An Advance Decision to Refuse Treatment (sometimes known as an advance directive or living will) is a legally binding document created under sections 24 to 26 of the Mental Capacity Act 2005 (MCA 2005). It allows any person aged 18 or over who has the mental capacity to do so to record in advance their decision to refuse specific medical treatments in specific circumstances, should they later lose the capacity to make or communicate those decisions themselves.

The concept of advance decisions is rooted in the fundamental common law principle of bodily autonomy — the right of every competent adult to decide what happens to their own body. The Mental Capacity Act 2005 placed this principle on a statutory footing for the first time in England and Wales, providing a clear legal framework for making, validating, and enforcing advance decisions. Before the MCA 2005, advance refusals were recognised by the courts through common law (notably in the case of Airedale NHS Trust v Bland [1993] and Re T (Adult: Refusal of Treatment) [1992]), but the statutory framework provides much greater certainty for both patients and healthcare professionals.

An advance decision operates purely as a refusal of treatment. It cannot be used to demand or request specific treatments — healthcare professionals are never obliged to provide treatment that is not clinically indicated. However, a valid and applicable advance decision has the same legal effect as a contemporaneous refusal made by a person with capacity: the treatment specified must not be carried out or continued (section 26(1) of the MCA 2005). A healthcare professional who provides treatment in the face of a valid and applicable advance decision could face a claim for battery or trespass to the person.

There are two broad categories of advance decision. A simple advance decision refuses treatments that are not life-sustaining. While the Act does not require it to be in writing, written records are strongly recommended as they provide clear evidence of the person's wishes. A more formal advance decision that includes refusal of life-sustaining treatment must comply with additional requirements set out in section 25(5) of the MCA 2005: it must be in writing, signed by the person (or by another person at their direction), witnessed, and must include an explicit statement that the decision applies even if the person's life is at risk. Life-sustaining treatment, as defined in section 4(10) of the Act, means any treatment that a healthcare professional considers necessary to sustain the patient's life.

An Advance Decision to Refuse Treatment is needed whenever you wish to record your clear and specific wishes about medical treatments you would not want to receive if you later lose the mental capacity to make those decisions yourself. It is a proactive measure that ensures your autonomy and personal values are respected even when you can no longer speak for yourself.

Common situations in which people choose to make an advance decision include: a diagnosis of a progressive condition such as dementia, motor neurone disease, Parkinson's disease, or multiple sclerosis, where the person anticipates gradually losing the ability to communicate their wishes; as part of broader advance care planning following a serious illness or major diagnosis; before undergoing high-risk surgery where there is a possibility of post-operative cognitive impairment or prolonged unconsciousness; strong personal, religious, or philosophical beliefs about specific treatments (for example, Jehovah's Witnesses who wish to refuse blood transfusions); and simply as a precautionary measure by any adult who wishes to plan ahead, regardless of their current state of health.

It is critically important to make an advance decision while you still have the mental capacity to do so. Once you have lost capacity, it is too late — the decision-making process will instead be governed by the best interests framework in section 4 of the MCA 2005 and, if applicable, by any attorneys appointed under a Lasting Power of Attorney for Health and Welfare. An advance decision made today can always be changed or withdrawn later while you still have capacity (section 24(3) of the MCA 2005), so there is no disadvantage to making one early.

The NHS also strongly encourages advance care planning conversations with your GP, particularly if you have a long-term or life-limiting condition. Having a written advance decision in your medical records ensures that healthcare teams across different settings (hospital, ambulance service, care home) can quickly identify and respect your wishes in an emergency.

A well-drafted Advance Decision to Refuse Treatment should contain several essential elements to ensure it is valid, applicable, and likely to be followed by healthcare professionals when the time comes.

Personal identification details must include your full legal name, date of birth, and current residential address. Including your NHS number is strongly recommended as it allows healthcare professionals to match the document to your medical records quickly, particularly in emergency situations.

Specification of treatments to refuse is the core of the document. Under section 24(1) of the MCA 2005, the advance decision must relate to specified treatment. The more precise you are about the treatments you wish to refuse, the more likely it is that the advance decision will be found applicable. Vague statements such as 'I refuse all treatment' are unlikely to be effective. Instead, list specific treatments by name — for example, cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition and hydration (including nasogastric and PEG feeding), intravenous antibiotics for life-threatening infections, or blood transfusions.

Circumstances in which the refusal applies must be clearly described. Under section 25(4), an advance decision is not applicable if the circumstances are different from those specified. Describing the circumstances in detail — for example, 'if I am diagnosed with a terminal illness with a life expectancy of less than six months' or 'if I am in a persistent vegetative state with no reasonable prospect of recovery' — reduces the risk that healthcare professionals will find the decision inapplicable.

The life-sustaining treatment declaration is mandatory if your advance decision includes refusal of any life-sustaining treatment. Section 25(5) of the MCA 2005 requires the document to be in writing, signed, witnessed, and to contain an express statement that the decision applies even if your life is at risk. Without this statement and the witnessing requirement, the refusal of life-sustaining treatment will not be legally binding.

Witness details are required if you are refusing life-sustaining treatment. The witness must be present when you sign (or acknowledge your signature) and must sign the document themselves. While the Act does not impose restrictions on who can be a witness, best practice is to choose someone who is independent — not a family member, your attorney, or anyone who might benefit from your death.

An emergency contact section, while not a statutory requirement, is strongly recommended. This ensures that healthcare professionals can quickly reach someone who knows about your advance decision and can provide further context if needed.

A statement regarding any existing Lasting Power of Attorney for Health and Welfare is important for establishing which document takes priority. Under section 25(2)(b), an LPA made after the advance decision may invalidate it if the LPA gives the attorney authority over the same treatment. Recording the chronological relationship between the two documents helps avoid confusion.

Finally, a clear declaration confirming your capacity, understanding, and voluntariness provides additional evidence that the advance decision was made freely and with full knowledge of its consequences. Regular review and re-signing is recommended to demonstrate that it remains your fixed decision.