Advance Decisions to Refuse Treatment (ADRT) Written by; Annamarie Challinor: Macmillan End of Life Care Team Lead John Glynn: Legal Services Manger East Cheshire Trust

Advance Decisions to Refuse Treatment (ADRT)

Replaces “living wills” or “advanced directives” Advance Decisions to Refuse Treatment (ADRT) Enables someone aged 18 years and over, while still capable to refuse specified medical treatment for a time in the future when they may lack the capacity to consent to or refuse that treatment. Replaces “living wills” or “advanced directives” ‘Living will’ valid if made prior to MCA 2005 Legally binding- prosecution for assault

Mental Capacity Act (2005) Protects infringement of human rights when a person lacks capacity due to illness, frailty, unconsciousness or mental health. 5 Core Principles Best Interest Decisions Independent Mental Capacity Advocates (IMCA’s) Advance Decision to Refuse Treatment (ADRT) Appointment of a Lasting Power of Attorney (LPA)

5 Core Principles of the Mental Capacity Act (2005); A person must be assumed to have capacity unless it is established that they lack capacity A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success A person is not to be treated as unable to make a decision merely because of diagnosis or because he makes an unwise decision An act done, or decision made under this Act for, or on behalf of a person who lacks capacity must be done or made in his best interests Before the act is done, or the decision is made , regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the persons rights and freedom of action

Decisions that may warrant an ADRT Refusal of treatments such as; Resuscitation- when no local DNAR proforma/policy PEG feeding Ventilator support Antibiotics Stent insertion Nasogastric feeding Receiving of blood products NB; ADRT’s can only be used to refuse treatment and not to request treatment or to refuse basic comfort & care

Validity of an ADRT Must be in writing if refusing treatment which is life sustaining- Template examples available Can only be made by a person age 18+ who has capacity Only applies when the person is incapacitated Must be signed by the maker and in the presence of a witness Must be a specific statement about a specific treatment in a specific circumstance Wording must clearly state ‘even if life is at risk’

Validity & Applicability of an ADRT No evidence to suggest the withdrawal of the ADRT No subsequent appointment of a LPA The patient should not have acted in a way inconsistent with the advance decision It must be applicable to the treatment in question There should be no significant changes in circumstances for which there are reasonable grounds for believing that these would have affected a person’s advance decision- consider time lapses during which time medical treatment advances have been made There should be no uncertainty or ambiguity concerning what should happen-emergency situation There should be no suspicion of foul play/ coercion

Validity & Applicability Checklist

Considering all the above it is totally understandable why many patients are advised to seek legal advice and why medical professionals are fearful and confused about ADRT’s With a knowledgeable GP/Consultant and good communication legal advice is not always needed No current local guidance re ADRT, reliant upon legal team advice National guidance is however available National guidance does not give any formal process re cancelling or reviewing ADRT Good communication is vital NWAS pilot will allow electronic notification

Legal advice may help to improve clarity but cannot be guaranteed to do so. It should be remembered that lawyers are not health care professionals and so may not be able to provide sufficient information about the benefits and burdens of different treatments or the circumstances in which decisions about them might arise. ECT Legal Team contact John Glynn ext 1768

Case Studies

Mrs A Case Studies- Miss B (2002 pre MCA) Malformation of blood vessels in the spine Executed ‘living will’ stating a wish for withdrawal of treatment if she was suffering from a life-threatening condition, permanent mental impairment or permanent unconsciousness Became tetraplegic following spinal haemorrhage, respiratory problems & required ventilator ‘Living will’ though not to be specific enough Underwent surgery- able to articulate words requesting withdrawal of ventilator 2 psychiatrists ?capacity- later proved to have Proceeding brought against hospital- unlawful trespass Ventilator withdrawn

Case Studies- Kerrie Woolterton 2009 (post MCA) Suicide woman allowed to die because doctors feared saving her would be assault Age 26 suffering with depression Drank poison and called ambulance Handed Dr’s at A&E a letter asking to be kept comfortable and not to try and save her life Conscious and had capacity when arrived at A&E doctors said her wishes were “abundantly clear” and although it was a “horrible thing” there had been no alternative but to let her die. “A deliberate decision to die may appear repugnant but any treatment given to save her life in the absence of her consent would have been unlawful” William Armstrong Norfolk Coroner

Advance Decisions to Refuse Treatment (ADRT) Annamarie Challinor Macmillan End of Life Programme Lead Annamarie.challinor@nhs.net Tel 07920 765269 or 01625 663177 John Glynn Legal Service Manager East Cheshire Trust johnglynn@nhs.net Tel 01625 661768 Bespoke training delivered on request