ADRT UK: Refuse Treatment Guide

An Advance Decision to Refuse Treatment (ADRT) is a legally binding document that allows you to refuse specific medical treatments in advance should you lose the capacity to make or communicate such decisions in the future. Under UK law, a properly formulated ADRT ensures healthcare professionals respect your wishes, even when you cannot express them. This guide outlines the essential components of a valid ADRT, how to create one, and important considerations to ensure your wishes are followed when it matters most.

What Is an ADRT and How It Works

An Advance Decision to Refuse Treatment (sometimes called a Living Will) is a formal declaration that specifies which medical treatments you do not consent to receive in particular circumstances if you lose decision-making capacity.

According to the Mental Capacity Act 2005, a valid ADRT is legally binding on healthcare professionals in England and Wales. Similar provisions exist in Scotland under the Adults with Incapacity (Scotland) Act 2000 and in Northern Ireland through common law.

The NHS explains that an ADRT comes into effect only when:

You lose the capacity to make or communicate the specific decision about treatment
The treatment and circumstances match those specified in your ADRT
There is no reason to believe you've changed your mind since creating the document

As clarified by the NHS website, an ADRT differs from an Advance Statement (which expresses general preferences) by specifically refusing particular medical treatments with legally binding force.

Essential Elements for a Valid ADRT

For your Advance Decision to be legally binding, it must include several key components. The Mental Capacity Act Code of Practice outlines these requirements:

Personal Identification Details

Your ADRT must clearly establish your identity through:

Full legal name
Date of birth
Current address
NHS number (if known)
Contact details
GP information

This information helps healthcare providers verify they are looking at the correct person's ADRT when making critical decisions.

Capacity Statement

Include a clear declaration that:

You had mental capacity when creating the document
You understand the nature and implications of refusing treatment
You were not under undue influence when making these decisions

This statement helps establish the validity of your decision-making at the time of creation.

Specific Treatments Refused

Your ADRT must clearly specify:

The exact treatments you are refusing
The specific circumstances in which the refusal applies

Vague statements like "no heroic measures" or "no extraordinary treatments" lack the specificity required for a legally binding ADRT. Instead, clearly name treatments such as:

Cardiopulmonary resuscitation (CPR)
Mechanical ventilation
Artificial nutrition and hydration
Antibiotics for life-threatening infections
Kidney dialysis

For each treatment, specify the circumstances in which the refusal applies, such as:

If you have a terminal illness
If you're in a persistent vegetative state
If you have severe brain damage with no prospect of recovery
If you have advanced dementia

According to Compassion in Dying, being specific about both treatments and circumstances strengthens the legal standing of your ADRT.

Life-Sustaining Treatment Statement

If refusing life-sustaining treatment, your ADRT must:

Explicitly state that the refusal applies even if your life is at risk
Include the statement: "I refuse this treatment even if my life is at risk as a result"
Be signed and witnessed

This additional requirement for life-sustaining treatments is explicitly mandated by Section 25(5) of the Mental Capacity Act 2005.

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Signature and Witness Requirements

A valid ADRT must be:

Signed by you (or by someone directed by you in your presence if you're unable to sign)
Signed in the presence of a witness
Signed by the witness in your presence

While the law doesn't specify who can witness your signature, choosing someone independent (not a spouse, partner, relative, or anyone who stands to benefit from your will) strengthens the document's credibility.

Date of Creation

Clearly date your ADRT to establish:

When it was created
That it represents your most current wishes
Its precedence over any earlier documents

Healthcare professionals are directed to follow the most recent valid ADRT, so dating is essential if you update your document.

Additional Recommended Components

While not strictly required for legal validity, these elements strengthen your ADRT and increase the likelihood your wishes will be followed:

Values Statement

A brief explanation of the values, beliefs, or experiences informing your decisions helps:

Provide context for your choices
Guide interpretation in unforeseen situations
Demonstrate your thoughtful consideration
Support the validity of your decisions

Age UK recommends including this context to help healthcare professionals understand your thinking.

GP Discussion Documentation

Including confirmation that you've discussed your ADRT with healthcare professionals strengthens its standing:

Note the date and name of professionals consulted
Include their comments if relevant
Consider asking them to countersign if they're willing

This demonstrates you made informed decisions with proper medical understanding.

Review Dates and Confirmation

Regular reviews strengthen your ADRT by showing ongoing commitment to your choices:

Include dates of reviews
Add confirmation that your wishes remain unchanged
Or note any modifications made (creating a new document)

The British Medical Association recommends reviewing your ADRT regularly to ensure it continues to reflect your wishes.

Sample ADRT Template Framework

While comprehensive ADRT forms are available from organizations like Compassion in Dying, this basic framework outlines the essential components:

ADVANCE DECISION TO REFUSE TREATMENT (ADRT)

1. PERSONAL DETAILS

Full Name: [Your full legal name]

Date of Birth: [DD/MM/YYYY]

Address: [Your current address]

NHS Number: [If known]

Telephone: [Your contact number]

GP Name and Surgery: [Your GP's details]

2. CAPACITY DECLARATION

I, [Your Name], make this Advance Decision to Refuse Treatment at a time when I have the capacity to make such decisions. I understand the nature and consequences of refusing the specified treatments, including that my life may be shortened as a result. I make this decision freely without pressure from others.

3. TREATMENT REFUSALS

I refuse the following specific treatments in the circumstances described:

Treatment 1: [Specific treatment, e.g., Cardiopulmonary Resuscitation (CPR)]

Circumstances: [Specific situation, e.g., If I have suffered severe brain damage with no reasonable prospect of recovery]

Treatment 2: [Specific treatment, e.g., Mechanical Ventilation]

Circumstances: [Specific situation, e.g., If I am in a persistent vegetative state]

[Add additional treatment refusals as needed]

4. LIFE-SUSTAINING TREATMENT STATEMENT

I confirm that my refusals above apply even if my life is at risk or may be shortened as a result of my decision.

5. VALUES STATEMENT

I have made these decisions based on the following beliefs and values:

[Brief explanation of your values, beliefs, or experiences that inform your decisions]

6. DISCUSSIONS WITH HEALTHCARE PROFESSIONALS

I have discussed this Advance Decision with:

Healthcare Professional: [Name and role]

Date of Discussion: [Date]

Comments: [Any relevant comments]

7. SIGNATURE

Signed (Your signature): ___________________

Date: ___________________

8. WITNESS

I witness that the person named above signed this document in my presence, appearing to understand its meaning and free from duress.

Witness Name: ___________________

Witness Signature: ___________________

Witness Address: ___________________

Date: ___________________

9. REVIEW DATES

This Advance Decision was reviewed on the following dates and remains an accurate statement of my wishes:

Review Date: _______________ Signature: _______________

Secure storage and accessibility

Creating a valid ADRT is only the first step—ensuring it's available when needed is equally important. The National Institute for Health and Care Excellence recommends multiple approaches to storage and accessibility:

Where to Keep Your ADRT

Store copies in multiple locations:

With your GP (ask them to add it to your medical records)
With your hospital consultant if you have one
At home in a prominent location (some people use the refrigerator door)
With your next of kin or trusted friends
With your solicitor if you have one
In a secure digital vault with emergency access features

Communication and Awareness

Ensure relevant people know about your ADRT:

Discuss it with close family members and friends
Inform healthcare professionals involved in your care
Carry a card in your wallet stating you have an ADRT and where to find it
Consider wearing a medical alert bracelet if refusing common emergency treatments
Create a list of everyone who has a copy so you can update them if you make changes

Electronic Record Systems

Take advantage of electronic health record systems:

Ask your GP to add your ADRT to your Summary Care Record with additional information
In England, consider registering with the NHS app which can provide access to your records
In Wales, ask about your Welsh GP record
In Scotland, discuss the Emergency Care Summary
In Northern Ireland, ask about the Northern Ireland Electronic Care Record

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Common Pitfalls to Avoid

According to research from the King's College London Cicely Saunders Institute, several common issues can undermine ADRTs:

Vague or Unclear Language

Avoid:

General statements like "no heroic measures"
Ambiguous terms open to interpretation
Conflicting or contradictory statements
Medical jargon you don't fully understand

Instead, use specific, clear language about exact treatments and precise circumstances.

Not Addressing Life-Sustaining Treatments Properly

Remember that refusals of life-sustaining treatments must:

Be in writing
Be signed and witnessed
Explicitly state that the refusal applies even if life is at risk

Failing to meet these requirements invalidates this portion of your ADRT.

Outdated Documents

ADRTs can become outdated due to:

Changes in your health situation
Advances in medical treatments
Evolution in your own views
Changes in your personal circumstances

Regular reviews (at least annually and after any significant health changes) help ensure your ADRT remains current.

Conflicting Documentation

Confusion can arise if you have:

Multiple versions of your ADRT with different dates
An ADRT and a Lasting Power of Attorney for Health and Welfare that conflict
Different wishes expressed to different healthcare providers

Always revoke previous versions explicitly, ensure consistency across documents, and communicate changes to everyone with copies.

Special Considerations for Different Medical Conditions

Tailoring your ADRT to your specific health situation strengthens its applicability. The General Medical Council advises healthcare professionals to consider the specificity of ADRTs to patient circumstances:

For Heart Conditions

Consider addressing:

Resuscitation preferences in case of cardiac arrest
Defibrillator use
Intensive care admission for heart failure
Mechanical circulatory support

For Respiratory Conditions

Specify wishes regarding:

Mechanical ventilation (invasive and non-invasive)
Tracheostomy
Oxygen therapy
Intensive care admission for respiratory failure

For Neurological Conditions

Address treatments like:

Artificial nutrition and hydration
Interventions during seizures
Ventilation for respiratory failure
Antibiotics for recurrent infections

For Cancer

Consider specifying:

Preferences about life-extending chemotherapy
Resuscitation in context of advanced disease
ICU admission criteria
Artificial nutrition and hydration

Next Steps: Creating Your ADRT

Follow these practical steps to create your ADRT:

Reflect on your values and preferences regarding medical treatments in serious illness or end-of-life situations.
Discuss your thoughts with trusted family members and healthcare professionals to ensure you understand the medical implications of your choices.
Research specific treatments you may wish to refuse, ensuring you understand their purpose, benefits, and limitations.
Draft your ADRT using a template from a reputable organization or the framework provided in this guide.
Review the draft with your GP or healthcare provider to confirm it clearly communicates your wishes and is medically sound.
Finalize the document with your signature and a witness as required by law.
Distribute copies to relevant individuals and organizations, keeping a list of who has received them.
Plan regular reviews to keep your ADRT current and reflective of your wishes.

By creating a comprehensive, clearly written Advance Decision to Refuse Treatment that follows legal requirements, you take control of your future medical care and provide invaluable guidance to healthcare professionals and loved ones during difficult times. This document ensures your voice is heard even when you cannot speak for yourself, giving both you and your family peace of mind.

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Advance Decision to Refuse Treatment (ADRT, UK): What to Include