Advance Decision to Refuse Treatment

The Only Legally Binding Healthcare Refusal in England

An Advance Decision to Refuse Treatment — commonly called an ADRT — is the sole statutory instrument under English law that lets you refuse specific medical treatments in advance. It is governed by Sections 24 to 26 of the Mental Capacity Act 2005, and when valid and applicable, it carries the same legal weight as a refusal made by a conscious patient with full capacity.

That last point matters more than people realise. A valid ADRT is not guidance. It is not a wish list. It is a binding legal instruction that clinicians must follow, even if they believe the treatment would benefit you.

What Makes It Valid

An ADRT must specify the exact medical treatments you refuse and the exact clinical circumstances under which those refusals apply. Vague language — "no heroic measures" or "no treatment if my quality of life is poor" — gives clinicians grounds to argue the document does not apply to the current situation. They can then default to life-prolonging treatment under the "best interests" principle.

If your ADRT covers life-sustaining treatment — mechanical ventilation, clinically assisted nutrition and hydration, or cardiopulmonary resuscitation — it must meet additional requirements:

• It must be in writing
• It must be signed by you (or signed by someone in your presence and at your direction)
• The signature must be witnessed
• It must include a clear statement that the decision applies "even if my life is at risk as a result"

Without that specific "even if my life is at risk as a result" formulation, a refusal of life-sustaining treatment is not legally binding.

What It Cannot Do

An ADRT cannot demand specific treatments. It cannot authorise anything illegal — assisted suicide and voluntary euthanasia remain criminal offences under the Suicide Act 1961. And it cannot refuse "basic care," which the Mental Capacity Act Code of Practice defines as warmth, shelter, basic hygiene, and the offer of food or drink by mouth.

The distinction between oral and artificial nutrition matters here. You can refuse clinically assisted nutrition and hydration — tube feeding, PEG feeding, intravenous fluids — through an ADRT. But you cannot refuse the physical offer of food and water by mouth.

When It Activates

An ADRT only takes effect when you are assessed as lacking decision-specific mental capacity. If you retain capacity — even fluctuating capacity, as often happens with dementia — you can override your own ADRT by making a contemporaneous decision.

This also means that if you have a lucid interval during a period of general incapacity, your real-time decision during that interval takes legal precedence over anything in your written ADRT.

The Relationship with an LPA

An ADRT and a Health and Welfare LPA interact through strict chronological priority. The relevant sequence is when the ADRT is made and when the LPA is registered. If you register a Health and Welfare LPA that grants authority over life-sustaining treatment after making an ADRT, the LPA can override the ADRT's refusals. If you make an ADRT after registering an LPA, the ADRT takes precedence for any specific treatment it validly and applicably refuses.

Unlike an LPA, an ADRT does not need to be registered with the Office of the Public Guardian. There is no registration fee. But it does need to be stored where clinicians can find it — your GP surgery, your hospital file, and with your named attorneys if you also have an LPA.

The England ADRT Guide provides clinically precise drafting templates for each major treatment refusal, along with the exact witnessing protocol and storage procedures to ensure your document holds up in an acute clinical setting.

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