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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Advance decision to refuse treatment (ADRT): legally binding refusal of specific treatments in specific circumstances, made while a person has capacity. Takes effect only when they lose capacity
- For ADRT refusing life-sustaining treatment: must be written, signed, witnessed, and include "even if life is at risk"
- Lasting Power of Attorney (LPA) for health and welfare: appointed person can make health decisions when the patient lacks capacity. Must be registered with the Office of the Public Guardian
- Advance statement: expression of wishes, preferences, values — NOT legally binding but MUST be considered in best interests decision
- ReSPECT (Recommended Summary Plan for Emergency Care and Treatment): structured document recording patient's preferences for emergency treatment, including CPR decisions
Overview
Advance care planning (ACP) is a voluntary process of discussion about future care between a patient and their healthcare providers, often involving family members. It becomes relevant when a person anticipates future loss of capacity (e.g. progressive dementia, terminal illness). The Mental Capacity Act 2005 provides the legal framework. Key instruments include: advance decisions to refuse treatment (legally binding under MCA sections 24-26), Lasting Powers of Attorney (sections 9-14), and advance statements (not legally binding but important). The ReSPECT process provides a nationally standardised document for recording emergency treatment preferences including resuscitation decisions.
Epidemiology
Despite strong advocacy, uptake of formal advance care planning remains low — approximately 5-10% of the UK population have an ADRT. LPA registrations have been increasing, with over 900,000 health and welfare LPAs registered in 2023. The ReSPECT form is now widely used across NHS trusts and has replaced many local DNAR form systems. Studies consistently show that ACP improves end-of-life outcomes, reduces unwanted hospital admissions, and increases the likelihood that patients receive care aligned with their values.
Key Instruments
Symptoms
Advance Decision to Refuse Treatment (ADRT / "Living Will"): specifies treatments to be refused in specified circumstances. Only covers refusal, NEVER demand for treatment
ADRT for life-sustaining treatment: MUST be written, signed, witnessed, and explicitly state the decision applies "even if life is at risk"
LPA Health and Welfare: attorney can consent to or refuse treatment (including life-sustaining treatment if specified) when patient lacks capacity
LPA Property and Affairs: separate LPA for financial decisions — does NOT cover health decisions
Advance Statement: written record of wishes, preferences, values. Not legally binding but must be taken into account in best interests assessment
ReSPECT form: agreed recommendations for emergency care including CPR decision. Applies in emergencies. Reviewed regularly
Signs
An ADRT is NOT valid if: the patient has withdrawn it, has created a subsequent LPA covering the same decision, or has done anything clearly inconsistent with it
If conflict between ADRT and LPA: the most recently made document takes precedence (if LPA was made after ADRT, LPA overrides)
Nobody can demand treatment — an advance directive can only REFUSE treatment, not insist on it
Assessment
First-line
Check for existing documentsSearch for: ADRT, registered LPA (check OPG register), ReSPECT form, DNAR/DNACPR, advance statement. Check medical records, patient's home, GP records
Assess validity and applicabilityADRT valid if: patient was ≥18 and had capacity when made, not withdrawn, applicable to current circumstances and proposed treatment
Second-line
Contact LPA attorneyIf patient lacks capacity and an LPA for health and welfare is registered — the attorney makes decisions in patient's best interests
Contact family and carersTo establish patient's known wishes, values, and beliefs (for best interests assessment)
Specialist
Court of ProtectionIf dispute over validity of ADRT, conflict between family members, or no LPA and complex decisions needed. Can appoint a court-appointed deputy
Independent Mental Capacity Advocate (IMCA)Must be instructed if serious medical treatment is proposed for an unbefriended patient (no family or friends to consult) who lacks capacity
1
Facilitating advance care planning
- Initiate conversations early — ideally when the patient has capacity and before crisis
- Explore values and preferences: what matters most to the patient? What treatments would they want or refuse?
- Discuss and document: encourage patients to write an ADRT if they wish to refuse specific treatments
- Advise on LPA: recommend appointing an LPA for health and welfare, and registering it with the OPG
- Complete ReSPECT form where available — collaborative process between patient, family, and healthcare team
2
When an ADRT exists
- Check validity: was the patient ≥18, did they have capacity, is it applicable to the current situation and treatment?
- If valid and applicable: the ADRT is legally binding — you MUST comply, even if you disagree or the patient will die
- If doubt about validity or applicability: treat in the patient's best interests pending clarification (may need legal advice)
- If ADRT conflicts with a more recently registered LPA that covers the same decision: LPA takes precedence
3
When an LPA for health exists
- LPA can only make decisions when the patient lacks capacity
- The attorney must act in the patient's best interests, considering their known wishes
- LPA can authorise or refuse treatment including life-sustaining treatment (if the LPA specifically grants this authority)
- The attorney cannot demand treatment that the clinical team considers futile or inappropriate
Complications
- Invalid ADRT: Treating against patient's known wishes because ADRT was not properly documented or was overlooked
- Overriding a valid ADRT: Assault/battery if a valid ADRT is ignored — the doctor has no legal authority to override it
- Conflict: Family members disagree with ADRT or with each other — may require Court of Protection
- Documents not available in emergency: ADRT at home but patient in ED — treat in best interests pending retrieval
UKMLA Exam Tips
- 1ADRT = legally binding refusal of treatment. It CAN refuse life-sustaining treatment IF written, signed, witnessed, and states "even if life is at risk"
- 2You CANNOT demand treatment through an ADRT or any other advance directive — only refuse it
- 3If LPA was made AFTER ADRT and covers the same decision → LPA overrides the ADRT
- 4LPA must be registered with OPG to be valid. An unregistered LPA has NO legal authority
- 5Emergency: if ADRT exists but cannot be verified and the patient will die → treat in best interests while attempting to verify
- 6ReSPECT is not legally binding in the way an ADRT is — it is a recommendation that clinicians should follow unless there is a good reason not to
- 7Nobody — not even an LPA attorney — can demand futile treatment
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