What is an advance decision?
An advance decision to refuse treatment (ADRT) is also known as a living will or advance directive. It is a legally binding document which allows a person to specify which treatments they would not want (including life sustaining treatments) in the future when they lack capacity. It does not allow an individual to specify what treatments they want nor does it allow a person to request assisted dying or euthanasia. Additionally, it does not allow an individual to refuse comfort measures.
For an advance decision to be valid, a person must be over 18 and have mental capacity at the time of making it. If refusing life sustaining treatments the document needs to be signed and witnessed.
If LPA for health and welfare is made after an advance decision, the LPA takes precedence and the attorney is not obliged to follow the wishes specified in the advance decision. So, an advance decision should be updated in the event of making an LPA. An advance decision can also be revoked whilst an individual still has the capacity to do so. It is a good idea to regularly review an advance decision.
An advance decision should be discussed with a doctor so that the person making it fully understands the nature of the treatments that they wish to opt out of, the circumstances under which they may arise and the implications of the decisions.
How do I make an advance decision?
Ideally, you should make an advance decision in writing and copies should be provided to loved ones and your GP. It is not strictly necessary for an advance decision to be in writing as you can simply tell your GP your preferences, but since it is essential that hospital staff be aware of it during an unplanned / emergency admission, it is a good idea to have it in writing and have a copy with you. Bear in mind that an advance decision only becomes valid if you lack mental capacity. In the absence of an advance decision, medical treatment is given in best interests.
An advance decision does not require filling out an official form but some people find that using a template is helpful. A useful template can be downloaded here. You need to list the treatments that you would not wish to have and the circumstances under which you would want to opt out. You cannot simply say that you refuse all medical treatment without being specific.
It is also a good idea to review the terms and conditions of your life insurance policy when deciding to make an advance decision as in some cases they will need to be notified.
What are life - sustaining treatments?
These include but are not limited to CPR, mechanical ventilation, artificial nutrition and hydration, and antibiotics. Life - sustaining treatment can vary from person to person depending on the reason you are in hospital. For example, in a patient having a severe asthma attack, non-invasive ventilation may be life - sustaining, whilst in a patient who is bleeding profusely, blood and intravenous fluids are life - sustaining.
Opting out of life - sustaining treatments legally requires a written document which has to state clearly that you wish to opt out of specific treatments even if your life is at risk, and it needs to be signed and witnessed. It is important, though that you specify the treatments and circumstances. You need to fully understand the treatments you wish to forego, and the risks/benefits of your decision. Speaking to a doctor before making your advance decision is highly recommended.
What are the benefits of an advance decision?
An advance decision allows you to have autonomy in choosing the treatments you would not want later on. It ensures that your wishes are respected, and that burdensome treatments which may do more harm than good are avoided. It also relieves the emotional strain placed on loved ones in stressful circumstances.
An advance decision is of course not something that everyone wants. Many people, including older people, are happy to have all medical treatments offered to them, and prefer that doctors be the ultimate decision makers. In people who are living with a terminal or progressive illness, however, an advance decision may be something worth considering.