advance decision. Under section 24(1) of the MCA 2005, the decision must relate to specified treatment. Vague statements such as 'I refuse all treatment' are unlikely to be found applicable in practice. The treatments should be listed by their precise medical names where possible — for example, 'cardiopulmonary resuscitation (CPR)', 'mechanical ventilation', 'artificial nutrition and hydration by nasogastric tube or PEG', or 'intravenous antibiotics for a life-threatening infection'. The more specific the refusal, the more likely it is to be found applicable.

The circumstances in which the refusal applies must be clearly described. Section 25(4) provides that an advance decision is not applicable if circumstances exist that the maker did not anticipate at the time of making it and that would have affected their decision. Describing the circumstances in detail — for example, 'if I am diagnosed with a terminal illness with no reasonable prospect of recovery within 12 months', or 'if I suffer irreversible brain damage leaving me permanently unable to communicate or recognise close family' — significantly reduces the risk of the advance decision being found inapplicable.

The life-sustaining treatment declaration is mandatory if the advance decision refuses any treatment that might be considered life-sustaining. This is a critical element: without the express statement that the decision applies 'even if my life is at risk', together with witnessing in accordance with section 25(6), the advance decision will not be legally binding in relation to life-sustaining treatment.

Witness details and signature requirements are essential. The witness must be present when the maker signs, must themselves sign the document, and must be independent. A solicitor or other professional witness is the ideal choice, particularly for refusals of life-sustaining treatment.

An emergency contact section, a GP details section, and (where relevant) a clause addressing the relationship between the advance decision and any existing Lasting Power of Attorney for Health and Welfare are all important ancillary provisions that make the document more effective in practice. A personal values statement, while not legally binding, provides important context and helps healthcare professionals understand the reasoning behind the specific refusals.