1. 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

2. Advance Decisions to Refuse Treatment (ADRT)

3. 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

4. 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. 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

6. 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

7. 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’

8. 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

9. Validity & Applicability Checklist

10. 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

11. 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

12. Case Studies

13. 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

14. 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

15. Advance Decisions to Refuse Treatment (ADRT)
Annamarie Challinor
Macmillan End of Life Programme Lead
Tel or
John Glynn
Legal Service Manager East Cheshire Trust
Tel
Bespoke training delivered on request