Most of us are used to making our own medical decisions. A doctor can recommend an operation, treatment or particular drug, but if we have the mental capacity to decide, the final choice is ours.
The harder question is what happens if, one day, you cannot make that decision for yourself.
You might be unconscious after an accident, have suffered a serious brain injury or be living with advanced dementia. Treatment may need to be considered at precisely the point when you can no longer explain what you would or would not want.
An advance decision to refuse treatment allows you to make some of those decisions beforehand.
Quick answer: An advance decision to refuse treatment, often called an ADRT or living will, allows somebody aged 18 or over who has mental capacity to specify medical treatment they want to refuse in the future if they later lack capacity to decide for themselves. If the advance decision is valid and applies to the treatment and circumstances in question, it is legally binding. Special formalities apply if it refuses life-sustaining treatment.
This guide explains what an advance decision can and cannot do, how to make one, when doctors must follow it and how it fits alongside a Health and Welfare Lasting Power of Attorney.
Jurisdiction: This guide covers the law in England and Wales. Scotland and Northern Ireland have different legal arrangements.
Contents
- What is an advance decision to refuse treatment?
- When does an advance decision apply?
- What treatment can you refuse?
- What can’t an advance decision do?
- How do you make an advance decision?
- Refusing life-sustaining treatment
- What do valid and applicable mean?
- Advance decision or Health and Welfare LPA?
- Which takes priority: An ADRT or LPA?
- What is an advance statement?
- Is an ADRT the same as a DNACPR decision?
- Making sure your advance decision can be found
- Can you change or cancel an advance decision?
- What if there is a dispute?
- Frequently asked questions
What is an advance decision to refuse treatment?
An advance decision to refuse treatment is a decision made while you have mental capacity about medical treatment you do not want to receive at a future time when you may lack capacity to make that decision.
You may also hear it called an advance decision, ADRT, advance directive or living will.
The expression “living will” can be misleading. This is not a Will dealing with your property after death. It operates while you are alive and concerns medical treatment.
The legal framework is contained in the Mental Capacity Act 2005. If an advance decision is valid and applicable to the particular treatment, it has the same effect as a refusal made by somebody who has capacity at that moment. Healthcare professionals must respect it.
The NHS guide to advance decisions to refuse treatment provides useful practical information.
When does an advance decision apply?
An advance decision is for a future situation in which you lack capacity to make the treatment decision yourself.
If you still have capacity when treatment is being discussed, you make the decision there and then. What you said years earlier in an ADRT does not stop you changing your mind.
Mental capacity is decision-specific and time-specific. Somebody may be unable to make one complicated treatment decision but still be perfectly capable of making others.
My separate guide explains how mental capacity is assessed in England and Wales.
If you lack capacity, the healthcare team must consider whether an advance decision exists and, if so, whether it is both valid and applicable to the treatment now being proposed.
What treatment can you refuse?
An advance decision can refuse a particular medical treatment, including treatment that may be necessary to keep you alive.
Depending on your circumstances and wishes, that might include cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition or hydration, antibiotics, surgery or another specified treatment.
You can also make the refusal conditional.
For example, you might be willing to receive a particular treatment while there is a reasonable prospect of recovery but want to refuse it in specified circumstances involving irreversible deterioration.
This is why clarity matters. Simply writing “I do not want heroic treatment” leaves a doctor with a difficult question: what treatment did you actually mean, and in what circumstances?
You do not necessarily need elaborate medical terminology, but the treatment being refused and the circumstances in which the refusal is intended to operate must be sufficiently clear.
Plain English is usually more useful here than impressive-sounding legal wording. The document needs to help a clinical team make a real treatment decision, sometimes quickly.
What can’t an advance decision do?
An advance decision is a right to refuse treatment. It is not a right to demand it.
You cannot use an ADRT to require a doctor to provide treatment that the clinical team considers inappropriate or unnecessary.
Nor can it require somebody to end your life or assist you to die. Refusing medical treatment, even where the consequence may be death, is legally different from asking another person to bring about your death.
An ADRT also does not deal with every aspect of future care. If you want to record broader wishes about matters such as where you would prefer to be cared for, religious beliefs or what is important to you, an advance statement may be more appropriate.
How do you make an advance decision?
You must be at least 18 and have the mental capacity to make the decision when you make it.
An advance decision does not generally have to be written down unless it concerns life-sustaining treatment. A verbal advance decision can therefore sometimes be legally effective.
In practice, writing it down has obvious advantages. Months or years later, a written document gives healthcare professionals much better evidence of what you decided than somebody trying to remember a conversation.
A useful written ADRT should identify you clearly and state the treatment or treatments you are refusing and the circumstances in which each refusal is intended to apply.
It is sensible to date the document. You may also wish to explain the beliefs or reasons behind a refusal if that would help somebody understand how you would approach an unforeseen situation.
Talking to a doctor or other appropriate healthcare professional before finalising the document can be particularly valuable where the treatment choices are complicated. They can help you understand what treatment might actually be offered and the consequences of refusing it.
Refusing life-sustaining treatment
The Mental Capacity Act imposes additional requirements where an advance decision is intended to refuse life-sustaining treatment.
In that situation, the decision must be in writing and signed by you, or by somebody signing on your behalf and at your direction if you are unable to sign.
Your signature must be made or acknowledged in the presence of a witness, and the witness must then sign or acknowledge their signature in your presence.
Crucially, the document must also contain a statement making clear that the refusal is to apply even if your life is at risk.
Without that statement and the required formalities, an advance decision will not operate as a binding refusal of life-sustaining treatment.
What counts as life-sustaining treatment depends on the circumstances. The Mental Capacity Act defines it by reference to treatment which the person providing healthcare regards as necessary to sustain life.
What do valid and applicable mean?
A doctor does not follow an ADRT merely because somebody produces a document headed “Living Will”. The healthcare team must establish that the decision remains valid and that it applies to the treatment and circumstances they are actually facing.
Is the advance decision still valid?
An advance decision may no longer be valid if, for example, you have withdrawn it, subsequently created a Health and Welfare LPA giving an attorney authority over the treatment in question, or later behaved in a way that is clearly inconsistent with the ADRT remaining your fixed decision.
There is no automatic expiry date.
Does it apply to this treatment and these circumstances?
The decision must also be applicable.
If the ADRT refuses one treatment but a different treatment is being proposed, it will not bind the healthcare team in relation to the different treatment.
The same applies if you specified particular circumstances and those circumstances have not arisen.
There may also be reasonable grounds for believing that circumstances have changed in a way that would have affected your decision had you anticipated them.
This is why a few broad phrases intended to cover everything can be less useful than a carefully thought-through refusal.
Advance decision or Health and Welfare LPA?
An ADRT and a Health and Welfare Lasting Power of Attorney solve different problems.
With an advance decision, you make the treatment refusal yourself in advance. If it later becomes valid and applicable, the decision has already been made.
With a Health and Welfare LPA, you appoint one or more attorneys to make health and welfare decisions if you later lack capacity. Depending on the authority you give them, that can include decisions about medical treatment and potentially life-sustaining treatment.
The LPA is more flexible because your attorney can consider circumstances that could not have been predicted years earlier. An ADRT is narrower but more direct if there is a particular treatment you know you would refuse in specified circumstances.
Some people choose one. Others make both.
My detailed guide explains how Lasting Powers of Attorney work.
Which takes priority: An ADRT or LPA?
Which document takes priority depends on timing and scope.
If you make an ADRT and later give a Health and Welfare attorney authority over the same treatment, the earlier ADRT may no longer be valid to that extent.
If you make the ADRT after creating the LPA, a valid and applicable refusal can prevent the attorney consenting to that treatment for you.
So the rule is not simply that the newest document always wins. If you have both, they should be reviewed together to make sure they do not conflict.
What is an advance statement?
An advance statement is different from an advance decision.
It records your wishes, feelings, beliefs and preferences about your future care. For example, you might say where you would prefer to be cared for, what matters to you in daily life or how religious or cultural beliefs should be reflected in your care.
An advance statement is not legally binding. However, anyone making a best-interests decision for you should take your wishes, feelings, beliefs and values into account.
The distinction is useful:
An ADRT says, in effect, “I refuse this treatment in these circumstances.”
An advance statement says, “These are the things I would like you to know and take into account when caring for me.”
The NHS has separate guidance on making an advance statement about your wishes.
Is an ADRT the same as a DNACPR decision?
No.
A DNACPR decision concerns one particular treatment: cardiopulmonary resuscitation if your heart or breathing stops.
A DNACPR form is a clinical record used to communicate a decision about CPR. The form itself is not legally binding in the same way as a valid and applicable ADRT.
If you have capacity, you can decide that you would not want CPR. If you want that refusal to operate as a legally binding decision at a future time when you lack capacity, it can be recorded in an ADRT that meets the requirements for refusing life-sustaining treatment.
The NHS explains the distinction in its guidance on DNACPR decisions.
A refusal of CPR also does not mean you are refusing every other form of treatment or care.
Making sure your advance decision can be found
A beautifully drafted ADRT is of little practical use if nobody knows it exists.
There is no central compulsory registration system for advance decisions in England and Wales.
Tell people who are likely to need to know about it. That may include your GP, relevant hospital or specialist team, close family members, carers and any Health and Welfare attorney.
Ask for a copy to be placed in your medical records where appropriate and make sure the people close to you know where the current version is kept.
If emergency treatment might be affected, accessibility becomes especially important. A clinical team faced with an urgent decision cannot follow an ADRT it has no reason to know exists.
Making the decision is only half the job. The right people need to be able to find it when it matters.
Can you change or cancel an advance decision?
Yes, provided you have the capacity to do so.
You can withdraw an advance decision, and a withdrawal does not generally have to be in writing even if the original decision was written down.
From a practical point of view, however, it is wise to remove or clearly mark old copies, tell everyone who holds one and update your medical records. The last thing you want is an obsolete document appearing during an emergency.
It is also sensible to review an ADRT from time to time, particularly after a significant change in your health, diagnosis, treatment options or personal circumstances.
An older advance decision is not automatically invalid simply because time has passed. But a recent review can help show that it still reflects your wishes.
What if there is a dispute?
Sometimes the difficulty is not discovering an ADRT but deciding whether it is valid or whether it applies to the present circumstances.
Family members may disagree with the healthcare team. There may be uncertainty about what the wording means, whether the person later changed their mind or whether a newer LPA affects the decision.
A relative cannot simply veto a valid and applicable advance decision because they dislike it. Equally, healthcare professionals should not withhold treatment unless they are satisfied that the legal requirements are met.
The Court of Protection can determine questions about whether an advance decision exists, is valid or is applicable to particular treatment.
Where there is a genuine dispute and life-sustaining treatment is involved, treatment necessary to sustain life or prevent serious deterioration can continue while a decision from the court is sought.
Frequently asked questions
Is a living will legally binding in the UK?
In England and Wales, an advance decision to refuse treatment can be legally binding if it complies with the Mental Capacity Act 2005 and is valid and applicable to the treatment and circumstances in question. Different law applies in Scotland and Northern Ireland.
Do I need a solicitor to make an advance decision?
No. There is no general requirement to use a solicitor. Legal advice may nevertheless be useful where the proposed refusals are complicated, there is already a Health and Welfare LPA or there is concern about capacity, family disagreement or the wording of the document.
Medical advice can be just as important because the document needs to describe future treatment decisions accurately.
Does an advance decision have to be witnessed?
Not every advance decision does. But an ADRT refusing life-sustaining treatment must be in writing and meet the statutory signing and witnessing requirements, as well as state that the refusal applies even if life is at risk.
Can my family override my living will?
Not if the advance decision is valid and applicable to the treatment. Family members may provide important evidence about your wishes or whether circumstances have changed, but they do not have a legal veto simply because they are your relatives.
Does an advance decision expire?
No fixed expiry period applies. It is nevertheless sensible to review the document periodically and after important changes in health or personal circumstances.
Making a decision now for a very different day
The hardest thing about an advance decision is that it asks you to think about circumstances you hope may never arise.
But the legal idea behind it is actually quite simple. Losing the ability to communicate a treatment decision does not have to mean losing every element of choice.
A carefully prepared ADRT can preserve a refusal you made while you were able to understand the decision and speak for yourself. The difficulty is making sure it says what you genuinely mean, covers the circumstances you have in mind and can actually be found when somebody needs it.
I would rather see a short, clear document that has been properly thought through and discussed than pages of vague wording about “dignity” or “heroic measures” which leave a clinical team guessing.
If you want somebody you trust to have wider authority to make health and welfare decisions for you, rather than making particular treatment refusals yourself in advance, my guide to Lasting Powers of Attorney explains that separate option.
Last legally reviewed: 31 August 2026
This guide is based on general principles of English and Welsh law, is intended for informational purposes only, and does not constitute legal advice or establish a professional relationship.
