ADRT Treatment Refusals England

The Five Major Treatment Refusals

Most ADRTs in England centre on five categories of life-sustaining treatment. Each one has specific drafting requirements, and each interacts differently with clinical practice.

Cardiopulmonary Resuscitation (CPR)

A refusal of CPR in an ADRT must use the statutory "even if my life is at risk as a result" formulation, must be in writing, and must be witnessed. A clinical DNACPR order on your hospital notes is not the same thing — DNACPR is a clinical recommendation, not a legal instruction. If you want your CPR refusal to be binding on the medical team regardless of their clinical judgement, it must be in your ADRT.

Precise phrasing matters: "I refuse cardiopulmonary resuscitation, including chest compressions and defibrillation, in any clinical circumstance" covers the full scope. If you only want to refuse CPR under specific conditions — for example, after a cardiac arrest secondary to a terminal diagnosis — define those conditions using clinical terminology.

Mechanical Ventilation

This covers two distinct interventions:

• Invasive ventilation via endotracheal intubation (a tube inserted through the mouth into the airway)
• Non-invasive ventilation such as CPAP or BiPAP (a mask delivering pressurised air)

You can refuse one without the other. Some people want to refuse intubation but accept a CPAP mask; others refuse both. Specify exactly which forms of ventilation you refuse and under what clinical triggers.

Clinically Assisted Nutrition and Hydration (CANH)

This is one of the most emotionally charged and clinically important refusals. CANH covers:

• Nasogastric tube feeding (a tube through the nose into the stomach)
• PEG tube feeding (a tube inserted surgically through the abdominal wall into the stomach)
• Intravenous fluids delivered through a drip or central line

You can legally refuse all of these. What you cannot refuse: the physical offer of food and water by mouth. The Mental Capacity Act Code of Practice classifies oral nutrition and hydration as "basic care," which falls outside the scope of an ADRT.

For dementia-specific ADRTs, CANH is the refusal that requires the most precise clinical triggering. Specify the cognitive staging threshold at which the refusal activates, using clear clinical criteria.

Antibiotics

Antibiotic refusals in an ADRT are unusual because antibiotics are not inherently life-sustaining — they treat infections, which may or may not be life-threatening. The drafting approach depends on your intent.

If you want to refuse antibiotics only when they would serve to prolong life in a terminal or irreversible condition, say so explicitly: "I refuse intravenous antibiotic therapy administered for the primary purpose of extending life when I have been diagnosed with a progressive, irreversible condition likely to result in death within 12 months."

If you want to refuse all antibiotics regardless — rare, but some people with advanced dementia or terminal conditions do — the refusal should make clear it covers all routes of administration (oral, intravenous, intramuscular).

Dialysis and Organ Support

Less common in ADRTs but increasingly relevant for people with chronic kidney disease or multi-organ conditions. A refusal of renal replacement therapy (haemodialysis, peritoneal dialysis) follows the same drafting principles: name the specific intervention, define the clinical trigger, and include the "even if my life is at risk as a result" clause.

The "Basic Care" Line

Every ADRT should include a positive statement alongside the refusals. Something like: "I request that palliative care, pain management, comfort measures, basic hygiene, warmth, and the offer of oral food and water continue at all times."

This serves two purposes. It reassures clinicians that the patient is not trying to refuse everything — just specific interventions. And it demonstrates an understanding of the basic care exclusion, which strengthens the document's credibility during a validity assessment.

Why Precision Is the Whole Game

An ADRT that says "I refuse life support" is almost useless. An ADRT that names each treatment, defines the clinical trigger using clear clinical criteria, includes the statement that it applies "even if my life is at risk as a result," and has been signed and witnessed is close to unassailable.

The England ADRT Guide includes a clinical phrasing registry with ready-to-use drafting templates for each of these treatment categories — calibrated to the clinical terminology that English hospital teams actually recognise and respond to.

See more England guides →