Refusal of treatment, advance decisions and future wishes

An adult who can make the relevant decision can refuse recommended treatment, including treatment that clinicians believe is life-saving. The response is not to raise the capacity threshold because the consequences are serious. Instead, ensure the patient has the information they need, check understanding and voluntariness, address communication barriers, explore reasons and document the decision.

A refusal can be narrow. A patient may refuse one component, route or duration of treatment while accepting others. Clarify exactly what is being refused rather than converting the discussion into an all-or-nothing label.

If the patient currently has capacity, their present decision generally governs. An old advance care plan or earlier expression of preference should inform the conversation but should not replace the person's current voice.

This distinction prevents a common error: treating an advance document as if it permanently freezes a person's choices. Advance planning is intended to support future care when the person cannot decide or communicate, not to silence a person who can decide now.

Future care planning can include values, preferences, emergency care plans, advance statements, advance decisions to refuse treatment and appointments of legal proxies. These are not interchangeable. A clinician must establish what document actually exists, which jurisdiction applies, whether it is current and what authority it carries.

The Mental Capacity Act 2005 provides a statutory framework for advance decisions to refuse specified treatment. When the person later lacks capacity, the clinician must establish that the advance decision exists and is valid and applicable to the treatment and circumstances. Refusal of life-sustaining treatment has additional formal requirements under the Act.

A lasting power of attorney for health and welfare may also carry treatment decision-making authority, but the scope of the attorney's authority must be checked rather than assumed.

Scotland uses the Adults with Incapacity framework and Scottish powers of attorney; the terminology and legal routes are not identical to the MCA. Northern Ireland has its own evolving framework and Department of Health material on advance decisions. The safest course is to identify the jurisdiction first and avoid using 'ADRT' as though it were a universal UK statutory label.

Resuscitation Council UK states that ReSPECT and other emergency treatment plans such as DNACPR are not legally binding documents. They record personalised clinical recommendations to guide future emergency care. A DNACPR recommendation applies to CPR and does not itself mean that all other treatment should stop.

A separate legally binding advance refusal may exist alongside an emergency plan. The clinician must not assume one document has the legal status of another.

Scenario 1

A capacitous patient refuses dialysis after demonstrating understanding that the decision is likely to shorten life.

Scenario 2

An unconscious patient arrives with a document labelled "living will" but the team has not established its status, validity or applicability.

Scenario 3

A ReSPECT plan recommends not attempting CPR; a clinician tells the family that the document is legally binding for all treatment.

• Clarify exactly what treatment is being accepted or refused.
• If the patient can decide now, give priority to their current decision.
• Identify the precise type and legal status of any future-care document.
• In England and Wales, check validity and applicability of an advance decision and any proxy authority.
• Do not describe ReSPECT or DNACPR as universally legally binding consent/refusal forms.
• Escalate uncertainty about legal status, applicability or authority and document the reasoning.