Alternatives to the Compassion in Dying ADRT Builder

The Compassion in Dying ADRT builder is the most-used free tool in England for creating an Advance Decision to Refuse Treatment. It produces a legally valid document, it's well-designed, and it's free. If you're looking for alternatives, it's not because the tool is broken — it's because the document it produces has specific limitations that matter when a clinical team actually tests it.

Here's what those limitations are, what the alternatives offer, and which option fits your situation.

What the Compassion in Dying Builder Does Well

Credit where it's deserved. The Compassion in Dying tool walks you through a structured questionnaire, generates a formatted ADRT document that meets the statutory requirements under the Mental Capacity Act 2005, and gives you a PDF to print, sign, and witness. It covers the basics of treatment refusal, includes the required declaration for life-sustaining treatment, and provides guidance on who should receive copies.

For someone who wants a basic, legally valid ADRT without paying anything, it's the best free option available in England. The charity behind it — Compassion in Dying, the operational arm of Dignity in Dying — has deep expertise in end-of-life rights.

Where It Falls Short

The builder's limitations aren't bugs. They're design choices that reflect the tool's purpose: to help as many people as possible create a valid ADRT at zero cost. That means it optimises for breadth (serving everyone) rather than depth (serving people with complex or high-stakes situations).

Generic treatment refusal language. The builder generates refusal statements using broad categories — "life-sustaining treatment," "artificial nutrition and hydration" — rather than naming specific clinical interventions. This matters because under Sections 25–26 of the Mental Capacity Act, an ADRT must be "applicable" to the specific treatment being offered. When a clinician in A&E is deciding whether to intubate, a refusal of "life-sustaining treatment" gives them more interpretive room than a refusal of "invasive mechanical ventilation via endotracheal intubation." That interpretive room is exactly where overrides happen.

Limited clinical trigger specificity. The builder allows you to specify conditions under which your refusals apply, but the options tend toward general language — "if I have a progressive illness" or "if I am permanently unconscious." These phrases don't map precisely to the diagnostic criteria a clinician would use to assess whether the ADRT applies to the patient's current presentation. A person with moderate-to-severe dementia, for instance, is neither "terminally ill" in the acute sense nor "permanently unconscious" — but they may be in exactly the state they wanted to refuse treatment in.

No LPA integration. The builder creates an ADRT only. It doesn't address the Lasting Power of Attorney for Health and Welfare — the complementary document that appoints someone to make healthcare decisions on your behalf. More critically, it doesn't explain the document precedence rules under the Mental Capacity Act: an LPA registered after an ADRT can override the ADRT's treatment refusals when it explicitly authorizes the attorney to consent to or refuse life-sustaining treatment. If you create an ADRT through the builder and later register an LPA without understanding this interaction, you may inadvertently weaken your advance decision.

No ReSPECT or DNACPR coordination. Clinical teams in England increasingly rely on the ReSPECT process (Recommended Summary Plan for Emergency Care and Treatment) as the primary emergency care planning tool. A standalone ADRT that doesn't align with the patient's ReSPECT form creates conflicting signals — and when documents conflict, clinicians default to active treatment.

No ward advocacy guidance. The builder helps you create a document. It doesn't prepare you (or your family) for what happens when a ward team questions, challenges, or attempts to override that document. Families facing clinical pushback need statutory references, escalation pathways, and scripts — none of which a document builder provides.

The Alternatives

Option 1: Step-by-step ADRT guide with clinical precision drafting

The Advance Decision to Refuse Treatment (ADRT) Guide takes a different approach. Instead of generating a finished document, it teaches you to draft treatment refusals using specific clinical terminology — naming the exact intervention, defining the clinical trigger using diagnostic criteria, and including the statutory override clause for life-sustaining treatment.

Best for: People with progressive conditions (especially dementia), families who have experienced clinical pushback, anyone who wants their ADRT to be enforceable rather than just valid.

Option 2: Solicitor-drafted ADRT

A solicitor specialising in elderly client services or wills and probate can draft an ADRT, typically as part of a broader estate planning package.

Cost: £150–£600+ per document, often bundled with LPA preparation.

Strengths: Bespoke legal drafting, professional capacity assessment (the solicitor can act as certificate provider for the LPA), useful for complex family situations.

Weaknesses: Most solicitors use standard legal templates that have the same generic language issue as the free builder. Their expertise is in legal validity, not clinical enforceability. Updates require a new appointment and fee.

Best for: People with complex estates, blended families, or active legal disputes who need solicitor involvement for reasons beyond the ADRT itself.

Option 3: My Decisions (mydecisions.org.uk)

Another free online tool, run by the charity Advance Care Planning UK. Similar to Compassion in Dying's builder but includes Advance Statements (positive treatment preferences, which are advisory rather than binding) alongside the ADRT.

Cost: Free.

Strengths: Combines ADRT and Advance Statement in one process, clean interface, produces a formatted document.

Weaknesses: Same clinical precision limitations as Compassion in Dying. No LPA integration, no ReSPECT coordination, no ward advocacy guidance. Less well-known, so some clinical teams may be less familiar with the output format.

Best for: People who want a free alternative to Compassion in Dying's builder and also want to record positive treatment preferences (Advance Statement) alongside their refusals.

Option 4: NHS Trust advance care planning forms

Many NHS trusts offer their own advance care planning documentation, often integrated with the ReSPECT process. Your GP practice or local hospital may have templates.

Cost: Free.

Strengths: Familiar to local clinical teams, may be automatically linked to your Summary Care Record.

Weaknesses: Varies enormously by trust. Some are comprehensive; others are basic checkbox forms. They're clinical documents, not statutory instruments — the DNACPR and ReSPECT forms are advisory, not legally binding. Using a trust form without a separate statutory ADRT leaves you without binding legal protection.

Best for: As a complement to a statutory ADRT, not a replacement. The trust forms ensure local clinical teams know about your wishes; the ADRT ensures those wishes are legally enforceable.

How to Decide

The decision tree is straightforward:

1. If you want a free, basic, legally valid ADRT and your situation is relatively simple (no progressive conditions, no complex family dynamics, no history of clinical disputes): the Compassion in Dying builder is the right choice.

2. If you have a progressive condition, especially dementia, or you've seen clinical teams override a family member's wishes, or you need the ADRT to coordinate with LPAs and ReSPECT: the ADRT guide gives you the clinical precision and document integration that free tools don't.

3. If you have a complex estate or family structure and need a solicitor involved for other reasons (trusts, contested wills, Court of Protection proceedings): have the solicitor draft the ADRT as part of the broader engagement, but consider supplementing their generic language with the clinical precision templates from a specialised guide.

4. If you want to record positive preferences ("I would like palliative sedation if available") alongside your refusals: use My Decisions or an NHS trust advance care planning form for the Advance Statement, and create a separate statutory ADRT for the binding refusals.

Frequently Asked Questions

Is the Compassion in Dying ADRT legally binding?

Yes. The document it produces meets the statutory requirements under the Mental Capacity Act 2005 for a valid ADRT. The question isn't legal validity — it's clinical applicability. A valid document with generic language can be deemed "not applicable" to a specific clinical situation, giving the treating team grounds to proceed with treatment. A valid document with precise clinical language is much harder to work around.

Can I use the Compassion in Dying builder and then modify the language myself?

Yes, and this is a reasonable middle path. The builder gives you a structurally complete document. You can then refine the treatment refusal language to be more clinically specific — naming interventions, defining clinical triggers, adding the statutory override clause where needed. The guide's Clinical Precision Protocol provides the templates for exactly this kind of refinement.

Does Compassion in Dying offer any support with LPAs?

Compassion in Dying's primary focus is advance decisions and end-of-life rights, not LPA registration. They offer general information about LPAs but don't provide the signing sequence walkthrough, certificate provider eligibility guidance, or OPG fee remission navigation that a dedicated guide covers. For LPA support, the OPG's own guidance at gov.uk is the official free resource, though it's written in civil service prose that many people find difficult to follow under pressure.

What if I've already used the builder and want to strengthen my ADRT?

You can create a new ADRT at any time. The most recent valid ADRT supersedes all earlier versions. If you've already signed a Compassion in Dying document and want to replace it with something more clinically precise, draft a new ADRT, sign and witness it with the current date, and destroy or clearly mark the old one as superseded. Notify your GP, your attorneys (if you have LPAs), and anyone who holds a copy of the previous version.

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