Advance Directive Mistakes to Avoid UK

Most Invalid ADRTs Fail on Technicalities, Not Intent

The person's wishes were clear. The document they created was not. Under the Mental Capacity Act 2005, an ADRT that does not meet specific legal requirements is treated as invalid — meaning doctors can (and will) override it in favour of their own clinical judgement.

The difference between a valid ADRT and an invalid one is rarely the person's understanding of what they want. It is almost always a technical failure in how the document was created.

Missing the Life-at-Risk Clause

This is the most consequential mistake. If your ADRT refuses any treatment that could be considered life-sustaining — refusing CPR, refusing mechanical ventilation, refusing clinically assisted nutrition and hydration — the document must contain the statutory written statement: "even if my life is at risk as a result."

Without this exact phrase (or close equivalent), any refusal of life-sustaining treatment in the ADRT is not legally binding. The clinical team can treat it as an expression of preference rather than a binding refusal, and they will proceed with treatment.

The clause must be in writing, not just discussed verbally. And it must relate specifically to the treatments being refused — a general statement somewhere in the document is not sufficient if it is ambiguous about which treatments the life-at-risk acknowledgement covers.

Vague Clinical Language

An ADRT must specify the exact treatments being refused and the exact circumstances under which the refusals apply. Clinicians cannot follow instructions they cannot interpret.

Phrases that commonly fail:

• "I do not want to be kept alive artificially" — too vague. What counts as "artificial"? Does this include antibiotics? Oxygen therapy? A feeding tube?
• "No treatment if I have no quality of life" — who defines quality of life? The clinical team will argue this is too subjective to apply.
• "I refuse treatment in the event of severe brain damage" — "severe" has no standardised clinical definition. A doctor can argue the patient's condition does not meet the threshold.

What works is clinical specificity: "I refuse clinically assisted nutrition and hydration (including nasogastric or PEG feeding) if I am diagnosed with a persistent disorder of consciousness lasting more than four weeks, even if my life is at risk as a result."

The more precisely you describe the treatments and the clinical scenarios, the harder it is for a clinician to argue the ADRT is "not applicable" to the current situation.

Witnessing Failures

If your ADRT covers life-sustaining treatment, it must be witnessed. The witness must:

• Be present when you sign the document
• Sign the document themselves
• Be 18 or older

There is no restriction on who can witness an ADRT (unlike the stricter rules for LPA witnesses — attorneys cannot witness LPA signatures). A family member, friend, or colleague can serve as witness.

The common error is not having a witness at all. People create ADRTs at home, sign them, and file them away without a witness signature. For refusals that do not cover life-sustaining treatment, a witness is not legally required. But for any refusal where your life could be at risk, the missing witness signature makes the entire refusal unenforceable.

Not Keeping the ADRT Current

An ADRT does not expire. But under Section 25 of the Mental Capacity Act 2005, a clinical team can question whether an old document still reflects the patient's current wishes, especially if the patient's circumstances have changed significantly since it was written.

More critically, if the patient has done anything "clearly inconsistent" with the ADRT while they still had capacity — accepting a treatment they previously refused, for example — the document can be deemed inapplicable.

The safeguard is periodic review. Re-signing and re-dating your ADRT (with a fresh witness signature if it covers life-sustaining treatment) every one to two years, or after any major health event, demonstrates that the document reflects your current wishes. Add a line: "I have reviewed this document on [date] and confirm it continues to reflect my wishes."

Creating an ADRT After Registering an LPA — Without Understanding Precedence

Under the Mental Capacity Act 2005, whichever document was created more recently takes priority. If you create an LPA for Health and Welfare that gives your attorney authority over life-sustaining treatment, and then later create an ADRT refusing specific treatments, the ADRT overrides the LPA on those specific treatments.

The mistake is not understanding this interaction. Some people create both documents without realising one could override the other. Others update one document without updating the other, creating a conflict that clinical teams must resolve — often by applying to the Court of Protection.

How to Avoid All of These

A single-page checklist that verifies each legal requirement before you sign can prevent every mistake above. Our England Advance Directive guide includes an ADRT drafting worksheet with built-in validation for the life-at-risk clause, witness requirements, clinical phrasing, and LPA precedence — so the document you create is valid the first time.

See more England guides →