What is an advance decision — and how do you make sure your wishes about medical treatment are respected?

What exactly is an advance decision — and is it the same as a living will?

The legal term is an Advance Decision to Refuse Treatment, or ADRT. In England and Wales, this is the document’s official name under the Mental Capacity Act 2005 — but you will also hear it called a living will, an advance directive, or simply an advance decision. They all refer to the same thing.

An advance decision lets you state, in writing, which medical treatments you would refuse in specific circumstances — before those circumstances arise. That might mean refusing to be placed on a ventilator, declining resuscitation, or refusing artificial nutrition if you were ever in a persistent vegetative state. The key point is that it only applies when you are no longer able to make or communicate your own decisions.

It is not the same as an Advance Statement, which is a broader written record of your general preferences and values. An advance statement is not legally binding — doctors should take it into account, but they are not required to follow it. An advance decision, by contrast, is legally binding, provided it is properly made.

Why does it matter if you already have a Lasting Power of Attorney?

Many people assume that giving someone a Lasting Power of Attorney (LPA) for health and welfare covers all eventualities — but there is an important gap. Your LPA attorney can make health decisions on your behalf, but only in areas where you have not already refused a specific treatment in a valid advance decision. An ADRT takes legal priority over your attorney on the treatments it covers.

The two documents work together rather than replacing each other. Your advance decision handles the specific treatments you know you would never want. Your LPA attorney handles everything else — the day-to-day health and care decisions that are harder to predict in advance.

If you have neither document, doctors will make decisions based on what they judge to be in your best interests. That may not reflect what you would have chosen — and by then, there is no way to ask you.

What treatments can you refuse — and what can you not refuse?

You can refuse almost any medical treatment, including:

• Cardiopulmonary resuscitation (CPR)
• Ventilation and artificial breathing support
• Artificial nutrition or hydration through a tube
• Dialysis
• Specific medications, operations, or blood transfusions

What you cannot do is request a specific treatment — doctors are not legally required to provide any treatment just because you have asked for it in writing. You cannot request assisted dying, which remains illegal in England and Wales. And you cannot refuse basic comfort care: pain relief, warmth, mouth care, and personal hygiene will always continue, regardless of your advance decision.

What makes an advance decision legally binding?

This is where many people go wrong. A vague or incomplete advance decision may not be followed, and doctors cannot be held responsible for acting without it if it did not meet the legal standard. For it to be valid under the Mental Capacity Act 2005, you must:

• Be 18 or over when you make it
• Have mental capacity at the time of writing
• Name the specific treatment you are refusing
• State the circumstances in which the refusal applies
• Not have said or done anything since that contradicts it

If your advance decision covers life-sustaining treatment — anything that keeps you alive, such as CPR, a ventilator, or a feeding tube — there are additional requirements. It must be in writing, signed by you, signed by a witness, and include a statement confirming it applies even if your life is at risk as a result. Without that phrase, for life-sustaining refusals, the decision is not legally binding.

How do you make an advance decision — and does it cost anything?

No, it is completely free. You do not need a solicitor. You can write your advance decision yourself or use a free template — and using a template is strongly recommended, because the wording needs to be precise.

The best starting point is the charity Compassion in Dying, which offers a free downloadable advance decision pack at compassionindying.org.uk. The pack includes clear guidance on how to word your decisions correctly, a model form, and instructions for what to do once it is signed. Age UK also has a helpful factsheet, and the NHS website (nhs.uk) explains the process in plain English.

Before you finalise anything, speak with your GP. They can advise on which treatments might be relevant given your particular health situation, help you word decisions accurately, and — crucially — add your advance decision to your medical record so it is accessible in an emergency. They cannot override your decision, but their input can make the difference between a document that stands up and one that leaves room for doubt.

Review your advance decision regularly — especially after any significant change in your health or circumstances. There is no expiry date, but an advance decision written ten years ago may no longer reflect your current wishes, and an outdated one could be challenged.

Where should you keep it — and who needs a copy?

An advance decision is only useful if the right people can find it when it matters. Once you have signed and witnessed it, take these steps:

• Give a copy to your GP — ask them to add it to your medical records and flag it so it appears in an emergency
• Give a copy to any hospital consultants who manage your ongoing care
• Give a copy to your LPA attorney, so they know what you have already decided
• Tell close family members that it exists and where the original is kept
• Keep the original somewhere accessible at home — not locked in a safe or held at a solicitor’s office where it cannot be retrieved quickly

One practical tip that many people overlook: the NHS Summary Care Record in England does not automatically store advance decisions. Sharing it directly with your GP practice is the only reliable way to make sure it is on your file. Some people also carry a card in their wallet noting that an advance decision exists and where it is held — particularly useful if they are taken to hospital by ambulance and cannot speak for themselves.