ADRT (Advance Decision to Refuse Treatment) Explained for UK Care Staff

An Advance Decision to Refuse Treatment, usually shortened to ADRT, lets a person with capacity set out in advance which medical treatments they don't want to receive if they later lose the capacity to make that decision themselves. It's a legally binding document under the Mental Capacity Act 2005 in England and Wales, and it's easy to confuse with other end-of-life documents care staff encounter, including DNACPR forms and Ireland's Advance Healthcare Directives — each of which works differently and carries different legal weight.

What an ADRT actually is

An ADRT is made by the person themselves, while they still have the mental capacity to understand and weigh up the decision, and it takes effect only if and when they later lose capacity for that specific treatment decision. It can refuse a wide range of treatments — resuscitation, ventilation, artificial nutrition, or specific medications, for example — but it cannot be used to demand a particular treatment or to refuse basic care such as being kept warm, clean, and comfortable, which must always be provided regardless of any ADRT in place.

When an ADRT is valid and applies

An ADRT remains valid unless the person has since withdrawn it, created a Lasting Power of Attorney covering the same treatment decision afterwards, or done something clearly inconsistent with the advance decision still representing their wishes. Beyond validity, an ADRT only actually applies to a specific situation if the person currently lacks capacity for that decision, the treatment being proposed matches what was specifically refused, the circumstances described in the document exist, and there's been no unanticipated change that would likely have altered the person's original decision. This is why a vague or poorly worded ADRT can create real difficulty in practice — the more specific the document, the more confidently staff and clinicians can apply it.

The stricter rules for refusing life-sustaining treatment

Refusing life-sustaining treatment carries extra legal formality that doesn't apply to other treatment refusals. To be valid, a refusal of life-sustaining treatment must be in writing (it can be written by someone else or recorded in healthcare notes), signed by the person or someone they've nominated to sign on their behalf, witnessed with both signatures present, and must include a clear statement that the refusal applies "even if my life is at risk." Refusals of treatment that isn't life-sustaining don't need to meet this formal standard and can be made verbally, though written documentation is still strongly recommended for clarity.

How an ADRT differs from a DNACPR

These two documents are often confused, but they work in opposite directions. An ADRT is the person's own advance refusal of treatment, made while they had capacity. A DNACPR (Do Not Attempt CPR) decision is a clinical decision made by a healthcare team, based on their judgement that resuscitation would not have a realistic prospect of success — it isn't something the person themselves signs or refuses. A resident can have one, both, or neither in place, and care staff need to know which document, if any, applies and where it's kept, since confusing the two in an emergency can lead to the wrong action being taken.

The role of care staff

Care staff aren't responsible for assessing an ADRT's validity or applicability — that sits with the clinical team — but staff do need to make reasonable efforts to locate an ADRT when they're told one exists, ensure it's easily accessible in an emergency, and flag it clearly to paramedics or attending clinicians. Where there's genuine doubt about whether an ADRT applies to the situation at hand, treatment should continue while the issue is resolved, if necessary through escalation to the Court of Protection — care staff should never assume an ADRT applies without clinical confirmation, nor dismiss one without proper review.

Frequently asked questions

Does an ADRT apply in Ireland the same way it does in England and Wales? No — Ireland has its own legal framework for advance planning under the Assisted Decision-Making (Capacity) Act 2015, covered separately in our guide to Advance Healthcare Directives in Ireland, which has different formal requirements from an ADRT.

Can a resident change their mind after making an ADRT? Yes, at any time while they still have capacity — a verbal or written change is enough to withdraw or amend an existing ADRT, and this should be documented clearly.

Where should an ADRT be kept in a care setting? It should be stored somewhere staff and emergency responders can access it quickly, with its existence and location flagged clearly in the resident's care plan and, where relevant, in a hospital passport or similar shared document.

Understanding ADRTs clearly, and where they fit alongside best interests decision-making under the Mental Capacity Act, helps care staff support a resident's own wishes with confidence during some of the most sensitive moments in their care.