Advance Decisions to Refuse Treatment

An Advance Decision to Refuse Treatment (ADRT) is a written statement which lets other people know about any specific treatments that you do not want to have in certain situations. It means they will know your wishes if you are ever unable to make decisions yourself.

You can make an advance decision if you are aged 18 or over and able to make decisions for yourself. An ADRT is legally binding as long as it meets the legal requirements of the Mental Capacity Act 2005.

Before making an ADRT, it is important to discuss it with one of your healthcare professionals. You will need to review your ADRT regularly to make sure it is up to date and reflects your current wishes.

You may hear doctors or nurses talk about a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) request. This is a document stating that you do not want to have cardiopulmonary resuscitation (CPR). CPR is a way of trying to restart the heart and breathing when they have stopped. Talk to your healthcare team about making a decision about CPR.


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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 particular treatment in a specific situation. It is a way of making sure that everyone knows what treatments you do not want to have, if you are unable to make your own decisions in the future.

Here are examples of situations where an ADRT can be used:

  • If your illness could not be cured and you became very unwell after all possible treatment, you would not want to be kept alive by being fed or given fluids through a feeding tube or drip.
  • If you are being fed or given fluids through a feeding tube or drip, you do not want this to continue if your condition were to get worse and it is not improving your quality of life.
  • You do not want to be given antibiotics for an infection if you are only expected to live for a few days.

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

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

It is important to be as clear as possible about:

  • the circumstances when you would like your ADRT to apply
  • what type of treatment you would want to refuse.

This is to make your wishes clear to anyone reading the document. It will also help them decide whether your ADRT meets all the legal requirements of the Mental Capacity Act 2005. If it does meet these, it is legally binding. This means it must be respected by your doctors and those involved in your care.

If you make an Advance Decision to refuse a specific treatment, you will still be given the best possible care. You will have support, comfort and medicines to control your symptoms.

I don’t want to be kept alive artificially. I’m now 85 and I’ve had a very good life. We’ve planned this with our solicitor and I’m happy with the arrangements.

Percy


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 discuss the decisions you would like to make with one of your healthcare professionals. This may be your GP, or a doctor or specialist nurse looking after you at the hospital. They will be able to tell you what the likely effects of stopping a treatment are and will make sure your ADRT meets legal requirements.


What should be included in an ADRT?

Although most Advance Decisions to Refuse Treatment can be made verbally (spoken), it is better to write it down. This helps avoid confusion later on.

There are certain situations where the law says that an ADRT must be in writing. For example, an ADRT that refuses treatment to keep you alive (life-sustaining treatment), such as having your heart restarted (resuscitation) or being put on a breathing machine (ventilator), must be:

  • written down
  • signed by you or someone else with you at the time
  • witnessed.

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 a particular 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.

ADRT checklist

There is nothing in law that says what must be included in an ADRT if it does not relate to treatment that will keep someone alive. 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, and healthcare professionals need to 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 ever lack the capacity to make decisions.
  • A statement of which treatment or treatments are to be refused, and the circumstances when your decision would apply.
  • 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 an ADRT that will keep you alive, it 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 

Sometimes, a person may wish to refuse a specific treatment in all circumstances, rather than identifying a specific one. For example, you may want to refuse a specific medication in all circumstances if you have an allergy or a religious objection to it.

If you want to make a statement about refusing a treatment in all circumstances, you should talk this through 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 write one that has a set format. There are various organisations that have created forms for people to use. Hospitals and hospices often have written information and forms that people can use to prepare their own ADRT.

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

Remember to review your ADRT regularly. It is important to do this so you know it is up to date and reflects your current wishes.


ADRT and Lasting Power of Attorney

An ADRT may become invalid if:

  • you have made a Lasting Power of Attorney after making an ADRT and
  • you have given your attorney the authority to accept or refuse treatment on your behalf.

You should let all the relevant people know if you are in this position. It is important to keep written records of when you made decisions and what they were. Make sure that everyone who may need to make decisions for you in the future knows where to find all your documents.

Here is an example of some of the information included in an ADRT document.

My Advance Decision to Refuse Treatment

I wish to refuse the following specific treatments *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.'In these circumstances
Cardiopulmonary resuscitation – I refuse cardiopulmonary resuscitation if my heart and lungs stop functioning, 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 spontaneously.
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.

An ADRT refusing life-sustaining treatment must be signed by you (or by another person in your presence and by your direction) and witnessed by someone else. The witness must sign the ADRT in the presence of you, or the nominated person directed by you to sign.


Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

What is a DNACPR request?

You may hear doctors or nurses talk about a DNACPR request. These may also be referred to as DNARs. A DNACPR is a written statement to not give cardiopulmonary resuscitation (CPR) if someone has a cardiac arrest.

A cardiac arrest is when the heart stops beating. If the breathing stops, it is called a respiratory arrest. They commonly happen together, which is known as a cardiopulmonary arrest. CPR is a way of trying to restart the heart and breathing when they have stopped.

Making a decision about CPR

You may have already made a decision about not wanting to be resuscitated in a specific situation and included this in your ADRT. However, if you have not made a decision about CPR and you want to, you should discuss this with your medical team or specialist nurse.

You may also want to talk this through with your family, a close friend or a spiritual carer, such as a chaplain. 

Your medical team will be able to tell you how successful CPR is likely to be in different situations. They will take into account any other health problems you have.

A senior healthcare professional may sometimes ask if you want CPR to be attempted if they believe you may have a cardiac arrest and that resuscitation could be successful. For example, you may have a cancer that cannot be cured but you are expected to live with the condition for a long time, sometimes years. In this situation, the doctor will make sure that you have all the information you need to make an informed decision. They will tell you:

  • what is likely to happen if you have CPR
  • how this might extend your life
  • what your quality of life might be.

If, after discussion with your medical team, you make the decision not to have CPR attempted, this is written as a DNACPR or not for CPR (NFCPR) order.

After a decision has been made

After discussing the DNACPR decision with you, a senior doctor or nurse who is responsible for your care will make, write and sign the DNACPR. This might be a hospital consultant, a palliative care doctor, a specialist or consultant nurse, or your GP. The decision will be clearly written in your medical and nursing notes.

If you are at home, you will be asked to keep a written record of your DNACPR where it can easily be found. This is so emergency services, such as out-of-hours ambulance services and doctors, will know your wishes.

Your decision about CPR will not affect any other care or treatment you have. You can change your mind at any time about whether CPR should be attempted. If you do change your mind, it is important to discuss this with a member of your healthcare team. They will discuss their views on your changed decision with you. If they agree with your changed decision, they will make sure this is recorded in your medical notes.

Remember to also tell your family or the person looking after you as this will help to avoid any confusion.

If your doctor feels that CPR is unlikely to be successful and does not believe it should be attempted, but you do not agree, you can ask for a second medical opinion from another senior doctor. They should also let your family know what they recommend, unless you have asked them not to.

Your healthcare team will take your wishes about CPR into account. However, you cannot insist a doctor attempts CPR if, in their clinical judgement, they think it is not appropriate.

We have more information about cardiopulmonary resuscitation for people with cancer. Call our support line on 0808 808 00 00 to order this.

Back to Advance care planning in England and Wales

Planning ahead

Planning ahead can help people know what care you would like if you become unable to make choices yourself.

Making a will

Having an up-to-date will ensures that your wishes for who you would like to leave your estate to are guaranteed.

Your wishes for your care

When planning ahead, it is important to think about how and where you would like to be cared for.

Funeral planning

Planning your funeral in advance means your family and friends can arrange the type of funeral you would like.