Refusing Treatment in Scotland: What Your Advance Directive Can and Cannot Cover

Every competent adult in Scotland has an absolute right to refuse medical treatment — even treatment that would save their life. That right is established in Scots common law and reinforced by Section 1 of the Adults with Incapacity (Scotland) Act 2000, which requires that any intervention must account for the adult's past and present wishes.

An advance directive lets you exercise that right prospectively: you document the specific treatments you refuse under defined clinical scenarios, so your choices hold even after you've lost the capacity to communicate them.

What You Can Refuse

There's no legal limit on which treatments you can refuse in an advance directive. The most commonly addressed interventions include:

Cardiopulmonary resuscitation (CPR) — chest compressions and defibrillation to restart the heart. This is also covered separately through DNACPR forms and ReSPECT plans in NHS Scotland, but including it in your advance directive creates an additional layer of documentation.

Mechanical ventilation — intubation and machine-assisted breathing. You can refuse this outright, or specify conditions (for example, accepting short-term ventilation following surgery but refusing long-term ventilation if you're in a persistent vegetative state).

Clinically assisted nutrition and hydration (CANH) — feeding tubes (nasogastric or PEG) and IV fluids delivered when you can no longer eat or drink independently. This is one of the most contested interventions in end-of-life care, and vague refusals are frequently challenged by clinical teams. Specify whether you mean you refuse CANH in all circumstances or only in defined scenarios.

Dialysis — renal replacement therapy. If you have existing kidney disease, a refusal of dialysis in the context of advancing multi-organ failure or late-stage dementia can be clearly drafted.

Antibiotics and blood products — some people choose to refuse antibiotics for secondary infections in the context of terminal illness, effectively allowing a natural death from infection rather than prolonging the dying process.

What Makes a Refusal Enforceable

A treatment refusal in your advance directive is legally binding in Scotland if it satisfies four conditions: you had decision-making capacity when you wrote it, you were fully informed about the treatments you're refusing, the refusal was made voluntarily (no coercion), and the clinical scenario that has arisen matches what the directive describes.

The fourth condition is where most directives fail. A general statement like "I refuse life-sustaining treatment" is almost impossible for a clinician to apply because every treatment could technically sustain life. Enforceable clauses name the intervention, the clinical scenario, and the explicit acknowledgement that refusal may result in death.

For example, a robust clause might read: "If I am diagnosed with advanced dementia such that I no longer recognise close family members and cannot communicate my wishes, I refuse clinically assisted nutrition and hydration, mechanical ventilation, and cardiopulmonary resuscitation. I maintain this refusal even if my life is at risk as a result."

That final sentence — the "sanctity of life" clause — is essential under Scots common law. Without it, clinicians may interpret your refusal as conditional and override it to preserve life.

What You Cannot Refuse in Advance

An advance directive is designed for refusals of medical treatment. If you have wishes about routine care such as hygiene, repositioning, or mouth care, record them separately in an advance statement or care plan and discuss them with your clinicians.

You also cannot use an advance directive to demand a specific treatment or to request interventions that your clinical team considers inappropriate. The directive only works in one direction: refusal.

Importantly, an advance directive cannot authorise euthanasia or assisted suicide. Scots law does not currently permit either, regardless of what a patient documents. A refusal of treatment that results in death is legal; an instruction to actively end life is not.

When Clinicians Can Override Your Refusal

A clinician in Scotland can lawfully override your advance directive if they have reasonable grounds to believe you've changed your mind since writing it (including verbal statements or behaviour inconsistent with the directive), the clinical situation doesn't match the scenarios described in the document, or the directive is so vague or ambiguous that it can't be safely applied to the current medical circumstances.

If a welfare attorney is in place, the clinical team must consult them. The attorney's job is to advocate for your recorded wishes — not substitute their own preferences. If a dispute arises between the clinical team and your attorney, the escalation route goes through the Mental Welfare Commission for Scotland, which appoints a Nominated Medical Practitioner to review the case.

Getting Your Refusals Onto NHS Records

Drafting precise refusal clauses is only half the job. The other half is making sure the right people can find them in an emergency. Bring the signed directive to your GP, ask them to scan it into your electronic record, flag it with a clinical alert, and upload the key details to your Key Information Summary (KIS) — the database that paramedics, NHS 24, and A&E staff actually check.

Our Scotland Advance Directive toolkit includes treatment-specific refusal templates for each of the interventions above, along with a GP request letter to ensure proper KIS upload.

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