Advance Healthcare Directive (Ireland)

An Advance Healthcare Directive in Ireland records a person's decisions about future medical treatment for use if they later lose the capacity to consent, under the framework of the Assisted Decision-Making (Capacity) Act 2015 (Part 8).

Before the 2015 Act, the legal basis for AHDs rested on the constitutional right to self-determination and the common law right to refuse medical treatment, both recognised by the Supreme Court in Re a Ward of Court [1996] 2 IR 79 and affirmed in subsequent decisions. The 2015 Act places these rights on a clear statutory footing and creates binding obligations on healthcare professionals to comply with valid directives.

Part 8 of the 2015 Act, encompassing sections 82 to 100, sets out the formal requirements for a valid AHD, the circumstances in which it is binding, the powers and duties of a Designated Healthcare Representative (DHR), and the mechanisms for resolving disputes between healthcare professionals and DHRs. Section 83 defines an AHD as a statement made by a relevant person specifying his or her will and preferences concerning treatment decisions that may be made on his or her behalf if the person subsequently lacks capacity. Section 84 sets out what an AHD may and may not cover — it may refuse specific treatments but cannot require the withholding of basic care or mandate unlawful acts.

The Decision Support Service (DSS), established under Chapter 6 of Part 5 of the 2015 Act, became fully operational on 26 April 2023 — the same date as the full commencement of the Act. The DSS is the independent statutory body responsible for overseeing supported decision-making arrangements in Ireland, and whilst it forms part of the Mental Health Commission it has its own distinct role and functions. The DSS maintains a register of Designated Healthcare Representatives, provides codes of practice for healthcare professionals and other parties, and can be contacted to verify the existence and terms of a registered AHD. Under section 85 of the 2015 Act, healthcare professionals must take all reasonable steps to ascertain whether a patient has made an AHD before administering treatment to an incapacitous patient. Failure to comply with a valid AHD may give rise to professional regulatory consequences and potential civil liability.

The 2015 Act was a landmark development in Irish law, implementing the recommendations of the Law Reform Commission's Report on Bioethics: Advance Care Directives (LRC 94-2009) and fulfilling Ireland's obligations under Article 9 of the Convention on Human Rights and Biomedicine (the Oviedo Convention), to which Ireland is a signatory. The Act is underpinned by the five functional principles set out in section 8: the presumption of capacity, the importance of supporting a person to make their own decision, the right of a person with capacity to make a decision that may be considered unwise, that any act done or decision made on behalf of a person who lacks capacity must be done or made in the person's best interests, and that the least restrictive intervention must be used.

In practical terms, an AHD empowers individuals to retain control over their medical care at a time when they can no longer speak for themselves — whether as a result of a sudden accident, a progressive neurological condition, advanced dementia, or terminal illness. A well-drafted AHD, reviewed regularly and communicated to healthcare providers and family members, is an essential component of thorough end-of-life planning alongside a will and an Enduring Power of Attorney.

An Advance Healthcare Directive is relevant and important for any adult resident in Ireland who wishes to retain control over their medical treatment in the event of future incapacity. While it is most commonly associated with older adults and those diagnosed with a serious illness, an AHD is appropriate for any person aged 18 or over — because accidents, sudden illness, or unexpected medical emergencies can affect people of any age.

You should consider making an Advance Healthcare Directive if you have been diagnosed with a progressive or terminal condition — such as dementia, motor neurone disease, advanced cancer, or Parkinson's disease — and wish to set out your preferences regarding life-sustaining treatment, resuscitation, artificial nutrition, and palliative care at an early stage while you still have full capacity to do so. An AHD made at this stage carries the greatest moral and legal force, as it can reflect carefully considered and informed preferences made with knowledge of the likely progression of the illness.

You should also consider making an AHD if you have strong personal, religious, or ethical convictions about certain medical treatments — for example, if you are a Jehovah's Witness who wishes to refuse blood transfusions under any circumstances, or if you have strong views about life-prolonging treatment in a persistent vegetative state or terminal condition. Without a valid AHD, healthcare professionals are required to make treatment decisions in your best interests — which may not align with your personal values or wishes.

For those without close family members or with complex family dynamics — for example, where there are estranged relatives, blended families, or disagreements about end-of-life care — an AHD and the appointment of a Designated Healthcare Representative are particularly important. They confirm that your medical care is directed by a person you trust and that your documented wishes take precedence over those of family members who may have conflicting views.

An AHD is also valuable for persons undergoing major surgery or invasive procedures, who may wish to record their preferences regarding resuscitation and intensive care in the event of serious complications. While a Do Not Attempt Resuscitation (DNAR) order can be made in a clinical setting, an AHD can address a broader range of situations and provides a more thorough record of your wishes.

From a practical perspective, the HSE and Decision Support Service recommend that you inform your GP of the existence and location of your AHD, provide a copy to your named Designated Healthcare Representative, and confirm the document is kept in an accessible location — not locked in a safe or stored only with your solicitor. The AHD should be reviewed and, where necessary, re-signed periodically to confirm that it continues to reflect your current wishes.

A significant context for the 2015 Act is the abolition of the wardship system: since 26 April 2023, new applications to have adults made Wards of Court can no longer be made. All existing adult Wards of Court are being discharged from wardship and transitioned to the new decision support framework within three years of that date (by 26 April 2026). This change makes proactive planning through an AHD and an Enduring Power of Attorney more important than ever, as the old wardship safety net no longer applies to persons who lose capacity without prior planning documents in place.

A valid and enforceable Irish Advance Healthcare Directive under the Assisted Decision-Making (Capacity) Act 2015 must contain a number of essential elements, and should also address several recommended provisions to confirm that it is thorough and effective.

The identification clause must state the full name, address (including Eircode), and date of birth of the maker. This information is critical for identifying the correct document in an emergency and confirming that it relates to the patient receiving treatment. The directive should also include the maker's PPS number and the name, address, and contact details of the maker's GP.

The capacity statement is a declaration by the maker that, at the date of signing, they are aged 18 or over, have read and understood the directive, and are making it freely and voluntarily without undue influence. This declaration supports the presumption of capacity under section 8(1) of the 2015 Act. It is strongly advisable — although not legally required — for the capacity statement to be supported by a letter from the maker's GP or a medical professional confirming that the maker had capacity at the date of signing.

The treatment refusal provisions are the heart of the AHD. Each refusal must specify: the treatment being refused (by name and description), the circumstances in which the refusal applies (for example, 'if I am in a persistent vegetative state from which I am unlikely to recover', or 'if I have end-stage dementia'), and whether the refusal is absolute or qualified. The refusal of life-sustaining treatment — such as CPR, mechanical ventilation, or artificial nutrition and hydration — must be stated in clear and unambiguous terms. Section 89(2)(b) of the 2015 Act requires that a refusal of life-sustaining treatment must expressly acknowledge that the effect of the refusal may result in the maker's death.

The Designated Healthcare Representative appointment, made under section 93 of the 2015 Act, should name the DHR, their address and contact details, and the scope of the authority granted to them. The DHR must sign the document to confirm their acceptance of the appointment, and their signature must be witnessed. The appointment should specify whether the DHR has the authority to consent to treatments not addressed in the AHD, to revoke the AHD on the maker's behalf, and to receive all healthcare information.

The witnesses clause must comply with the requirements of section 87 of the 2015 Act — the AHD must be signed by the maker in the presence of a witness who is aged 18 or over, is not the maker's healthcare professional, and is not a person who would benefit financially from the maker's death. The witness confirms that the maker signed the document freely and appeared to have capacity at the time.

The date and review information should record the date the AHD was signed and any subsequent dates on which it was reviewed and confirmed. The document should state whether any previous AHD has been revoked and, if so, the date of revocation. For registered arrangements, the Decision Support Service (DSS) — the independent statutory body established under Chapter 6 of Part 5 of the Assisted Decision-Making (Capacity) Act 2015 and operating under the auspices of the Mental Health Commission — can be contacted to confirm current registration status and to verify that healthcare providers are able to locate and act upon the directive in an emergency.

The HSE (Health Service Executive), as the primary provider of public health services in Ireland, has issued guidance on AHDs within its clinical policies, and HSE clinical staff are bound by section 85 of the Assisted Decision-Making (Capacity) Act 2015 to take all reasonable steps to ascertain whether a patient has made an AHD before providing treatment to a patient who lacks capacity. The Medical Council of Ireland's Guide to Professional Conduct and Ethics also addresses AHDs and the obligations of registered medical practitioners under Irish law.

Disputes between healthcare professionals and Designated Healthcare Representatives regarding the validity or applicability of an AHD may be referred to the Circuit Court under section 97 of the Assisted Decision-Making (Capacity) Act 2015. The High Court retains inherent jurisdiction in cases raising constitutional questions about the right to life, the right to bodily integrity, and the right to self-determination — rights recognised by the Supreme Court in Re a Ward of Court [1996] 2 IR 79 and in Fitzpatrick v FK [2008] IEHC 104. The Law Reform Commission's Report on Bioethics: Advance Care Directives (LRC 94-2009) provided the foundational analysis that led to Part 8 of the 2015 Act. The forms-legal.com Advance Healthcare Directive (Ireland) template covers the mandatory elements under the Assisted Decision-Making (Capacity) Act 2015.

Under the Succession Act 1965, Section 67 governs distribution of estates in Ireland. The Probate Office of the High Court of Ireland administers estate matters. The Capital Acquisitions Tax Consolidation Act 2003 (CATCA) and Revenue Commissioners govern inheritance tax. Section 89 of the Succession Act 1965 sets out the formal requirements for valid wills. The Data Protection Act 2018 and GDPR apply to personal data held by executors.