Advance decisions to refuse treatment

Advance decisions to refuse treatment (ADRTs) are crucial legal documents governed by the Mental Capacity Act 2005, aiming to ensure that individuals' healthcare wishes are respected even when they lack the capacity to express them. A recent case in the Court of Protection, Re AB (ADRT: Validity and applicability) [2025] EWCOP 20 (T3), highlights the importance of taking appropriate steps after signing an ADRT. Ann Stanyer, a consultant at Wedlake Bell LLP, emphasises that a signed, written ADRT must be recognised by clinicians: "a signed, written ADRT that is valid and applicable to the clinical situation is legally binding on clinicians."

The Judge further reinforced the legal authority of an ADRT, stating that there is no need for a best interests discussion once an individual has made a valid decision regarding their treatment. The ruling underscores that the wishes of family members cannot override this legally binding document, nor can the opinions of clinicians about the wisdom of the ADRT influence treatment decisions.

However, the validity of an ADRT is not absolute. The Mental Capacity Act outlines scenarios where an ADRT becomes invalid, such as when it has been revoked or when an individual has created a lasting power of attorney for health and welfare. The Judge indicated that medical professionals should proactively verify the validity of an ADRT by consulting with the patient's family or friends, as there might be recent changes affecting its applicability. Following the case, the hospital trust updated its guidelines, allowing clinicians to assume an ADRT's validity unless there are specific doubts raised.

In circumstances where family members dispute the authenticity or relevance of an ADRT for treatment, the matter should be promptly referred to the Court of Protection or legal advice sought. Although cases of authenticity disputes are infrequent, ensuring that primary care physicians are aware of an ADRT can mitigate the risk of misunderstandings regarding its legitimacy.

Stanyer urges individuals who have signed an ADRT to share this vital information with their GP and close family members. She notes that, "if no one knows about the ADRT then it cannot be taken into account." Timely communication is essential, as demonstrated in this case where the patient's family took four months to provide the ADRT to medical professionals after the patient had lost consciousness.

The importance of clarity in drafting ADRTs cannot be overstated. A well-drafted document with clear language significantly reduces the risk of misinterpretation. Stanyer advises that individuals ensure their ADRT is succinct and straightforward, stating, “the drafting should not provide scope for any misinterpretation.”

To avoid potential issues, regularly reviewing an ADRT and keeping medical practitioners and family members informed of its existence are recommended practical steps. It is prudent to request documentation of the ADRT be noted in medical records as well. Different GP surgeries may maintain varied record-keeping practices, making it prudent to check how and where information is stored.

Additionally, those with a lasting power of attorney for health and welfare must ensure that GPs have updates regarding the addresses of those named within the LPA and verify that any registered LPAs are appropriately documented. By following these sensible precautions, individuals can ensure their healthcare preferences are respected and minimise complications during critical times, avoiding the challenges faced by the parties involved in the Re AB case.