What is an advance decision to refuse treatment (ADRT)?

An advance decision to refuse treatment (ADRT) is a written statement of your wishes to refuse a certain treatment in a specific situation. It is a way of making sure everyone knows what treatments you do not want to have, if you become unable to make your own decisions. It will only be used if you cannot make or communicate a decision for yourself.

For example, you may decide one of the following things:

  • If your illness cannot be cured and you become very unwell after having all possible treatment, you do not want to be kept alive by being fed through a feeding tube or have fluids through a drip.
  • If your condition and quality of life is not improving and is getting worse while you are being fed through a feeding tube or having fluids through a drip, you do not want these treatments to continue.
  • If you are very ill and only expected to live for a few days, you do not want to be given antibiotics for an infection.

We have an example below of how some of this information could be written in an ADRT document.

It is important to be as clear as possible about:

  • the treatment you would like to refuse
  • the circumstances when you would like your ADRT to apply.

It is helpful to include as much detail as possible to make your wishes clear to anyone reading the document. This will help them decide whether your ADRT meets the legal requirements of the Mental Capacity Act 2005. If it does, it is legally binding. This means it must be followed by your healthcare team, if they know about it.

An ADRT cannot include a request to be given specific treatments, or to have your life ended. You can request, but not insist on, treatment in your wishes for your care.

If you refuse a certain treatment, you will still have the best possible care and support, and medicines to help control your symptoms.

You can only make an advance decision to refuse treatment if you live in England or Wales. If you live in Scotland, please see our information on advance directives.

Who can make an ADRT and who should be involved?

You can only make an ADRT if you are aged 18 or over, and are able to understand what it is and what it means for you. This is called having mental capacity.

Before making an ADRT, it is important to talk with a member of your healthcare team. This may be your GP, specialist doctor or specialist nurse. They will be able to tell you what the likely effects of stopping a treatment will be. They will also make sure your ADRT meets legal requirements.

It is also important to discuss your decisions with your family, so they understand your wishes. This can be important to prevent any confusion or distress at a later stage. It also makes it more likely that your wishes will be followed.

What should be included in an ADRT?

Although you can usually make most advance decisions to refuse treatment verbally (spoken), it is better to write it down. This helps avoid confusion later.

There are certain situations where the law says an ADRT must be in writing. For example, it must be in writing if it states that you refuse treatment to keep you alive.

You must write down your wishes if you:

In these situations, an ADRT must also be:

  • signed by you, or someone else who was with you at the time of it being written
  • signed in the presence of a witness
  • signed by the witness, with the date.

It must say exactly what treatment you want to refuse and in which situation. This is because you may want to refuse a treatment in one situation, but not in another. It must also contain a statement such as, ‘I refuse this treatment even if my life is at risk as a result’, to make it legal.

What is a DNACPR decision?

You may hear doctors or nurses talk about a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision. This is a written record stating the decision not to give CPR if someone’s heart or breathing stops. These may also be called DNARs (do not attempt resuscitation).

You may have already made a decision about not wanting to be resuscitated in a specific situation and included this in your ADRT. If you have not made a decision about CPR but you want to, talk to your GP, cancer doctor or specialist nurse. You may also want to talk to your family, a close friend, or a spiritual or religious leader.

ADRT checklist

If an ADRT is not about treatment that will keep someone alive, there is nothing in law that says what must be included. However, it is advisable to include the following:

  • Your name, date of birth, address and any obvious distinguishing features – for example, a birth mark. This is in case you are unconscious or unable to communicate. It will help healthcare professionals identify you.
  • The name, address and phone number of your GP and whether they have a copy of your ADRT.
  • A statement saying that the ADRT should be used if you cannot make or communicate a decision for yourself.
  • A statement with the exact treatment or treatments to be refused and the circumstances when your decision would apply. This is because you may want to refuse a treatment in one situation, but not in another.
  • The date your ADRT was created.
  • Your signature and a dated signature of at least one witness, if it is a written statement.
  • If it is a decision to refuse treatment that would keep you alive, your ADRT must also include the statement, ‘I refuse this treatment even if my life is at risk as a result’.

If you refuse a treatment in all circumstances

You might wish to refuse a specific treatment in all circumstances, rather than in just one specific situation.

For example, you may want to refuse a specific medication in all circumstances if you:

  • have an allergy
  • do not want the medication for religious reasons.

If you want to make a statement about refusing a treatment in all circumstances, you should talk with a healthcare professional first. They will make sure that your ADRT is clear for any health professional who may need to use it in the future.

Writing an ADRT

You can write your own ADRT, but you may find it easier to use a form. There are organisations that have created forms for people to use. Hospitals and hospices often have information and forms that you can use to prepare your own ADRT.

We have created an ADRT document that has been adapted from the National End of Life Care Programme.

Reviewing your ADRT

You can change your mind and rewrite your ADRT at any time. But this must be clearly recorded.

Reviewing your ADRT regularly makes sure it is up to date and reflects your current wishes. This is important as your wishes may change if your condition changes.

If you decide to cancel your ADRT, tell your healthcare team and the people close to you.

ADRT and lasting power of attorney

An ADRT may become invalid if:

  • You have made a lasting power of attorney (LPA) for health and welfare decisions after making an ADRT.
  • You have given your attorney the authority to accept or refuse treatment on your behalf.

You should tell any doctors, nurses, family or friends who will be involved in your care what you have done. It is important to keep written records of when you made decisions and what they were. Make sure you tell everyone who may need to make decisions for you in the future where to find all your documents.

Example ADRT document

My advance decision to refuse treatment

I wish to refuse the following specific treatments In these circumstances
Cardiopulmonary resuscitation – I refuse cardiopulmonary resuscitation if my heart and lungs stop working, even if my life is at risk as a result. If I have terminal cancer and my heart and lungs stop functioning in a way that allows me to breathe on my own.
Artificial feeding or hydration – I refuse artificial feeding or hydration, even if my life is at risk as a result. If I have terminal cancer, become unconscious and am unable to swallow fluids or food unaided.

If you wish to refuse a treatment that is, or may be, life-sustaining, you must state in the box: ‘I am refusing this treatment even if my life is at risk as a result.'

An ADRT refusing life-sustaining treatment must be signed by you, or by another person in your presence and by your direction.

It must also be witnessed by someone else. The witness must sign the ADRT in the presence of you, or the nominated person directed by you to sign.

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