Choosing a Substitute Decision Maker in Northern Ireland

In England, you appoint a Health and Welfare Lasting Power of Attorney and they make medical decisions on your behalf when you can't. In Scotland, a Welfare Power of Attorney does the same thing. In Northern Ireland, you can't appoint anyone to make healthcare decisions for you. Full stop.

This isn't a gap in the system that nobody's noticed. The Mental Capacity Act (Northern Ireland) 2016 includes provisions to introduce health-and-welfare LPAs, but those sections remain unimplemented. The Department of Health has been phasing in the Act since 2019, and welfare proxies haven't reached the front of the queue.

So what actually happens when someone in Northern Ireland loses the capacity to make medical decisions?

The Current Framework

When you lose mental capacity for a specific treatment decision, the clinical team makes that decision using a "best interests" assessment. This involves:

• Considering any wishes you expressed while you had capacity
• Taking into account your beliefs, values, and the factors you would have considered
• Consulting people close to you — family, friends, carers — for their views on what you would have wanted
• Weighing the medical options and their likely outcomes

Your family's input matters, but it's advisory. The consultant or senior clinician makes the final decision. If your family disagrees with the clinical team's assessment, they may need to seek a court declaration from the High Court — an expensive and time-consuming process that rarely produces results in emergency timeframes.

The Nominated Person (Limited Current Role)

The Mental Capacity Act (NI) 2016 includes a "nominated person" role for deprivation-of-liberty decisions. A person with capacity can choose and appoint a nominated person, who must be consulted in that limited context. This isn't a Health and Welfare LPA and does not give the nominated person general authority over medical treatment.

But no general healthcare-proxy arrangement is operational yet. If you're planning today, you can't rely on a general proxy to make treatment decisions for you.

The Only Tool You Have

In the absence of a healthcare proxy mechanism, your Advance Decision to Refuse Treatment (ADRT) is the only legally binding tool for controlling your future medical treatment. An ADRT doesn't appoint a proxy — it records your own decisions, made while you have capacity, about which treatments you refuse in specified circumstances.

This creates a fundamental limitation: an ADRT can only address scenarios you've anticipated. Real medical situations are messy, and decisions often arise that no advance document could have predicted. A healthcare proxy can adapt to novel situations in real time. An ADRT cannot.

This limitation makes two things essential:

Draft broadly enough to cover the most likely scenarios. Work with your GP to identify the treatments and circumstances most relevant to your health profile. A person with early dementia faces different likely interventions than someone with a cardiac condition.

Pair the ADRT with an advance statement. An advance statement records your values, preferences, and general wishes about care — not as legally binding refusals, but as guidance that clinical teams must consider during best-interests assessments. If a situation arises that your ADRT doesn't cover, your advance statement gives clinicians the closest possible understanding of what you would have wanted.

Making Your Family's Voice Count

Even without legal proxy authority, your family can still influence treatment decisions significantly:

Make sure they know your wishes. A family member who can articulate your specific preferences — "she always said she wouldn't want to be on a ventilator if there was no chance of recovery" — carries more weight in a best-interests consultation than one who can only say "we think she wouldn't have wanted this."

Designate a primary spokesperson. While NI law doesn't recognise a formal healthcare proxy, having one person identified as your preferred spokesperson reduces confusion during crisis moments. Make sure your GP records and hospital notes identify this person.

Put your wishes in writing beyond the ADRT. A detailed advance statement, a letter to your family explaining your reasoning, even a video recording of your wishes — all of these create evidence of your considered preferences that strengthens your family's hand during best-interests discussions.

What Happens Without Any Planning

If you lose capacity without an ADRT, an advance statement, or even informal conversations about your wishes, clinical teams make decisions with almost no information about what you would have wanted. Your family gets consulted, but if they disagree with each other — which happens often — the clinical team resolves the disagreement however they see fit.

In the worst case, if no family member is available or willing to act, and the decisions involve significant financial or property matters, the Office of Care and Protection may appoint a Controller to manage your affairs. Controllership applications take months, cost a £326 court fee, and come with ongoing annual administration fees of £407 to £570. The process is slow, expensive, and entirely avoidable with proper planning.

Our Northern Ireland Advance Decision to Refuse Treatment guide addresses this gap directly — combining NI-specific ADRT templates with advance statement frameworks and a family communication plan that positions your chosen spokesperson as effectively as the current legal framework allows.

See more Northern Ireland guides →