An advance decision lets you refuse specific medical treatments in the future — in case you lose the capacity to communicate your wishes yourself. If valid and applicable, it is legally binding on the healthcare professionals treating you under the Mental Capacity Act 2005.
You may also hear the terms “advance directive” and “living will” — these all refer to the same thing. “Advance decision to refuse treatment” (ADRT) is the legal term used in the Act, but living will is the phrase most people recognise.
This guide explains what an advance decision can and cannot cover, the requirements that make it legally valid, how to make one, and how it fits alongside other planning tools such as a lasting power of attorney.
Quick summary
- An advance decision lets you refuse specific treatments in advance — it cannot request treatments or request euthanasia
- To be legally binding, it must meet the requirements of the Mental Capacity Act 2005, sections 24–26
- Refusing life-sustaining treatment has stricter requirements: the document must be written, signed, and witnessed, and must explicitly state it applies even if your life is at risk
- You can cancel or update it at any time while you have capacity
- There is no official register — tell your GP and give copies to those who may need it
What is an advance decision?
An advance decision is a formal statement you make now, while you have mental capacity, specifying that you refuse one or more named medical treatments if a situation arises in the future when you can no longer decide for yourself.
The situation might be a stroke, a serious accident, an advanced illness such as dementia, or any other circumstance that removes your ability to communicate. Once you lose capacity, doctors must follow a valid, applicable advance decision — they cannot override it on grounds of best interests.
An advance decision is different from an advance statement. An advance statement records your general preferences and wishes about care — where you’d like to be treated, what’s important to you, cultural or religious considerations. An advance statement is not legally binding, but healthcare teams should take it into account. An advance decision, by contrast, is a refusal of specific treatment, and it is binding.
What can an advance decision cover?
You can use an advance decision to refuse any medical treatment that you could refuse in the present. Common examples include:
- Cardiopulmonary resuscitation (CPR)
- Mechanical ventilation (breathing machines)
- Clinically assisted nutrition and hydration (feeding tubes or drips)
- Antibiotics — in circumstances where you do not want life to be prolonged
- Dialysis
- Blood transfusions
You can make the refusal unconditional, or you can attach conditions — for example, “I refuse CPR if I have been diagnosed with terminal cancer and have less than six months to live.” Being specific about the circumstances you are considering helps to ensure the advance decision applies when you intend it to.
What an advance decision cannot do
| What you can do | What you cannot do |
|---|---|
| Refuse a named treatment | Request a specific treatment |
| Refuse treatment in specific circumstances | Request euthanasia or assisted suicide (both illegal in the UK) |
| Refuse life-sustaining treatment (with the right formalities) | Ask for something that would cause your death directly |
| Refuse treatment you consider undignified or contrary to your values | Bind clinicians to act in ways that are unlawful or contrary to professional standards |
An advance decision is about the right to refuse — not a right to demand. If you want someone to make treatment decisions on your behalf (rather than simply refusing specific ones), a lasting power of attorney for health and welfare gives your chosen person that authority.
What makes an advance decision legally valid?
Under the Mental Capacity Act 2005, an advance decision is valid if:
- You were aged 18 or over when you made it
- You had mental capacity at the time — you understood what you were deciding
- You were not under pressure from anyone else
- You have not withdrawn it since, either verbally or in writing
- You have not made a subsequent lasting power of attorney that gives an attorney authority over the same treatment decisions
- Your actions since making it do not clearly contradict it — for example, consenting to the same treatment you purported to refuse
An advance decision is applicable to a treatment if:
- The treatment is the one you specified (or is reasonably covered by what you specified)
- The circumstances match those you described
- You currently lack the capacity to consent or refuse that treatment yourself
Healthcare professionals must check all of these things before following an advance decision. If there is any doubt about validity or applicability, they may apply to the Court of Protection for guidance.
Extra requirements for refusing life-sustaining treatment
These are the most important rules to get right. If your advance decision refuses treatment that is needed to keep you alive — CPR, a ventilator, a feeding tube — it must meet stricter requirements under section 25(5) of the Mental Capacity Act 2005:
- It must be in writing
- It must be signed by you (or by someone else in your presence and at your direction, if you cannot write)
- The signature must be witnessed by another person, who then also signs
- It must include a clear written statement that the decision applies “even if my life is at risk”
Without this statement — specifically, those words or their clear equivalent — a refusal of life-sustaining treatment has no legal force. A verbal instruction to a doctor, or a document that simply says “no CPR”, is not enough if life-sustaining treatment is what you are refusing.
How to make an advance decision
There is no required template in law, but using one reduces the chance of ambiguity. Compassion in Dying — a UK charity that supports people to plan for end-of-life care — provides a free template document and an online tool to guide you through the process.
The steps are:
1. Decide what you want to refuse — and in what circumstances. Be specific. Rather than “I refuse all treatment”, describe the situation: the illness, the stage, what quality of life you would consider unacceptable.
2. Write it down. This is mandatory if you are refusing life-sustaining treatment; it is good practice for any advance decision.
3. Sign it. Sign in front of a witness. The witness then signs too. The witness should be an adult who is not named as a beneficiary in your will and does not stand to gain financially from your death.
4. Discuss it with your GP. Your GP can add a copy to your medical notes. This ensures it will be found quickly if you are treated in an emergency. It is not legally required, but it is one of the most important things you can do.
5. Tell the people around you. Give a copy to close family or carers, and tell them where the original is kept. If you are admitted to hospital, take a copy with you.
Do you need a solicitor?
No. The Mental Capacity Act 2005 does not require a solicitor to prepare or witness an advance decision. Many people make one using the Compassion in Dying template without any legal help.
A solicitor can be useful if your situation is complex — for example, if you want to refuse treatment in very specific clinical circumstances, or if you are concerned about family members challenging your decision. But for most people, the free template and guidance from Compassion in Dying is sufficient.
Where to keep it and how to make sure it is found
There is no official register for advance decisions in England and Wales. This is unlike, say, the lasting power of attorney, which must be registered with the Office of the Public Guardian before it has legal force.
Because there is no register, it is entirely up to you to make sure the document can be found when needed. The practical steps are:
- Ask your GP to add it to your medical record — this is the most important step, since GPs and hospitals can access your record when treating you
- Give a copy to any relevant family member or carer — especially anyone likely to be present in an emergency
- Keep a copy at home in a place your family knows about
- Carry a note in your wallet stating that you have an advance decision and where it is held
- If you have a care plan or are receiving palliative care, ask for it to be included
Some people also register with the Universal Decisions service offered by Compassion in Dying, which stores a copy securely and issues a wallet card. This is voluntary and not an official register, but can be useful if you move between different healthcare settings.
Can you change or cancel an advance decision?
Yes — at any time, as long as you still have mental capacity. Under section 24(3) of the Mental Capacity Act 2005, you can withdraw an advance decision in any way that makes your intention clear. A withdrawal does not have to be in writing — telling your doctor, a nurse, or a family member that you no longer wish the decision to apply is enough.
If you want to change rather than cancel it — for example, to add new circumstances or remove a particular treatment from the refusal — you should write a new document. The same formalities apply to the amended version. If the change relates to life-sustaining treatment, the written/signed/witnessed rules apply to the new version.
It is good practice to date your advance decision clearly, and to review it periodically — particularly after a significant change in your health, or if several years have passed. A well-kept, recently dated document is more likely to be accepted without question.
Advance decision vs lasting power of attorney: the difference
Both are tools for planning ahead. They work in different ways, and many people choose to have both.
| Advance decision | Health and welfare LPA | |
|---|---|---|
| What it does | Refuses named treatments in advance | Appoints a person to make health decisions on your behalf |
| Legal basis | Mental Capacity Act 2005, sections 24–26 | Mental Capacity Act 2005, sections 9–14 |
| Registration required? | No | Yes — must be registered with the Office of the Public Guardian (fee: £92) before it can be used |
| Solicitor required? | No | No, but many people use one |
| Flexibility | Specific — only covers the treatments you name in the circumstances you describe | Broad — your attorney can make any health and welfare decision you haven't specifically restricted |
| Who decides? | You — in advance | Your attorney — at the time, guided by your known wishes |
| Conflict rule | If an LPA made after the advance decision gives an attorney authority over the same treatment, the LPA takes precedence | Overrides a prior advance decision for the same treatments if the LPA was made later |
One important point: if you make a health and welfare LPA after your advance decision, and that LPA gives your attorney authority to make the same treatment decisions, the LPA takes precedence. If you want your advance decision to stand, make sure your LPA either does not cover those treatments or explicitly states that your advance decision should be respected.
If you have not yet made a lasting power of attorney, the planning ahead hub and the LPA guide cover what is involved. Our guide to organ donation in the UK covers how to register your donation decision and how the opt-out system works across all four UK nations.
If you are treated contrary to your advance decision
If a clinician treats you in a way that your valid and applicable advance decision refused, they could face civil liability or criminal prosecution. The NHS guidance on advance care planning confirms that a valid advance decision takes precedence over any best-interests decision made by clinicians or family members.
However, clinicians are protected from liability if they provide treatment in good faith where they were not aware of an advance decision, or where they had reasonable grounds to believe it was invalid or inapplicable. This is why making sure the document is accessible — particularly through your GP’s records — is so important.
Scotland: a different legal framework
The Mental Capacity Act 2005 applies only in England and Wales. In Scotland, the Adults with Incapacity (Scotland) Act 2000 governs decisions about medical treatment for people who lack capacity.
Unlike in England and Wales, advance decisions (called advance directives in Scotland) are not legally binding under the AWI Act — the Act makes no specific provision for them. However, a Scottish court will treat an advance directive as strong evidence of a person’s wishes if there is a dispute. In practice, healthcare professionals in Scotland are expected to respect clearly expressed advance directives as part of the Act’s principles, which require them to take account of the past and present wishes of the person.
If you are in Scotland, the My ACP resource (a Scottish Government and NHS Scotland initiative) offers guidance on advance care planning in the Scottish context.
Getting help
- Compassion in Dying — free advance decision template, helpline (0800 999 2434), and guidance on completing the form
- NHS — Advance decision to refuse treatment — overview and links to further support
- Mental Capacity Act 2005 — sections 24–26, which govern advance decisions in England and Wales
- Your GP — the best first conversation; they can add the document to your record and answer questions about your own care
Making an advance decision is one part of a broader picture of planning ahead. Other pages that may be useful:
- Lasting power of attorney: a complete guide — appointing someone to make decisions on your behalf
- Pre-paid funeral plans: a complete UK guide — arranging and paying for your funeral in advance
- Writing a will — recording what happens to your estate