What is an Advance Decision to Refuse Treatment (ADRT)?
During severe illness people are often unconscious or otherwise unable to communicate their wishes - at the very time when many critical decisions need to be made. An Advance Decision to Refuse Treatment is a document by which you can state in advance that you wish to refuse specified medical treatment in specified circumstances. |
It is sometimes referred to an ADRT or ‘living will’ although it is totally unrelated to an actual will. We have used the term Advance Decision here.
The purpose of an Advance Decision is to give you confidence that your wishes regarding health care will be carried out if you cannot speak for yourself.
It comes into effect only if you are unable to make or to communicate your own decisions.
A clear and properly made Advance Decision will be binding on your family and on your doctors if the circumstances to which it relates arise after you have lost mental capacity. Because of this, and because it can be difficult to predict what circumstances will arise in the future, and Advance Decision is a very powerful document which should be entered into only with great care, and after consulting with appropriate professionals such as your doctor.
Whilst it is possible to make an Advance Decision about treatment that you do not want to receive, you cannot make a legally enforceable Advance Decision about what treatment you would want to receive, i.e. doctors may decide not to carry out the treatment that you have requested, particularly if they consider it medically inappropriate. Alternatives to consider as regards the decisions that you would want to be made include a Health and Welfare Lasting Power of Attorney and an Advance Statement.
Life Sustaining Treatment
An Advance Decision can say that you do not want to receive life-sustaining treatment, i.e. treatment that may be needed to keep you alive. If you include this it is important to be precise about what life sustaining treatment you do not wish to receive, and the circumstances in which you do not wish to receive it. It must be clear that you do not want the treatment even though it may be needed to keep you alive. You must ensure that your Advance Decision is in writing and properly witnessed if it relates to life sustaining treatment.
What are the Formalities?
Any person who is aged over 18 and who has the mental capacity to make decisions about such matters can make an Advance Decision. Legally enforceable advance decisions can be written in layman’s terms, but they must be specific. It is not even necessary for an Advance Decision to be in writing (unless it relates to life sustaining treatment), although you may find it easier to be clear and feel more confident that people will know of your wishes if your Advance Decision is written down.
To be legally binding, an advance decision that relates to life sustaining treatment must be in writing, and signed by the person who is making it, or signed on their behalf, in their presence, and under their direction.
The signature of the person making the Advance Decision must also be witnessed, and the witness must sign, or acknowledge his or her signature in the presence of the person who is making the advance decision. An Advance Decision about life sustaining treatment must clearly state that it applies to that treatment, even if life is at risk.
An Advance Decision will not be applicable if the treatment proposed to be given is different from the one that was specified, or if the circumstances are not as specified in the Advance Decision. You should therefore be very clear about what treatment you do not want to receive, and in what circumstances.
There may be some treatments that you would want to receive in some circumstances, and not in others. You should be careful not to restrict your doctors in ways that you do not intend, for example by saying that you do not want to receive a particular treatment that can be used to prolong life in some circumstances, but which can also be used to treat a simple non-life threatening condition, or to minimise pain and suffering in other situations, unless of course you do not wish to receive the treatment or medication in any circumstance.
This is one reason why great care is needed, and why it is strongly recommended that that you discuss any plans you have to record an Advance Decision with professionals who are able to assist, including your doctor. You may also find it helpful and supportive to also involve those people who are closest to you, such as family or close friends.
Reviewing and Changing an Advance Decision?
Your wishes as stated in an Advance Decision are not final; you can change them at any time while you remain mentally capable of doing so.
You should consider reviewing your Advance Decision on a regular basis, to ensure that it continues to reflect your wishes and takes into account your current circumstances.
You can even change an Advance Decision verbally. If you do change your Advance Decision or want to cancel it, it is best to destroy all copies of the old or cancelled version.
Your Advance Decision may also not be acted upon if you have done something since making your Advance Decision, which clearly indicates that you have changed your mind. This reinforces how important it can be to keep your Advance Decision up to date, and to make sure that your wishes are clear.
Alternatives to an Advance Decision
It can be difficult to anticipate the circumstances that may arise in the future, and so to make the Advance Decision sufficiently specific, and valid when and if needed. An alternative is to have a Health and Welfare Lasting Power of Attorney and to give the attorney power to accept or refuse life-sustaining treatment. You may also wish to consider an Advance Statement, which can sit alongside an Advance Decision and/or a Health and Welfare Lasting Power of Attorney.
An Advance Decision ceases to have effect if you later appoint an attorney under a Lasting Power of Attorney, and give that attorney(s) authority to make decisions about the treatment covered by your advance decisions. If you make an Advance Decision after you have appointed an attorney under a Lasting Power of Attorney, the Advance Decision will be valid, and the Attorney will not be able to make decisions on matters covered by your Advance Decision.
Practical Steps
It is a good idea to think about who needs to know about your Advance Decision, and about how you may bring it to the attention of people who may need to know in an emergency. Some people wear a bracelet or other indicator for this purpose, some carry a card in their wallet, and some people even carry their Advance Decision with them. You can ask your General Practitioner to record your Advance Decision on your medical records
If you are admitted to hospital or to a residential aged care facility, make sure the hospital or staff know that you have an Advance Decision and either give them a copy of it or tell them where a copy can be obtained.
http://www.nhs.uk/Planners/end-of-life-care/Pages/advance-decision-to-refuse-treatment.aspx
Catherine J., UK
NOTE: Unless otherwise stated, the information in this document is based on the laws of England. People living in other places are invited to make their own inquiries. This document is for general information purposes only and does not constitute, and is in no way an alternative to obtaining legal advice.
The purpose of an Advance Decision is to give you confidence that your wishes regarding health care will be carried out if you cannot speak for yourself.
It comes into effect only if you are unable to make or to communicate your own decisions.
A clear and properly made Advance Decision will be binding on your family and on your doctors if the circumstances to which it relates arise after you have lost mental capacity. Because of this, and because it can be difficult to predict what circumstances will arise in the future, and Advance Decision is a very powerful document which should be entered into only with great care, and after consulting with appropriate professionals such as your doctor.
Whilst it is possible to make an Advance Decision about treatment that you do not want to receive, you cannot make a legally enforceable Advance Decision about what treatment you would want to receive, i.e. doctors may decide not to carry out the treatment that you have requested, particularly if they consider it medically inappropriate. Alternatives to consider as regards the decisions that you would want to be made include a Health and Welfare Lasting Power of Attorney and an Advance Statement.
Life Sustaining Treatment
An Advance Decision can say that you do not want to receive life-sustaining treatment, i.e. treatment that may be needed to keep you alive. If you include this it is important to be precise about what life sustaining treatment you do not wish to receive, and the circumstances in which you do not wish to receive it. It must be clear that you do not want the treatment even though it may be needed to keep you alive. You must ensure that your Advance Decision is in writing and properly witnessed if it relates to life sustaining treatment.
What are the Formalities?
Any person who is aged over 18 and who has the mental capacity to make decisions about such matters can make an Advance Decision. Legally enforceable advance decisions can be written in layman’s terms, but they must be specific. It is not even necessary for an Advance Decision to be in writing (unless it relates to life sustaining treatment), although you may find it easier to be clear and feel more confident that people will know of your wishes if your Advance Decision is written down.
To be legally binding, an advance decision that relates to life sustaining treatment must be in writing, and signed by the person who is making it, or signed on their behalf, in their presence, and under their direction.
The signature of the person making the Advance Decision must also be witnessed, and the witness must sign, or acknowledge his or her signature in the presence of the person who is making the advance decision. An Advance Decision about life sustaining treatment must clearly state that it applies to that treatment, even if life is at risk.
An Advance Decision will not be applicable if the treatment proposed to be given is different from the one that was specified, or if the circumstances are not as specified in the Advance Decision. You should therefore be very clear about what treatment you do not want to receive, and in what circumstances.
There may be some treatments that you would want to receive in some circumstances, and not in others. You should be careful not to restrict your doctors in ways that you do not intend, for example by saying that you do not want to receive a particular treatment that can be used to prolong life in some circumstances, but which can also be used to treat a simple non-life threatening condition, or to minimise pain and suffering in other situations, unless of course you do not wish to receive the treatment or medication in any circumstance.
This is one reason why great care is needed, and why it is strongly recommended that that you discuss any plans you have to record an Advance Decision with professionals who are able to assist, including your doctor. You may also find it helpful and supportive to also involve those people who are closest to you, such as family or close friends.
Reviewing and Changing an Advance Decision?
Your wishes as stated in an Advance Decision are not final; you can change them at any time while you remain mentally capable of doing so.
You should consider reviewing your Advance Decision on a regular basis, to ensure that it continues to reflect your wishes and takes into account your current circumstances.
You can even change an Advance Decision verbally. If you do change your Advance Decision or want to cancel it, it is best to destroy all copies of the old or cancelled version.
Your Advance Decision may also not be acted upon if you have done something since making your Advance Decision, which clearly indicates that you have changed your mind. This reinforces how important it can be to keep your Advance Decision up to date, and to make sure that your wishes are clear.
Alternatives to an Advance Decision
It can be difficult to anticipate the circumstances that may arise in the future, and so to make the Advance Decision sufficiently specific, and valid when and if needed. An alternative is to have a Health and Welfare Lasting Power of Attorney and to give the attorney power to accept or refuse life-sustaining treatment. You may also wish to consider an Advance Statement, which can sit alongside an Advance Decision and/or a Health and Welfare Lasting Power of Attorney.
An Advance Decision ceases to have effect if you later appoint an attorney under a Lasting Power of Attorney, and give that attorney(s) authority to make decisions about the treatment covered by your advance decisions. If you make an Advance Decision after you have appointed an attorney under a Lasting Power of Attorney, the Advance Decision will be valid, and the Attorney will not be able to make decisions on matters covered by your Advance Decision.
Practical Steps
It is a good idea to think about who needs to know about your Advance Decision, and about how you may bring it to the attention of people who may need to know in an emergency. Some people wear a bracelet or other indicator for this purpose, some carry a card in their wallet, and some people even carry their Advance Decision with them. You can ask your General Practitioner to record your Advance Decision on your medical records
If you are admitted to hospital or to a residential aged care facility, make sure the hospital or staff know that you have an Advance Decision and either give them a copy of it or tell them where a copy can be obtained.
http://www.nhs.uk/Planners/end-of-life-care/Pages/advance-decision-to-refuse-treatment.aspx
Catherine J., UK
NOTE: Unless otherwise stated, the information in this document is based on the laws of England. People living in other places are invited to make their own inquiries. This document is for general information purposes only and does not constitute, and is in no way an alternative to obtaining legal advice.