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Health / End-of-LifeUnited Kingdom
Free Advance Decision to Refuse Treatment Template (MCA 2005)
An Advance Decision to Refuse Treatment (ADRT) is the statutory means by which a capacitous adult in England and Wales can refuse specified medical treatment in advance under the Mental Capacity Act 2005 sections 24 to 26. The refusal binds clinicians at a time when the maker no longer has capacity, provided the decision is valid and applicable on the facts. Refusal of life-sustaining treatment requires the additional formality of writing, signature, witness and an express statement that the refusal is to apply "even if life is at risk". Our free United Kingdom template builds a comprehensive ADRT covering maker details, treatments refused, life-sustaining statement, witness details and distribution, with four Expert clauses on validity and applicability framework cross-check, Mental Health Act interface, Re T binding effect and Aintree best-interests framework, and Lasting Power of Attorney Health and Welfare interface.
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Advance Decision to Refuse Treatment
Mental Capacity Act 2005 Sections 24 To 26 · 10 June 2026
ADVANCE DECISION TO REFUSE TREATMENT
I, Eleanor Margaret Whitfield, of 38 Heather Bank, Sheffield S10 4QT, born on 4 November 1948, make this Advance Decision to Refuse Treatment under the Mental Capacity Act 2005. I make this decision while I have capacity. I intend it to apply to a time at which I no longer have capacity to consent to or to refuse the treatment specified. I make this decision having considered the consequences and having sought such advice as I have considered appropriate.
I, Eleanor Margaret Whitfield, of 38 Heather Bank, Sheffield S10 4QT, born on 4 November 1948, make this Advance Decision to Refuse Treatment under the Mental Capacity Act 2005. I make this decision while I have capacity. I intend it to apply to a time at which I no longer have capacity to consent to or to refuse the treatment specified. I make this decision having considered the consequences and having sought such advice as I have considered appropriate.
1. MAKER PARTICULARS
| FULL NAME | Eleanor Margaret Whitfield |
| ADDRESS | 38 Heather Bank, Sheffield S10 4QT |
| DATE OF BIRTH | 4 November 1948 |
| NHS NUMBER | 654 230 8891 |
| TELEPHONE | 0114 555 7720 |
| GP | Dr Jasmin Patel |
| GP PRACTICE | Heather Bank Medical Centre, 14 Western Road, Sheffield S10 5BG |
2. TREATMENTS THAT I REFUSE.
I refuse the following treatments where the circumstances in section 3 below are present:
(a) cardiopulmonary resuscitation (CPR), including chest compressions, defibrillation, intubation and ventilation given for the purpose of resuscitation;
(b) artificial ventilation given other than for short post-operative recovery;
(c) clinically assisted nutrition and hydration given by nasogastric tube, percutaneous endoscopic gastrostomy (PEG) or intravenous route;
(d) antibiotics given for treatment of pneumonia or other intercurrent infection where I am in the terminal phase of an irreversible illness;
(e) long-term renal dialysis (haemodialysis or peritoneal) where I am no longer able to engage with my surroundings;
(f) chemotherapy and radiotherapy given for life prolongation rather than symptom control;
I make this list non-exhaustively. The general statement at section 2A applies to any treatment of the same character given in the circumstances described.
Specific circumstances:
The refusals above apply if at any time I have a permanent and irreversible condition that has destroyed my ability to recognise my family, to communicate meaningfully or to engage with my surroundings, or if I am in the final stage of an irreversible neurodegenerative illness (such as advanced Alzheimer disease, Lewy body dementia or motor neurone disease) where treatment would prolong dying rather than restore meaningful life.
2A. GENERAL REFUSAL STATEMENT.
I do not wish my life to be prolonged by treatment that has no realistic prospect of restoring me to a state of awareness and meaningful engagement with my family and surroundings. I have lived a full life and I value the quality of my final period above its mere length. I want clinicians to focus on comfort, dignity, and the relief of distress rather than on prolongation. I have discussed this position with my daughter, my GP and the local hospice team and they understand and respect my decision.
I refuse the following treatments where the circumstances in section 3 below are present:
(a) cardiopulmonary resuscitation (CPR), including chest compressions, defibrillation, intubation and ventilation given for the purpose of resuscitation;
(b) artificial ventilation given other than for short post-operative recovery;
(c) clinically assisted nutrition and hydration given by nasogastric tube, percutaneous endoscopic gastrostomy (PEG) or intravenous route;
(d) antibiotics given for treatment of pneumonia or other intercurrent infection where I am in the terminal phase of an irreversible illness;
(e) long-term renal dialysis (haemodialysis or peritoneal) where I am no longer able to engage with my surroundings;
(f) chemotherapy and radiotherapy given for life prolongation rather than symptom control;
I make this list non-exhaustively. The general statement at section 2A applies to any treatment of the same character given in the circumstances described.
Specific circumstances:
The refusals above apply if at any time I have a permanent and irreversible condition that has destroyed my ability to recognise my family, to communicate meaningfully or to engage with my surroundings, or if I am in the final stage of an irreversible neurodegenerative illness (such as advanced Alzheimer disease, Lewy body dementia or motor neurone disease) where treatment would prolong dying rather than restore meaningful life.
2A. GENERAL REFUSAL STATEMENT.
I do not wish my life to be prolonged by treatment that has no realistic prospect of restoring me to a state of awareness and meaningful engagement with my family and surroundings. I have lived a full life and I value the quality of my final period above its mere length. I want clinicians to focus on comfort, dignity, and the relief of distress rather than on prolongation. I have discussed this position with my daughter, my GP and the local hospice team and they understand and respect my decision.
3. LIFE-SUSTAINING TREATMENT STATEMENT.
This decision is to apply to the treatments specified even if my life is at risk as a consequence of the refusal.
I confirm that I understand the consequences of refusing these treatments and that the consequences may include my death.
Comfort care and palliation:
I continue to consent to all comfort care, palliation, oral hygiene, mouth care, repositioning for pressure-area care, analgesia, anxiolytic medication and any other treatment whose primary purpose is the relief of distress and the maintenance of dignity. I particularly want continued access to the Sheffield Northern Hospice team who have been involved in my care since 2024 and to my parish priest Father Michael Connolly for end-of-life sacraments.
This decision is to apply to the treatments specified even if my life is at risk as a consequence of the refusal.
I confirm that I understand the consequences of refusing these treatments and that the consequences may include my death.
Comfort care and palliation:
I continue to consent to all comfort care, palliation, oral hygiene, mouth care, repositioning for pressure-area care, analgesia, anxiolytic medication and any other treatment whose primary purpose is the relief of distress and the maintenance of dignity. I particularly want continued access to the Sheffield Northern Hospice team who have been involved in my care since 2024 and to my parish priest Father Michael Connolly for end-of-life sacraments.
4. WITNESS.
My signature is witnessed in my presence by Catherine Anne Harper of 7 Western Crescent, Sheffield S10 4QU, Neighbour and friend of nine years.
The witness is independent of me — not a beneficiary under my will and not a person who would inherit from me on intestacy.
Witness signature date: 10 June 2026.
My signature is witnessed in my presence by Catherine Anne Harper of 7 Western Crescent, Sheffield S10 4QU, Neighbour and friend of nine years.
The witness is independent of me — not a beneficiary under my will and not a person who would inherit from me on intestacy.
Witness signature date: 10 June 2026.
5. DISTRIBUTION AND ACCESSIBILITY.
I have lodged or will lodge a copy of this Advance Decision with: my General Practitioner (Dr Jasmin Patel); the identified hospital trust (Sheffield Teaching Hospitals NHS Foundation Trust); the donee of any Lasting Power of Attorney for Health and Welfare (Helena Margaret Whitfield (daughter, LPA Health and Welfare donee under instrument dated 14 April 2024)); a named member of my family (Helena Margaret Whitfield (daughter)).
I consent to the contents of this Advance Decision being recorded in the Summary Care Record additional information field through my GP practice so that emergency clinicians can be alerted to the existence of the decision.
I have lodged or will lodge a copy of this Advance Decision with: my General Practitioner (Dr Jasmin Patel); the identified hospital trust (Sheffield Teaching Hospitals NHS Foundation Trust); the donee of any Lasting Power of Attorney for Health and Welfare (Helena Margaret Whitfield (daughter, LPA Health and Welfare donee under instrument dated 14 April 2024)); a named member of my family (Helena Margaret Whitfield (daughter)).
I consent to the contents of this Advance Decision being recorded in the Summary Care Record additional information field through my GP practice so that emergency clinicians can be alerted to the existence of the decision.
6. VALIDITY AND APPLICABILITY FRAMEWORK CROSS-CHECK.
The Mental Capacity Act 2005 sections 24 to 26 prescribe the framework for validity and applicability. The maker addresses each limb so that any clinician considering the decision at a future time can satisfy the reasonable-belief test for validity and applicability without delay.
(a) Capacity at making position:
I have capacity at the time of making this Advance Decision. My GP Dr Jasmin Patel has conducted a contemporaneous capacity assessment at the consultation on 8 June 2026 and has documented in my GP record that I have capacity to make this decision under sections 2 and 3 of the Mental Capacity Act 2005. A copy of the contemporaneous capacity assessment is filed with this document.
(b) Not withdrawn position:
If at any time I wish to withdraw this Advance Decision in whole or in part I will do so in writing and lodge the withdrawal with the same recipients as the original. Any verbal expression of doubt about specific treatments in clinical conversation should not be treated as a withdrawal of the decision as a whole unless I expressly say so and the position is documented in writing. Routine engagement with palliative-care discussions is consistent with this decision and is not a withdrawal of it.
(c) Not inconsistent position:
I have done nothing inconsistent with this decision remaining a fixed decision. My continued engagement with palliative-care conversations, my discussions with the Sheffield Northern Hospice team, and my participation in end-of-life planning consultations with my GP are all consistent with this decision rather than against it. I will not engage in any treatment-acceptance discussions that would imply withdrawal of this Advance Decision.
(d) Scope position:
The scope of the refusals in section 2 is broad enough to cover obvious variant treatments — including any equivalent of CPR by mechanical chest compression device, any modification of ventilation strategy and any equivalent of clinically assisted nutrition and hydration whether by nasogastric tube, percutaneous endoscopic gastrostomy or intravenous route. The scope is specific enough to engage the section 25(3) applicability test — the circumstances in section 3 must be present for the refusals to operate.
The Mental Capacity Act 2005 sections 24 to 26 prescribe the framework for validity and applicability. The maker addresses each limb so that any clinician considering the decision at a future time can satisfy the reasonable-belief test for validity and applicability without delay.
(a) Capacity at making position:
I have capacity at the time of making this Advance Decision. My GP Dr Jasmin Patel has conducted a contemporaneous capacity assessment at the consultation on 8 June 2026 and has documented in my GP record that I have capacity to make this decision under sections 2 and 3 of the Mental Capacity Act 2005. A copy of the contemporaneous capacity assessment is filed with this document.
(b) Not withdrawn position:
If at any time I wish to withdraw this Advance Decision in whole or in part I will do so in writing and lodge the withdrawal with the same recipients as the original. Any verbal expression of doubt about specific treatments in clinical conversation should not be treated as a withdrawal of the decision as a whole unless I expressly say so and the position is documented in writing. Routine engagement with palliative-care discussions is consistent with this decision and is not a withdrawal of it.
(c) Not inconsistent position:
I have done nothing inconsistent with this decision remaining a fixed decision. My continued engagement with palliative-care conversations, my discussions with the Sheffield Northern Hospice team, and my participation in end-of-life planning consultations with my GP are all consistent with this decision rather than against it. I will not engage in any treatment-acceptance discussions that would imply withdrawal of this Advance Decision.
(d) Scope position:
The scope of the refusals in section 2 is broad enough to cover obvious variant treatments — including any equivalent of CPR by mechanical chest compression device, any modification of ventilation strategy and any equivalent of clinically assisted nutrition and hydration whether by nasogastric tube, percutaneous endoscopic gastrostomy or intravenous route. The scope is specific enough to engage the section 25(3) applicability test — the circumstances in section 3 must be present for the refusals to operate.
7. MENTAL HEALTH ACT INTERFACE POSITION.
The Mental Health Act 1983 compulsory treatment provisions can override an Advance Decision for treatment of the mental disorder for which the maker has been detained. The Advance Decision remains operative for physical health treatments and for treatment of the mental disorder in voluntary settings.
(a) Physical health position:
This Advance Decision remains operative for physical health treatments even if I am at any time detained under the Mental Health Act 1983. The compulsory treatment provisions in sections 62 and 63 of the Mental Health Act 1983 cover treatment of mental disorder only. The refusals in section 2 above relate to physical health treatments and remain binding in a Mental Health Act detention setting.
(b) Voluntary setting position:
This Advance Decision remains operative for treatment of any mental disorder in voluntary, non-detained settings. Informal admission to a mental health unit does not engage the Mental Health Act 1983 compulsory treatment provisions. The refusals in section 2 above remain operative in a voluntary mental health setting as in any other setting.
(c) Emergency override acknowledgement:
I acknowledge that the Mental Health Act 1983 compulsory treatment provisions may override this Advance Decision for treatment of mental disorder where I am detained under the Act. I have considered this and the decision remains as set out. The Mental Health Act 1983 compulsory treatment override does not affect the refusals of physical health treatments in section 2.
The Mental Health Act 1983 compulsory treatment provisions can override an Advance Decision for treatment of the mental disorder for which the maker has been detained. The Advance Decision remains operative for physical health treatments and for treatment of the mental disorder in voluntary settings.
(a) Physical health position:
This Advance Decision remains operative for physical health treatments even if I am at any time detained under the Mental Health Act 1983. The compulsory treatment provisions in sections 62 and 63 of the Mental Health Act 1983 cover treatment of mental disorder only. The refusals in section 2 above relate to physical health treatments and remain binding in a Mental Health Act detention setting.
(b) Voluntary setting position:
This Advance Decision remains operative for treatment of any mental disorder in voluntary, non-detained settings. Informal admission to a mental health unit does not engage the Mental Health Act 1983 compulsory treatment provisions. The refusals in section 2 above remain operative in a voluntary mental health setting as in any other setting.
(c) Emergency override acknowledgement:
I acknowledge that the Mental Health Act 1983 compulsory treatment provisions may override this Advance Decision for treatment of mental disorder where I am detained under the Act. I have considered this and the decision remains as set out. The Mental Health Act 1983 compulsory treatment override does not affect the refusals of physical health treatments in section 2.
8. RE T BINDING EFFECT AND AINTREE FRAMEWORK CROSS-REFERENCE.
Re T (Adult: Refusal of Treatment) [1992] 4 All ER 649 (CA) confirms that a capacitous adult may refuse treatment for any reason or for no reason, even where the refusal will result in death. This Advance Decision operationalises that common-law principle for the period of subsequent incapacity. Where the Advance Decision is for any reason held not valid or not applicable, the best-interests framework in Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67 applies as a back-up.
(a) Re T autonomous refusal position:
I rely on the Re T autonomous refusal principle. <em>Re T (Adult: Refusal of Treatment)</em> [1992] 4 All ER 649 (CA) confirms that a capacitous adult may refuse treatment for any reason or for no reason. My capacitous decision recorded in this Advance Decision is binding without reference to its reasonableness or to clinical disagreement. The decision is to be honoured at the time of subsequent incapacity as if it were made by me at that point with capacity.
(b) Aintree holistic position:
Where for any reason this Advance Decision is held not valid or not applicable in particular circumstances, the best-interests framework in <em>Aintree University Hospitals NHS Foundation Trust v James</em> [2013] UKSC 67 applies. Lady Hale at paragraphs 35-45 emphasised the holistic welfare assessment giving substantial weight to the patient values. The values expressed in this Advance Decision are decisive evidence of my best interests under section 4 of the Mental Capacity Act 2005 and should be applied in any best-interests assessment as the principal evidence of my wishes and feelings.
(c) Judicial clarification route:
If there is any genuine doubt as to the existence, validity or applicability of this Advance Decision at the time treatment falls to be considered, the issue may be referred to the Court of Protection under section 26(4) of the Mental Capacity Act 2005 for a declaration. My LPA donee and the family have authority and standing to seek such a declaration. Pending judicial clarification, my donee and family should be consulted in any best-interests assessment as the principal source of evidence about my wishes and feelings.
Re T (Adult: Refusal of Treatment) [1992] 4 All ER 649 (CA) confirms that a capacitous adult may refuse treatment for any reason or for no reason, even where the refusal will result in death. This Advance Decision operationalises that common-law principle for the period of subsequent incapacity. Where the Advance Decision is for any reason held not valid or not applicable, the best-interests framework in Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67 applies as a back-up.
(a) Re T autonomous refusal position:
I rely on the Re T autonomous refusal principle. <em>Re T (Adult: Refusal of Treatment)</em> [1992] 4 All ER 649 (CA) confirms that a capacitous adult may refuse treatment for any reason or for no reason. My capacitous decision recorded in this Advance Decision is binding without reference to its reasonableness or to clinical disagreement. The decision is to be honoured at the time of subsequent incapacity as if it were made by me at that point with capacity.
(b) Aintree holistic position:
Where for any reason this Advance Decision is held not valid or not applicable in particular circumstances, the best-interests framework in <em>Aintree University Hospitals NHS Foundation Trust v James</em> [2013] UKSC 67 applies. Lady Hale at paragraphs 35-45 emphasised the holistic welfare assessment giving substantial weight to the patient values. The values expressed in this Advance Decision are decisive evidence of my best interests under section 4 of the Mental Capacity Act 2005 and should be applied in any best-interests assessment as the principal evidence of my wishes and feelings.
(c) Judicial clarification route:
If there is any genuine doubt as to the existence, validity or applicability of this Advance Decision at the time treatment falls to be considered, the issue may be referred to the Court of Protection under section 26(4) of the Mental Capacity Act 2005 for a declaration. My LPA donee and the family have authority and standing to seek such a declaration. Pending judicial clarification, my donee and family should be consulted in any best-interests assessment as the principal source of evidence about my wishes and feelings.
9. LASTING POWER OF ATTORNEY HEALTH AND WELFARE INTERFACE.
A subsequent grant of a Lasting Power of Attorney for Health and Welfare conferring authority on the donee to refuse the treatment revokes this Advance Decision for that treatment under section 25(2)(b) of the Mental Capacity Act 2005. The Advance Decision remains operative for treatments outside the donee authority and for periods when the LPA has not been activated.
(a) LPA revocation position:
I have granted a Lasting Power of Attorney for Health and Welfare in favour of my daughter Helena Margaret Whitfield by instrument dated 14 April 2024 and registered with the Office of the Public Guardian. The LPA confers authority on the donee to consent or refuse life-sustaining treatment on my behalf. The donee position is therefore in alignment with this Advance Decision and the donee will act in accordance with my wishes as recorded here and in our discussions.
(b) LPA donee priority position:
In accordance with section 25(2)(b) of the Mental Capacity Act 2005, where the donee has authority to refuse the relevant treatment, the donee decision applies and this Advance Decision is treated as documentary evidence of my prior values rather than as the operative refusal. My donee is fully informed of my values and will refuse the treatments in section 2 on my behalf as a matter of donee priority.
(c) Family communication position:
I have discussed this Advance Decision with my daughter Helena Margaret Whitfield (LPA donee), my son Robert James Whitfield, my GP Dr Jasmin Patel and the Sheffield Northern Hospice palliative-care team. Each understands my position and the reasons for it. A written summary of the family communication is filed with this document. I do not wish my family to be put in the position of taking the decision at the bedside — I have made it now while I have capacity.
A subsequent grant of a Lasting Power of Attorney for Health and Welfare conferring authority on the donee to refuse the treatment revokes this Advance Decision for that treatment under section 25(2)(b) of the Mental Capacity Act 2005. The Advance Decision remains operative for treatments outside the donee authority and for periods when the LPA has not been activated.
(a) LPA revocation position:
I have granted a Lasting Power of Attorney for Health and Welfare in favour of my daughter Helena Margaret Whitfield by instrument dated 14 April 2024 and registered with the Office of the Public Guardian. The LPA confers authority on the donee to consent or refuse life-sustaining treatment on my behalf. The donee position is therefore in alignment with this Advance Decision and the donee will act in accordance with my wishes as recorded here and in our discussions.
(b) LPA donee priority position:
In accordance with section 25(2)(b) of the Mental Capacity Act 2005, where the donee has authority to refuse the relevant treatment, the donee decision applies and this Advance Decision is treated as documentary evidence of my prior values rather than as the operative refusal. My donee is fully informed of my values and will refuse the treatments in section 2 on my behalf as a matter of donee priority.
(c) Family communication position:
I have discussed this Advance Decision with my daughter Helena Margaret Whitfield (LPA donee), my son Robert James Whitfield, my GP Dr Jasmin Patel and the Sheffield Northern Hospice palliative-care team. Each understands my position and the reasons for it. A written summary of the family communication is filed with this document. I do not wish my family to be put in the position of taking the decision at the bedside — I have made it now while I have capacity.
10. SIGNATURE AND ATTESTATION.
I sign this Advance Decision to Refuse Treatment with effect from the date set out at the head of the document. I confirm that I am eighteen years of age or older, that I have capacity at the time of signing and that I make this decision freely without pressure. I have considered the consequences and the implications for my care.
I sign this Advance Decision to Refuse Treatment with effect from the date set out at the head of the document. I confirm that I am eighteen years of age or older, that I have capacity at the time of signing and that I make this decision freely without pressure. I have considered the consequences and the implications for my care.
MAKER
Eleanor Margaret Whitfield
Date: ____________________
WITNESS
Catherine Anne Harper
Date: ____________________
Available as a print-ready PDF or an editable Microsoft Word (.docx) file.
What Is an Advance Decision to Refuse Treatment?
An Advance Decision to Refuse Treatment (ADRT) is a statutory document under the Mental Capacity Act 2005 by which a capacitous adult in England and Wales can refuse specified medical treatment at a future time when he or she no longer has capacity to consent to or to refuse the treatment. The ADRT is the operative form of the common-law autonomous refusal principle confirmed in Re T (Adult: Refusal of Treatment) [1992] 4 All ER 649 (CA) — a capacitous adult may refuse treatment for any reason or for no reason, even where the refusal will result in death. The ADRT operationalises the principle for the period of subsequent incapacity.
The MCA does not prescribe a fixed statutory form. The best-practice ADRT format published by the National Council for Palliative Care, the Resuscitation Council UK and adopted across NHS Trusts is widely used. Where the ADRT refuses life-sustaining treatment, section 25(5) and (6) of the MCA requires the additional formality: (a) the decision is in writing; (b) the maker has signed (or signature has been made in the maker presence at the maker direction); (c) the decision is verified by a statement that it is to apply to the treatment "even if life is at risk"; (d) the signature is witnessed; (e) the witness has signed in the maker presence. Without these formalities, the refusal does not cover treatments where life is at risk and clinicians can lawfully provide life-sustaining treatment under section 5 of the MCA.
Validity under section 25(1) and (4) requires that the maker was an adult with capacity at the time of making, the ADRT has not been withdrawn, the maker has not conferred subsequent authority on a donee of a Lasting Power of Attorney for Health and Welfare to consent or refuse the treatment, and the maker has not done anything clearly inconsistent with the ADRT remaining a fixed decision. Applicability under section 25(3) requires that the treatment falls within the scope of what is refused, the circumstances specified by the maker are present, and there are no reasonable grounds for believing that circumstances exist which the maker did not anticipate and which would have affected the decision. Where for any reason the ADRT is held not valid or not applicable, the best-interests framework in Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67 applies — the patient values expressed in the ADRT are decisive evidence of best interests.
What's Covered in This Template
Our United Kingdom Advance Decision template builds a comprehensive document covering maker details, treatments refused, life-sustaining statement, witness details and distribution, with four Expert clauses on validity and applicability framework, Mental Health Act interface, Re T binding effect and Aintree best-interests, and LPA Health and Welfare interface.
Maker Details and GP Identification
Captures the maker full name, address, date of birth, NHS number and telephone, plus the maker GP name and practice address. The maker identification anchors the document and the GP identification supports the distribution and Summary Care Record additional information flag.
Treatments Refused — Comprehensive List
Captures the specific treatments refused — cardiopulmonary resuscitation (CPR) including chest compressions, defibrillation, intubation and ventilation given for resuscitation; artificial ventilation given other than for short post-operative recovery; clinically assisted nutrition and hydration by nasogastric tube, percutaneous endoscopic gastrostomy (PEG) or intravenous route; antibiotics in the terminal phase of irreversible illness; blood products; long-term renal dialysis; chemotherapy and radiotherapy given for life prolongation rather than symptom control. Specific circumstances and a general refusal statement are added.
Life-Sustaining Treatment Statement — The Heart of the Document
Captures the express statement that the refusal applies "even if life is at risk" — the section 25(5) and (6) requirement for life-sustaining treatment refusal to operate. Without this statement, the refusal does NOT cover treatments where life is at risk and clinicians can lawfully provide life-sustaining treatment under section 5 of the MCA. Comfort care, palliation and dignity preferences are captured separately.
Witness Details and Independence
Captures the witness name, address, relationship to the maker and signature date. Witness independence is captured separately — not a beneficiary under the maker will, not a person who would inherit on intestacy. While the MCA does not specifically require an independent witness, best practice strongly favours one to avoid any later challenge to validity on grounds of undue influence or interest in the maker death.
Distribution to GP, Hospital, LPA Donee and Family
Captures the lodging arrangements — copy to GP (recommended), copy to identified hospital trust, copy to LPA donee (where the maker has granted an LPA Health and Welfare), copy to named family or friend, and Summary Care Record additional information flag consent. Distribution is the practical step that makes the ADRT effective at the bedside.
Validity and Applicability Framework Cross-Check (Expert)
Expert clause pre-stages the validity and applicability framework so clinicians can satisfy the reasonable-belief test under section 5 of the MCA without delay. Each limb is addressed — capacity at making (with contemporaneous capacity assessment filed), not withdrawn (written withdrawal lodging arrangements), not inconsistent (palliative-care engagement consistent), and scope (broad enough for variant treatments, specific enough for s.25(3) applicability).
Mental Health Act Interface (Expert)
Expert clause maps the Mental Health Act 1983 boundary. The compulsory treatment provisions in sections 62 and 63 of the MHA 1983 can override the ADRT for treatment of the mental disorder for which the patient has been detained. The ADRT remains operative for physical health treatments and for treatment of the mental disorder in voluntary, non-detained settings.
Re T Binding Effect and Aintree Framework (Expert)
Expert clause pre-stages the Re T autonomous refusal principle and the Aintree best-interests back-up. Per Re T (Adult: Refusal of Treatment) [1992] 4 All ER 649 (CA) a capacitous adult may refuse treatment for any reason or for no reason. Per Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67 even where the ADRT is held not valid or not applicable, the patient values expressed in it are decisive evidence of best interests.
LPA Health and Welfare Interface (Expert)
Expert clause maps the LPA interface. Where a subsequent Lasting Power of Attorney for Health and Welfare confers authority on the donee to refuse the relevant treatment, the donee decision applies under section 25(2)(b) of the MCA — the ADRT remains as documentary evidence of the maker prior values. Where no LPA is in force, the ADRT remains operative in full.
Comfort Care and Palliation Preferences
Pre-staged comfort care and palliation request — continued consent to all comfort care, palliation, oral hygiene, mouth care, repositioning for pressure-area care, analgesia, anxiolytic medication and any treatment whose primary purpose is the relief of distress and maintenance of dignity. Specific preferences for hospice involvement, religious or spiritual care and contact with named family or friends are captured.
Summary Care Record Additional Information Flag
Pre-staged consent to the contents of the ADRT being recorded in the Summary Care Record additional information field through the maker GP practice. The SCR additional information flag alerts emergency clinicians to the existence of the ADRT and supports immediate compliance at the bedside.
Court of Protection Clarification Route
Where there is genuine doubt as to existence, validity or applicability of the ADRT at the time treatment falls to be considered, the issue may be referred to the Court of Protection under section 26(4) of the MCA for a declaration. The LPA donee and family have authority and standing to seek such a declaration. Pending judicial clarification, the donee and family should be consulted in any best-interests assessment.
How to Build an Advance Decision to Refuse Treatment
Follow these steps to produce a comprehensive Advance Decision under the Mental Capacity Act 2005 sections 24 to 26 that binds clinicians at the time of subsequent incapacity.
- 1
Confirm Capacity at the Time of Making
Capacity at the time of making is the threshold requirement. Where doubt exists or the document anticipates challenge, ask your GP to conduct a contemporaneous capacity assessment under sections 2 and 3 of the MCA and document the assessment in your GP record. File a copy with the ADRT itself.
- 2
List the Treatments You Refuse
List the specific treatments you refuse — CPR, artificial ventilation, clinically assisted nutrition and hydration, antibiotics in the terminal phase, blood products, long-term dialysis, chemotherapy and radiotherapy given for life prolongation rather than symptom control. Add a general statement capturing your overall values to support broad interpretation in variant cases.
- 3
Specify the Circumstances
Specify the circumstances in which the refusals apply — permanent and irreversible loss of awareness, advanced neurodegenerative illness (Alzheimer disease, Lewy body dementia, motor neurone disease), terminal phase of cancer, or other clinical context. The circumstances form the section 25(3) applicability test — the listed circumstances must be present for the refusals to operate.
- 4
Make the Life-Sustaining Treatment Statement
Make the express statement that the refusal applies "even if life is at risk" — this is the section 25(5) and (6) requirement for life-sustaining treatment refusal to operate. Without this statement, the refusal does NOT cover treatments where life is at risk and clinicians can lawfully provide life-sustaining treatment under section 5 of the MCA.
- 5
Choose an Independent Witness
Choose a witness who is not a beneficiary under your will and not a person who would inherit on intestacy. While the MCA does not strictly require an independent witness, best practice strongly favours one. The witness must sign in your presence; you must sign in the witness presence (or have signature made at your direction in your presence).
- 6
Lodge Copies with GP, Hospital, LPA Donee and Family
Lodge a copy with your GP for recording on your medical record. Lodge a copy with any hospital trust where treatment is anticipated. Lodge a copy with any LPA donee you have appointed. Lodge a copy with a named family member or close friend. Consent to the Summary Care Record additional information flag so emergency clinicians are alerted to the ADRT.
- 7
Cross-Check Validity and Applicability (Expert)
Expert clause. Pre-stage the section 25(1) to (4) validity framework — capacity at making (with contemporaneous assessment), not withdrawn (written withdrawal arrangements), not inconsistent (palliative-care engagement supports rather than contradicts), and scope (broad enough for variant treatments, specific enough for applicability). Each limb supports a clinician applying the reasonable-belief test under section 5 of the MCA.
- 8
Map the Mental Health Act Boundary (Expert)
Expert clause. The compulsory treatment provisions in sections 62 and 63 of the Mental Health Act 1983 can override the ADRT for treatment of the mental disorder for which you have been detained. The ADRT remains operative for physical health treatments and for treatment of the mental disorder in voluntary settings. Pre-stage the position to avoid confusion at the time of treatment.
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Engage Re T Binding Effect and Aintree Framework (Expert)
Expert clause. Per Re T (Adult: Refusal of Treatment) [1992] 4 All ER 649 (CA) your capacitous refusal is binding without reference to its reasonableness or to clinical disagreement. Per Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67, even where the ADRT is held not valid or not applicable, your values expressed in it are decisive evidence of best interests under section 4 of the MCA.
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Map the LPA Interface (Expert)
Expert clause. Where you have granted a Lasting Power of Attorney for Health and Welfare conferring authority on the donee to refuse the relevant treatment, the donee decision applies under section 25(2)(b) of the MCA — your ADRT remains as documentary evidence of your prior values. Where no LPA is in force, your ADRT remains operative in full.
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Discuss with Family, GP and Palliative-Care Team
Discuss the ADRT with your family, your GP and any palliative-care team involved in your care. Record the discussion in writing and file the record with the ADRT. The family communication supports the validity framework (not inconsistent), the applicability framework (your wishes are widely known) and the practical operation of the ADRT at the bedside.
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Legal Considerations — Advance Decision to Refuse Treatment
The Mental Capacity Act 2005 sections 24 to 26 provides the statutory framework for advance refusals of treatment by capacitous adults in England and Wales. The framework operationalises the common-law autonomous refusal principle confirmed in Re T (Adult: Refusal of Treatment) [1992] 4 All ER 649 (CA) for the period of subsequent incapacity. The Court of Protection has jurisdiction to determine existence, validity and applicability of an Advance Decision under section 26(4).
This template is for general information and does not constitute legal advice. Advance Decisions involve substantive medical law, end-of-life decision-making and the interface with Lasting Powers of Attorney, the Mental Health Act 1983 and the Court of Protection jurisdiction. Where the Advance Decision is complex, anticipates Jehovah Witness blood-product refusal, anticipates clinically assisted nutrition and hydration questions, or anticipates a Mental Health Act detention context, advice from a solicitor experienced in mental capacity law, an end-of-life specialist clinician, the local hospice palliative-care team or a Court of Protection deputy is recommended. Compassion in Dying, Marie Curie, Macmillan Cancer Support and your local hospice provide free first-tier guidance. The MCA Code of Practice Chapter 9 published by the Ministry of Justice provides detailed best-practice guidance.
Reviewed for England and Wales (Scotland — Adults with Incapacity (Scotland) Act 2000 separate; Northern Ireland — Mental Capacity Act (Northern Ireland) 2016 separate)
Statutory Basis — Mental Capacity Act 2005 sections 24 to 26
The MCA sections 24 to 26 prescribe the statutory framework. Section 24 defines an Advance Decision. Section 25 sets out validity (the maker was an adult with capacity, the decision has not been withdrawn, no subsequent LPA donee has authority, the maker has not done anything clearly inconsistent) and applicability (the treatment falls within scope, the circumstances are present, no reasonable grounds for believing the maker would have decided differently). Section 26 sets out the effect — a valid and applicable ADRT has the same effect as a refusal made at the point of treatment by a capacitous adult.
Life-Sustaining Treatment Formality — section 25(5) and (6)
Where the ADRT refuses life-sustaining treatment, the additional formality applies: (a) the decision is in writing; (b) the maker has signed (or signature has been made in the maker presence at the maker direction); (c) the decision is verified by a statement that it is to apply "even if life is at risk"; (d) the signature is witnessed; (e) the witness has signed in the maker presence. The formality is mandatory — without it, life-sustaining treatment refusal does not operate.
Clinician Protection under section 5
Section 5 of the MCA protects clinicians who reasonably believe that an ADRT is not valid or not applicable and who act in what they reasonably consider to be the patient best interests. The protection is grounded in the reasonable-belief test — the clinician must have considered the document, the contemporaneous capacity evidence, the family or LPA donee position, and the patient values where known. Pre-staging the validity and applicability framework in the document supports the clinician satisfying the test without delay.
Aintree Best-Interests Framework where ADRT Not Applicable
Where the ADRT is held not valid or not applicable, the best-interests checklist in section 4 of the MCA applies. Per Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67, the best-interests assessment is a holistic welfare evaluation considering the patient values, the burdens and benefits of treatment, and the perspective of family and others close to the patient. Lady Hale at paragraphs 35-45 emphasised the focus on the patient subjective values rather than the clinician objective view of welfare. The patient values expressed in the ADRT remain decisive evidence under section 4 even where the ADRT itself is held not to operate.
LPA Health and Welfare Interface
A Lasting Power of Attorney for Health and Welfare conferring authority on the donee to refuse the relevant treatment revokes the ADRT for that treatment under section 25(2)(b). The ADRT remains operative for treatments outside the donee authority and for periods when the LPA has not been activated. Pre-stage the position by recording whether you have granted an LPA and the scope of the donee authority.
Mental Health Act 1983 Interface
The compulsory treatment provisions in sections 62 and 63 of the Mental Health Act 1983 can override the ADRT for treatment of the mental disorder for which the patient has been detained under section 3, section 37 or other qualifying section. The ADRT remains operative for physical health treatments and for treatment of the mental disorder in voluntary, non-detained settings. The interface is mapped in the Expert clause and acknowledged in the document.
Frequently Asked Questions
Build Your Advance Decision to Refuse Treatment
Produce a comprehensive Advance Decision to Refuse Treatment for England and Wales under the Mental Capacity Act 2005 sections 24 to 26 — maker details with GP identification, treatments refused (CPR, artificial ventilation, clinically assisted nutrition and hydration, antibiotics in terminal phase, blood products, long-term renal dialysis, chemotherapy and radiotherapy), specific circumstances of application, life-sustaining treatment statement with the express "even if life is at risk" verification, witness details and independence, distribution to GP, hospital, LPA donee and family with Summary Care Record additional information flag consent, and four Expert clauses on the validity and applicability framework cross-check (capacity at making with contemporaneous assessment, not withdrawn, not inconsistent, scope), Mental Health Act interface mapping the compulsory treatment override boundary, Re T binding effect and Aintree best-interests framework cross-reference (R (Aintree) v James [2013] UKSC 67), and Lasting Power of Attorney Health and Welfare interface with donee priority and family communication.
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