Advance Decision to Refuse Treatment (ADRT): How is it applied in a care home?

Advance Decision to Refuse Treatment (ADRT) is key to advance care planning and this guide highlights how to create an ADRT (also known as living will), what makes an ADRT form valid, when an advance decision can be overruled and how care home staff ensure a resident’s wishes are respected and care is lawful.

At a glance

• An Advance Decision to Refuse Treatment is a legally binding document that allows a care home resident to refuse specific medical treatments if they lose mental capacity.
• Care homes must have a valid and applicable ADRT, as required by the Mental Capacity Act 2005, to ensure a resident’s wishes are respected.
• ADRTs should be identified on admission, clearly recorded in care plans and readily available to staff and healthcare professionals in an emergency.
• By correctly applying it, care homes provide reassurance to residents and families.

What is an Advance Decision to Refuse Treatment (ADRT)?

An advance Decision to Refuse Treatment is a decision you can make now to refuse a specific type of treatment in the future.

It is also known as a living will or advance decision (or in Scotland an advance directive).

It is a legally binding document that allows a person (aged 18 or over, with mental capacity) to refuse specific medical treatments in the future, in case they lose the ability to make or communicate decisions themselves.

In England and Wales, an advance decision to refuse treatment is covered by the Mental Capacity Act 2005.

An ADRT can:

• Enable you to refuse one or more specific treatments.
• Applies only in certain circumstances.
• Includes refusals of life-sustaining treatment (with additional legal requirements).

An ADRT is not euthanasia. ADRTs are about refusing treatment, not about ending your life or asking someone to help you die.

What is life-sustaining treatment?

You can refuse a treatment that could potentially keep you alive, known as life-sustaining treatment.

This is treatment that replaces or supports ailing bodily functions, such as:

• Ventilation: this may be used if you cannot breathe by yourself.
• Cardiopulmonary resuscitation (CPR): this may be used if your heart stops.
• Antibiotics: this can help your body fight infection.

An ADRT cannot:

• Ask for specific treatments.
• Refuse basic care such as comfort, warmth, food or drink by mouth.
• Be made on behalf of someone else.

Who makes an advance decision?

You make the advance decision, if you have the mental capacity to make such decisions.

You may want to discuss this with a doctor or nurse who knows about your medical history before you make a decision.

If you decide to refuse life-sustaining treatment in the future, your advance decision needs to be:

• Written down.
• Signed by you.
• Signed by a witness.

Why do ADRTs matter in a care home?

Many care home residents live with long-term conditions, frailty or dementia.

An advance decision helps ensure that medical decisions reflect the resident’s own values and preferences, even if they can no longer speak for themselves.

Planning ahead for future healthcare decisions can give peace of mind and help families and care professionals act with confidence.

For care homes, an advance decision to refuse treatment:

• Supports person-centred care.
• Reduces uncertainty during medical emergencies.
• Helps avoid unnecessary or unwanted hospital admissions.
• Gives clarity for families and professionals.

Is an ADRT legally binding in a care home?

Yes, if it is valid and applicable, it is legally binding and must be followed by care home staff and healthcare professionals.

Failing to follow a valid advance decision to refuse treatment could result in legal consequences, while following one correctly protects staff acting in good faith.

What makes an ADRT valid?

An ADRT is valid if:

• The person was aged 18+ when it was made.
• They had mental capacity at the time.
• It was made voluntarily, without pressure.
• It has not been withdrawn or overridden by a later decision.
• The person has not since done anything clearly inconsistent with the ADRT.

If the ADRT refuses life-sustaining treatment, it must also:

• Be in writing.
• Be signed by the person (or someone on their behalf).
• Be witnessed.
• Clearly state that it applies even if life is at risk.

When is an ADRT applicable?

An ADRT is applicable when:

• The treatment being proposed is the one refused in the ADRT.
• The circumstances described in the ADRT match the current situation.

If there is any doubt about validity or applicability, care staff should seek urgent medical or legal advice but must always act in the resident’s best interests while this is clarified.

What’s the difference between ADRT and DNACPR?

Although often confused, ADRTs and DNACPR orders are different:

• ADRT: Made by the individual; can refuse multiple treatments and applies in specific circumstances.
• DNACPR: A clinical decision about cardiopulmonary resuscitation only.

A resident may have one of these, both, or neither.

Can I have an ADRT?

• You can only make an ADRT if you are aged 18+ 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 talk with a member of your healthcare team.

How to get an ADRT form

1. Decide: Identify treatments you’d refuse and under what conditions.
2. Document: Write it down clearly. You can use templates from NHS or charities.
3. Witness: For life-sustaining refusal, get it signed and witnessed.
4. Share: Give copies to your GP, family, and hospital.
5. Review: Check and update it regularly.

ADRT form template

You can download this template of an Advanced Decision to Refuse Treatment (ADRT) form created by the Alzheimer’s Society.

How are is it used in a care home?

Upon admission to a care home, the care home should ask a new resident (or their representatives) whether an ADRT exists and request a copy.

This should be:

• Recorded in the resident’s care plan.
• Shared with relevant staff.
• Flagged clearly for emergencies.

When care planning in a care home, ADRTs should be considered alongside:

• Advance Statements of wishes and preferences.
• Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions.
• Emergency healthcare plans (such as ReSPECT forms).
• Lasting Power of Attorney (Health and Welfare), if one exists.

In an emergency, if a resident becomes seriously unwell and lacks capacity:

• Staff must check whether an ADRT applies.
• Emergency services and clinicians should be informed immediately.
• The ADRT should be made available as quickly as possible.

What if care home staff cannot find the ADRT in an emergency?

If the ADRT is not immediately available, staff should act in the resident’s best interests and seek urgent medical guidance.

Can relatives overrule an ADRT?

Families do not have the legal authority to override a valid ADRT unless they hold Health and Welfare Lasting Power of Attorney and the ADRT was made before the LPA.

Can an LPA overrule ADRT?

If you make an ADRT first, the LPA will override your advance decision because it was made more recently.

This is only if it gives your attorney(s) the power to deal with the same decision about treatment.

What if I make an LPA first before an ADRT?

If you make an LPA first, a valid and applicable advance decision will stop your appointed attorney from agreeing to treatment (as it was made more recently).

Can doctors overrule ADRT?

An ADRT will not be valid if you’ve given someone power of attorney (to make decisions on your behalf), after making the advance decision. If you’re detained under the Mental Health Act (1983), doctors have statutory authority to give you treatment for mental disorder. This may override your advance decision.

Care homes should:

• Communicate clearly with families.
• Explain the legal status of ADRTs.
• Offer reassurance that the resident’s wishes are being respected.

Care home providers should ensure:

• Care home staff are trained in the Mental Capacity Act.
• ADRTs are easy to locate in care records.
• Policies clearly explain how advance decisions are handled.
• Staff know when to escalate concerns or seek advice.

The Care Quality Commission (CQC) expects services to respect advance decisions as part of delivering safe, effective, and well-led care.

Can a care home resident change or cancel their ADRT?

Yes. An ADRT can be changed or withdrawn at any time, while the person has mental capacity.

Advance Decisions to Refuse Treatment play a vital role in ensuring residents’ voices continue to be heard, even when they cannot speak for themselves.

FAQs