Advance Directives in Care Homes and Hospitals in Northern Ireland

Moving into a care home or being admitted to hospital changes the dynamics of healthcare decision-making almost overnight. Decisions that used to happen in your own living room — which treatments you'd accept, which you'd refuse, how aggressively you want to be resuscitated — now pass through clinical teams, ward protocols, and care home policies that may not know your wishes exist.

In Northern Ireland, where there's no Health and Welfare Power of Attorney to appoint a medical proxy, this transition is especially precarious. Your Advance Decision to Refuse Treatment is the only mechanism for recording legally binding treatment refusals across these settings.

What Happens to Your ADRT When You Enter a Care Home

When a person moves into residential or nursing care in Northern Ireland, there's no automatic process that transfers their advance directive into the care home's records. The care home's admissions team will typically ask about existing advance care plans, but they're asking — they're not checking with your GP or searching any central register, because no such register exists.

This means you (or your family, if you're helping an elderly parent) need to actively hand over a copy of the ADRT during the admission process. Ask the care home manager to confirm in writing that the document has been placed in the resident's care file and that all staff with clinical responsibilities have been made aware of it.

For nursing homes specifically — those providing round-the-clock nursing care — the registered nurse on duty needs to understand the specific treatments being refused. A blanket "no aggressive treatment" statement is too vague to give clinicians a clear, applicable refusal. If your ADRT refuses CPR, mechanical ventilation, or clinically assisted nutrition, those refusals need to be clearly flagged in the nursing care plan so they're accessible during an emergency, not buried in an admissions folder.

Hospital Admissions and Emergency Departments

Hospital settings present a different challenge. If someone with an ADRT is admitted to a Northern Ireland hospital — whether it's the Royal Victoria in Belfast, Altnagelvin in Derry, or Craigavon Area Hospital — the admitting team needs to locate the directive quickly, especially if the patient arrives without capacity.

The strongest safeguard is having the ADRT already recorded in the patient's GP electronic record with an emergency flag. A hospital clinician may be able to find the directive through the patient's electronic care record if the GP practice has scanned and flagged it. But this only works if the GP practice actually scanned and flagged the document — and not all practices do this consistently across Northern Ireland's five Health and Social Care Trusts.

As a practical backup, keep a wallet card or medical alert noting that an ADRT exists and where it's held. If a family member accompanies the patient to A&E, they should tell the triage nurse immediately and provide a copy of the directive if they have one.

The ReSPECT Form and How It Interacts with Your ADRT

Many hospitals and care homes in Northern Ireland use the ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process. This is a clinician-led conversation that produces a summary form outlining recommended treatments in an emergency. It is not the same thing as an ADRT, and it doesn't replace one.

A ReSPECT form reflects clinical recommendations — it records what treatments a doctor thinks are appropriate given the patient's condition. An ADRT reflects the patient's own legally binding refusals. If there's a conflict between the two, the valid ADRT takes precedence under common law.

The risk comes when a care home or hospital creates a ReSPECT form without checking whether the patient already has an ADRT. The ReSPECT might recommend treatments the patient has explicitly refused. Make sure whoever is leading the ReSPECT conversation knows the ADRT exists and has read it before finalising the form.

Practical Steps for Care Transitions

Whether you're planning your own care transition or managing one for a parent, the same checklist applies:

• Before admission: confirm the ADRT is up to date. If it refuses life-sustaining treatment, confirm it is in writing, signed and dated, witnessed by an independent adult who also signs and dates the document, and includes the "even if my life is at risk" clause
• During admission: hand a certified copy to the care home manager or hospital admissions team, and ask for written confirmation it's been added to the care file
• After admission: verify with the GP that the electronic record flag is still active and linked to the correct document version
• At every care review: ask whether the clinical team has reviewed the ADRT and whether it still aligns with the current care plan

The Northern Ireland Advance Decision to Refuse Treatment guide includes a document distribution log and an HSC Trust directory — both designed for exactly this kind of transition, so every copy is tracked and every relevant clinician knows where to find it.

When Care Settings Change Again

Care transitions don't happen just once. A care home resident might be hospitalised for a fall, then transferred back. A hospital patient might be moved from a medical ward to a rehabilitation unit. Each move is a point where the ADRT can get lost in paperwork or simply not follow the patient.

The best protection is redundancy: copies with the GP, copies in the care home file, copies held by a trusted family member, and a wallet card on the person themselves. In Northern Ireland's fragmented system — five separate HSC Trusts and no central ADRT register — this belt-and-braces approach isn't paranoia. It's the only reliable strategy.

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