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 unable to make those decisions yourself.

You can make an ADRT if you are aged 18 or over and are able to make decisions for yourself. Before making an ADRT, it is important to discuss it with one of the healthcare professionals looking after you. 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) decision. This is a written record stating not to give cardiopulmonary resuscitation (CPR) if someone has a cardiac arrest. 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. It may also set out the specific circumstances in which you would not want a particular treatment.

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 become 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.
  • You do not want to be resuscitated if your heart stops.

Later on in this section, 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.

An ADRT cannot be used to refuse any basic care you might need to keep you comfortable. This includes warmth, shelter, food and fluids by mouth, and pain control.


ADRT and the law

In Northern Ireland, an ADRT is legally binding although it is governed by common law instead of an Act. This means it must be followed by your health and social care team, as long as they know about it.

An ADRT must meet certain criteria. For example:

  • you must be able to make the decision in the first place – this is called having mental capacity
  • the treatment being refused must apply to the decision that has to be made at the time.

Your health and social care team will be able to tell you more about this.


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 means for you (having mental capacity).

Before making an ADRT, it is important to discuss the decisions you would like to make with one of your health and social care 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 what may happen if you have the treatment.

A solicitor can also discuss an ADRT with you, help you write one and make sure it meets legal requirements.


What should be included in an ADRT?

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 who is 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 particular distinguishing features (for example, a birth mark). This is in case you are unconscious or unable to communicate, and 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. Two witnesses are usually preferred if it is a written statement. The witnesses should be over the age of 18.
  • 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.


Questioning an ADRT

Sometimes there may be situations when a doctor does not act on, or questions whether it is right to act on, an ADRT. This might happen in the following situations:

  • What you say you want in your Advance Decision does not match up with your lifestyle. For example, you may have changed your religion since you wrote it.
  • Medical circumstances have changed since you made your Advance Decision. For example, a recent development in treatment may have become available that strongly improves your outlook (prognosis). This may have led you to make a different decision, if had you known about it.

Your ADRT may also be questioned or overturned if:

  • you made your Advance Decision when you did not have the required mental capacity
  • it is believed that you were influenced by others to make the Advance Decision.


An example of an ADRT from someone with cancer

My Advance Decision to Refuse Treatment

I wish to refuse the following specific treatmentsIn these circumstances
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.
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 food or fluids unaided.


An example of an ADRT from someone with motor neurone disease (MND)

My Advance Decision to Refuse Treatment

I wish to refuse the following specific treatmentsIn these circumstances
I refuse assisted ventilation (breathing using a machine), even if my life is at risk as a result.If my motor neurone disease progresses so that I can no longer breathe by myself.
I refuse artificial feeding or hydration, even if my life is at risk as a result.If my motor neurone disease has deteriorated so that I cannot swallow safely without the help of others.


Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

What is a DNACPR decision?

You may hear doctors or nurses talk about a DNACPR decision. This may also be referred to as a DNAR or NFCPR. A DNACPR is a written record of a decision not to 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 will 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 a senior healthcare professional believes that CPR will not be successful and so not be appropriate for you, a decision will be made not to attempt CPR in the event that you have a cardiac arrest. The doctor will discuss this decision with you. 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. But you cannot insist a doctor attempts CPR if their clinical judgement is that it is not appropriate. If you do not agree with this decision, you can ask for a second opinion from another senior doctor.

After a decision has been made

After discussing the DNACPR decision with you, a senior doctor who is responsible for your care will make, write and sign the DNACPR. This might be a hospital consultant, a palliative care doctor 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 that emergency services, such as out-of-hours ambulance services and doctors, will know about it.

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. If you wish to change your decision after talking with your healthcare team, 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.

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 Northern Ireland

Planning ahead

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

Making a will

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Your wishes for your care

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

Enduring Power of Attorney

An Enduring Power of Attorney (EPA) allows you to choose other people to make decisions on your behalf.

Funeral planning

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