Advance Care Directive (UK)

An Advance Care Directive in the United Kingdom is a legally binding written instrument.

The Mental Capacity Act 2005 (MCA 2005) provides the complete statutory framework for advance decisions in England and Wales. Section 24 of the MCA 2005 defines an advance decision as a decision made by a person aged 18 or over with capacity to refuse specified treatment if at a future time and in specified circumstances they lack capacity to consent to or refuse treatment. Sections 25 and 26 set out the requirements for validity and applicability and the binding effect of a valid and applicable ADRT. The MCA 2005 Code of Practice (2007), issued by the Lord Chancellor under section 42 of the Act, provides authoritative guidance for healthcare professionals on applying these provisions. NHS trusts in England are required under the Health and Social Care Act 2008 to have policies for identifying and acting on advance decisions.

An ADRT must be distinguished from an Advance Statement, which is a non-binding expression of a person's wishes, feelings, beliefs, and values that healthcare professionals must consider when making best interests decisions under section 4 of the MCA 2005, but are not legally required to follow. An ADRT is also distinct from a Lasting Power of Attorney for Health and Welfare (LPA), which appoints another person — the attorney — to make health and welfare decisions. Both documents can coexist, but where a valid and applicable ADRT conflicts with an LPA, the document made later in time takes precedence.

The Advance Decision to Refuse Treatment applies only in England and Wales. Scotland has a separate regime under the Adults with Incapacity (Scotland) Act 2000, which provides for advance directives and welfare powers of attorney. Northern Ireland is governed by the Mental Capacity Act (Northern Ireland) 2016. Healthcare professionals operating across devolved jurisdictions must apply the relevant statutory framework for the jurisdiction in which the patient is being treated.

For an ADRT to be valid under section 25 of the MCA 2005, the person making it must be at least 18, must have had capacity to make, vary, or withdraw it at the time it was made, and must not have withdrawn it while they had capacity. The ADRT must specify the treatment to be refused with sufficient clarity that the healthcare professional can identify whether it applies to the situation in which they are treating the patient. If the ADRT refuses life-sustaining treatment, it must be in writing, signed by the maker (or at their direction), witnessed in writing, and include a statement that the decision is to apply even if life is at risk.

A UK Advance Care Directive (ADRT) is needed by any adult in England and Wales who wishes to record decisions about refusing future medical treatments in circumstances where they may no longer have the capacity to make or communicate those decisions. The document has particular importance in the following situations.

Any adult with a progressive or life-limiting condition — including dementia, motor neurone disease, multiple sclerosis, cancer, or Parkinson's disease — who wants to record their wishes about treatment options such as cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition and hydration, or dialysis, should complete an ADRT while they retain mental capacity. Once capacity is lost, the opportunity to make a legally binding ADRT is gone.

Adults undergoing elective surgery or treatment with a risk of complications affecting decision-making capacity may use an ADRT to record their wishes about emergency treatments in case they cannot consent or refuse in the moment. Anaesthetists and surgeons at NHS trusts are required by the MCA 2005 Code of Practice to check for advance decisions before proceeding.

An ADRT is needed alongside a Lasting Power of Attorney for Health and Welfare where a person wants both to appoint a trusted decision-maker and to set absolute limits on treatment that even the attorney cannot override. The ADRT and LPA together form a complete advance care planning package.

Older adults in England and Wales who are approaching or residing in care homes should complete an ADRT and advance statement as part of care planning under the Care Act 2014. The NHS Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process integrates advance decisions into clinical records across care settings.

Any adult who has strong objections on religious, personal, or cultural grounds to particular treatments — such as blood transfusions (for Jehovah's Witnesses), certain anaesthetic or sedative drugs, or artificial life prolongation — should record these refusals in a valid ADRT to confirm they are respected.

A valid UK Advance Care Directive (ADRT) under the Mental Capacity Act 2005 must contain specific elements to be legally binding on healthcare professionals in England and Wales.

Identification of the maker is the first requirement. The document must clearly identify the person making the advance decision by full name, date of birth, and address. Healthcare professionals must be able to confirm that the ADRT relates to the specific patient in their care. Including a photograph, NHS number, and GP's name and practice address strengthens identification.

A statement of capacity and understanding confirms that the person has mental capacity under section 2 of the MCA 2005 at the time of making the document and understands the nature and effect of the advance decision. Healthcare professionals who doubt the maker's capacity at the time of signing may not be bound by the ADRT.

Specification of treatments to be refused must be sufficiently precise that a healthcare professional can determine whether the ADRT applies to the treatment proposed. Vague statements such as "I don't want aggressive treatment" are insufficient. The document should name specific treatments — for example, cardiopulmonary resuscitation, mechanical ventilation via endotracheal intubation, artificial nutrition through a nasogastric or PEG tube, dialysis, or blood transfusions — and specify the circumstances in which the refusal applies.

Specification of circumstances defines when the refusal applies. The treatment and the circumstances must both match the situation in which treatment is proposed for the ADRT to be applicable under section 25(4) of the MCA 2005. For example, a refusal of CPR applies only if the heart stops. A refusal of antibiotics may apply only in specified conditions of severe cognitive decline.

A life-sustaining treatment statement is a mandatory additional requirement under section 25(5) of the MCA 2005 if the ADRT refuses life-sustaining treatment. The document must be in writing, signed by the maker, witnessed in writing, and must include an express statement that the decision applies even if the maker's life is at risk as a result of refusing the treatment. Without this statement and witnessing, a refusal of life-sustaining treatment has no legal effect.

Date of creation and review dates should be recorded. An ADRT does not expire, but healthcare professionals may give less weight to an undated or very old document. The MCA 2005 Code of Practice recommends reviewing the ADRT after any significant change in health or circumstances.

A revocation and supersession clause confirms the maker's intention to revoke any previous advance decisions and states that this document represents their current wishes. Any previous ADRT relating to the same treatments should be destroyed and healthcare providers notified.

Under the Wills Act 1837, Section 9 sets formal requirements for valid wills in England and Wales. The Administration of Estates Act 1925 governs intestate succession. The Inheritance (Provision for Family and Dependants) Act 1975 allows dependants to contest estates. The Probate Registry processes applications for grants of probate. HM Revenue and Customs (HMRC) administers inheritance tax under the Inheritance Tax Act 1984. The forms-legal.com Advance Care Directive (UK) template covers the mandatory elements under Wills Act 1837.