Key Facts

Advance decisions and LPAs are key mechanisms for advance care planning. They empower individuals to maintain control over future healthcare decisions if they lose capacity. Understanding their legal requirements is essential for clinical practice.

Advance Decision to Refuse Treatment (ADRT)

• Made by a competent adult (≥18) while they have capacity
• Specifies treatment(s) to be refused in specified circumstances
• Legally binding if valid and applicable
• Can be verbal for non-life-sustaining treatments
• Must be written, signed, witnessed for life-sustaining treatments
• Does NOT need to be on a specific form
• Can be revoked at any time while the person has capacity (verbal revocation is sufficient)

Validity Requirements for ADRT

• Person was ≥18 and had capacity when it was made
• Person has not withdrawn it
• Person has not subsequently created an LPA covering the same decisions
• Person has not acted inconsistently with the ADRT
• No reasonable grounds to believe circumstances have changed that would affect the decision

Lasting Power of Attorney (LPA)

• Must be made while person has capacity
• Registered with Office of the Public Guardian
• Health and welfare LPA: covers care, treatment, living arrangements; only operational when person lacks capacity
• Property and financial affairs LPA: covers money, property, bills; can operate while person has capacity if specified
• Attorney must act in person's best interests when person lacks capacity
• Replaced the previous Enduring Power of Attorney (EPA) for financial affairs

Clinical Scenarios

• Jehovah's Witness ADRT refusing blood transfusion: if valid and applicable, must be respected even if refusal leads to death
• Dementia patient with health and welfare LPA: attorney makes treatment decisions
• Patient in ICU with ADRT refusing ventilation: clinical team must assess validity and applicability before withdrawing treatment
• Patient with advance statement preferring home death: must be considered but not legally binding; feeds into best interests if patient lacks capacity

When ADRT May NOT Apply

• Decision was made without adequate information
• Circumstances have changed significantly since it was made
• Person has acted inconsistently with the decision (e.g. stated they no longer hold those views)
• Treatment proposed is different from that specified in the ADRT
• Person subsequently created an LPA covering the same decisions

Common Challenges

• ADRT not available in emergency
• Uncertainty about validity or applicability
• Disagreement between clinical team and family about ADRT
• Unclear whether specific treatment is covered by the ADRT
• Patient's views may have changed (but no revocation documented)

Assessment When ADRT Presented

1. Is there a valid ADRT?
2. Does the person now lack capacity for this specific decision?
3. Is the ADRT applicable to the current situation?
4. Has the person done anything inconsistent with the ADRT?
5. Is there a subsequent LPA covering the same decisions?
6. If ADRT is valid and applicable: follow it
7. If uncertain: treat in best interests while seeking clarification
8. In emergency: can provide treatment to prevent death while ADRT validity is being established

LPA Verification

• Ask for registered LPA document (must be registered with OPG)
• Check scope: does it cover health and welfare decisions?
• Check any restrictions or conditions
• Verify the attorney's identity
• Confirm person lacks capacity for the relevant decision
• Check OPG register if uncertain about validity

Working with ADRTs

• Respect valid and applicable ADRTs — they are legally binding
• If in doubt about validity/applicability: treat in best interests while seeking clarification (for non-life-sustaining treatment)
• For life-sustaining treatment: if reasonable doubt, provide treatment while seeking legal advice
• Document assessment of ADRT validity and applicability
• Keep copies of ADRTs in medical records

Working with LPA Attorneys

• Confirm LPA is registered and covers health/welfare
• Provide attorney with same information as you would the patient
• Attorney must make decisions in person's best interests (not their own)
• If disagreement with attorney's decision: discuss, seek second opinion, apply to Court of Protection if necessary
• Attorney cannot demand treatment that is not clinically indicated

Encouraging Advance Care Planning

• Discuss with patients with progressive conditions (dementia, cancer, MND, heart failure)
• ReSPECT process for emergency treatment preferences
• Encourage patients to appoint LPA while they have capacity
• Provide information about ADRTs and advance statements
• Record discussions and preferences in medical records

Referral Criteria

• Dispute about ADRT validity: legal advice/Court of Protection
• Dispute with LPA attorney: attempt resolution, then Court of Protection
• Complex advance care planning: palliative care team, ethics committee

• Advance care planning improves end-of-life care and reduces unwanted interventions
• Patients with ADRTs are more likely to have their wishes respected
• LPA uptake is increasing but remains low: approximately 5 million registered in England/Wales
• Documentation and accessibility of ADRTs remain challenges (not always available in emergency)
• ReSPECT forms are increasingly used to complement ADRTs for emergency care preferences

ADRT Requirements Summary

LPA Key Points