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Advance decisions and living wills

An advance decision — sometimes called a living will or advance directive — is a written statement in which a person who currently has capacity sets out medical treatments they wish to refuse in the future, in the event they later lose the capacity to make that decision themselves. In England and Wales it is a legally binding instrument under sections 24–26 of the Mental Capacity Act 2005; healthcare professionals must follow a valid and applicable advance decision, even where they would otherwise consider treatment to be in the patient's best interests, and even where it would prolong life. [source: nhs-uk/advance-decision-to-refuse-treatment-2026-05-02.html]

This is not the same as a will. A will deals with property after death; an advance decision deals with medical care during life when the person cannot speak for themselves. The two documents are independent — most people who have one will eventually want the other, but they do different jobs.

If you can only do one thing today: write down — in plain language — the specific treatments you would not want, and the specific circumstances in which the refusal would apply. Vague statements ("no extraordinary measures") cannot be acted on by clinicians; specific refusals ("if I have advanced dementia and can no longer swallow safely, I do not want artificial nutrition or hydration") can.

Decision vs statement: a critical distinction

Two different documents are often confused:

  • An advance decision to refuse treatment (ADRT) is a legally binding refusal of named medical treatments. If valid and applicable, clinicians must follow it. Governed by the Mental Capacity Act 2005 in England and Wales.
  • An advance statement of wishes is a non-binding expression of preferences and values about future care ("I would prefer to remain at home", "pain relief should be prioritised even if it shortens life"). Clinicians should consider it as part of the best-interests assessment but are not bound by it.

Many people have both — the statement captures the broader values; the decision makes the specific refusals enforceable. [source: nhs-uk/advance-decision-to-refuse-treatment-2026-05-02.html]

What an advance decision can and cannot do

Can refuse: almost any specific medical treatment — surgery, blood transfusion, antibiotics, chemotherapy, dialysis, ventilation, cardiopulmonary resuscitation, artificial nutrition and hydration. The refusal can be tied to specified conditions ("if I am in a persistent vegetative state", "if I have advanced dementia and can no longer recognise my family"). [source: nhs-uk/advance-decision-to-refuse-treatment-2026-05-02.html]

Cannot do:

  • Cannot demand treatment. An advance decision only refuses; it cannot oblige a clinician to provide a treatment they consider futile or harmful. (A separate advance statement can express a preference.)
  • Cannot refuse basic care. Warmth, hygiene, food and drink offered orally, and pain relief cannot be refused. The clinician's duty to keep the patient comfortable is unaffected.
  • Cannot override compulsory mental-health treatment authorised under the Mental Health Act 1983 in England and Wales. A patient detained under the Mental Health Act can be treated for their mental disorder regardless of an ADRT — though the ADRT remains binding for any unrelated physical condition.

Validity and applicability — the two tests

For an advance decision to bind the clinician treating the patient at the relevant moment, both of the following must be true:

Validity (Mental Capacity Act 2005 s.25):

  • The person had capacity when the document was made.
  • The person made it voluntarily, without pressure.
  • The person has not withdrawn it.
  • The person has done nothing since that clearly suggests a change of mind.

Applicability (s.25(4)):

  • The medical situation matches the one described in the document.
  • The person currently lacks capacity to make the decision about that treatment.
  • No circumstances exist that the person did not anticipate and that would have affected their decision.

If either test fails, the clinician falls back on the standard best-interests assessment.

The extra rules for refusing life-sustaining treatment

Where the refusal covers treatment without which the person would die — artificial nutrition and hydration, ventilation, CPR, certain medications — sections 25(5)–(6) of the Act add stricter formalities. The ADRT must:

  • Be in writing.
  • Be signed by the person in the presence of an adult witness.
  • Include an explicit statement that the refusal applies even if the person's life is at risk.
  • Be signed by the witness in the person's presence.

Without these formalities, an attempt to refuse life-sustaining treatment in advance is invalid — the document may still be considered as evidence of wishes for the best-interests assessment, but it cannot bind the clinician. Refusals of treatment that are not life-sustaining can be made informally (even orally, in principle), though writing them down is the only practical way to ensure they are followed. [source: legislation-gov-uk/mental-capacity-act-2005-2026-05-02.html]

Scotland and Northern Ireland

The Mental Capacity Act 2005 does not apply in Scotland or Northern Ireland. The position is similar in substance but different in legal source.

Scotland. The Adults with Incapacity (Scotland) Act 2000 governs decision-making for adults who lack capacity, but it does not create a statutory advance-decision regime. Advance statements are recognised at common law and in clinical practice; Scottish courts have consistently held that a person's autonomous decision made while they had capacity should normally be respected when capacity is lost. The practical position is therefore close to that in England and Wales — a clearly written, signed and witnessed advance statement will be respected — but the legal force comes from the common law and General Medical Council guidance rather than from a specific statute.

Northern Ireland. The Mental Capacity Act (Northern Ireland) 2016 has been passed but is only partially in force, and it does not codify advance decisions. The position remains governed by common law: a valid and applicable advance refusal of treatment is binding on clinicians. The Department of Health published a review of the area in 2019; further reform may follow as the 2016 Act is commenced in stages. Northern Ireland does not currently have a Health and Welfare Lasting Power of Attorney equivalent — see Lasting power of attorney — so an advance decision is the strongest tool currently available for shaping future medical decisions.

How an advance decision interacts with a Lasting Power of Attorney

This is the single most-confused area. The rule, in England and Wales:

  • An advance decision made first, then a Health and Welfare LPA made later, can be overridden by the attorney only if the LPA explicitly gives the attorney authority over the same treatment that the advance decision refuses. A general grant of welfare authority is not enough.
  • A Health and Welfare LPA made first, then an advance decision made later, cannot be overridden by the attorney — the later expression of the donor's own wishes prevails.

The practical consequence: if both documents are intended to coexist, draft them together (or revisit the older one when making the newer) and make sure they say the same thing about the treatments that matter most. The same principle applies in Scotland between an advance statement and a welfare power of attorney.

How to make an advance decision

Step 1 — Identify the refusals that matter. Be specific. Useful prompts: which treatments would I refuse if I had advanced dementia? In a persistent vegetative state? With a terminal diagnosis and weeks to live? After a catastrophic stroke? Generic phrases like "no extraordinary measures" cannot be acted on by clinicians; they need named treatments and named conditions.

Step 2 — Write it down. Include:

  • Full name, date of birth, and date of the document.
  • Each treatment being refused, with the circumstances in which the refusal applies.
  • For any refusal of life-sustaining treatment, the explicit "even if my life is at risk" statement.
  • A short statement that the person understands what they are refusing and accepts the consequences.

There is no statutory form. Many people use the NHS template (downloadable from the NHS website) or a template from a hospice or charity such as Compassion in Dying. Both are equally valid if the formalities are met. [source: nhs-uk/advance-decision-to-refuse-treatment-2026-05-02.html]

Step 3 — Sign and (for life-sustaining refusals) witness. Sign in the witness's presence; the witness signs in yours. The witness can be anyone aged 18 or over but should not have a financial interest in the person's death and ideally is not someone involved in the person's care. A friend or neighbour is fine.

Step 4 — Tell the people who need to know.

  • Your GP. Ask them to add a copy to your medical record. This is the single most important step — emergency teams often consult GP records first.
  • Your hospital consultants if you are under specialist care.
  • Your family and any nominated welfare attorney.
  • Anyone who provides regular care (district nurse, care home, hospice).

A copy in a drawer that nobody knows about is worse than no document at all — when the moment comes, clinicians will treat in the patient's best interests because they have no evidence of an advance decision.

Step 5 — Review every few years. Personal circumstances and medical possibilities change. Review the advance decision every 3 to 5 years, after a significant change in health, before making or updating an LPA, and after any change of GP or move. To change an advance decision, write a new one, destroy the old, and re-distribute the new one to everyone who held a copy.

What this guide doesn't cover

  • Advance care planning in detail — the broader process (typically led by GP or hospice teams) of discussing future care, recording preferences, and identifying the people involved. Advance decisions and statements are tools used within that process, not the whole of it.
  • Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions — clinical decisions made by doctors, recorded on a hospital or community DNACPR form. A patient's advance decision can refuse CPR, but the DNACPR form itself is the clinician's record, not the patient's instrument.
  • Court of Protection welfare decisions for patients who already lack capacity and have no advance decision in place. See the Court of Protection entity.
  • Voluntary assisted dying / assisted suicide — currently unlawful across the UK; outside the scope of an advance decision (which can only refuse treatment, not request action).

If you're struggling, you don't have to do this alone. Samaritans (116 123, 24/7) | Cruse Bereavement Care (0808 808 1677) | Mind (0300 123 3393)

Next: Where to keep a will

Last verified: 2 May 2026 against nhs.uk advance decision guidance and the Mental Capacity Act 2005, ss.24–26.