Advance Directive vs Power of Attorney UK
They Do Different Jobs
An Advance Decision to Refuse Treatment (ADRT) and a Health and Welfare Lasting Power of Attorney (LPA) are not interchangeable. They solve different problems, and most people in England need both.
An ADRT is a direct instruction. It tells clinicians exactly which treatments you refuse under exactly which clinical circumstances. When valid and applicable, it is legally binding — no one gets a vote on whether to follow it.
An LPA for Health and Welfare appoints a person to make decisions for you. It delegates authority rather than issuing instructions. Your attorney makes real-time judgement calls about your medical treatment, care arrangements, and daily living when you lack capacity to decide for yourself.
An Advance Statement — often confused with both — records your values, preferences, and general wishes. It is not legally binding. Clinicians must take it into account during best-interests assessments but can override it if clinical evidence points in a different direction.
The Precedence Rule
When an ADRT and a Health and Welfare LPA coexist, the relevant sequence is when the ADRT and LPA are made; the LPA must also be registered before it can be used. This rule is strict and chronological.
Scenario one: You make an ADRT refusing ventilation. Later, you make and register a Health and Welfare LPA that grants your attorney authority over life-sustaining treatment. The LPA overrides the ADRT. Your attorney can consent to ventilation despite your earlier written refusal.
Scenario two: You make and register a Health and Welfare LPA first. Later, you make an ADRT refusing ventilation. The ADRT overrides the LPA on that specific treatment. Your attorney cannot consent to ventilation, because your most recent capacitous instruction explicitly refuses it.
This sequencing trap is the most dangerous coordination error in English advance care planning. Many people set up an LPA and an ADRT without checking when each document was made or registered, leaving a quiet conflict in their documents that only surfaces during a clinical crisis.
Why You Usually Need Both
An ADRT handles the treatments you know you want to refuse — the predictable scenarios you can specify in advance. But medical situations are not always predictable. A purely mechanical set of treatment refusals cannot cover every possible clinical decision.
An LPA fills that gap. Your attorney can respond to situations you never anticipated — an experimental treatment option, a surgical complication, a change in your prognosis that shifts the calculus of what care makes sense. The LPA gives someone you trust the flexibility to advocate for you in real time.
The strongest planning position is to execute both in a deliberate sequence:
- Make and sign your ADRT first, covering the specific treatment refusals you feel certain about
- Make and register your Health and Welfare LPA afterwards, ensuring the attorney understands the ADRT exists and respects its terms
- Include a preference clause in the LPA directing the attorney to honour the ADRT's treatment refusals unless circumstances materially change
This way, the LPA technically has precedence (it was made later and must be registered before it can be used), but the attorney is guided by your documented wishes in the ADRT.
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The Cost Difference
An ADRT costs nothing to make and nothing to register — because it does not require registration.
A Health and Welfare LPA costs £92 to register with the Office of the Public Guardian. If you are also registering a Property and Financial Affairs LPA, the total is £184. Low-income applicants may qualify for a 50% fee reduction if their gross annual income is under £12,000.
The England ADRT Guide covers the full coordination strategy between both documents, including the signing sequence, how to handle the precedence rule, and a framework for ensuring your attorney and your written refusals work as a coherent system rather than contradicting each other.
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