Advance decisions in psychiatry: England and Wales

by Dr Lisa Williams and Dr John Rigby


Last updated: October 2018


'Advance directives' or 'living wills' were originally designed for terminally ill patients. They are now seen as increasingly relevant to psychiatry, where self-determination has been recognised as a fundamental ethical principle.


Following the implementation of the Mental Capacity Act 2005, there are two sorts of advance decisions – advance statements and Advance Decisions to Refuse Treatment (ADRTs).


These anticipate a time when the capacity to make a treatment decision has been lost, and detail a person’s wishes for future medical treatment. As such, they are a way of enhancing patient autonomy and choice.


As advance treatment refusals become more commonplace in clinical practice, psychiatrists may well be called upon to give an opinion about a person’s capacity to make an ADRT or be presented with one by a patient. Thus, they need to feel confident in this area.


This module will:


  • define the terminology used in advance decision-making, emphasising the differences between advance statements and ADRTs


  • discuss the relevant legal issues and the assessment of capacity, which is crucial in this area


  • highlight the particular conflict of ADRTs and the Mental Health Act 1983


  • look at the risks and benefits of having an ADRT (and how to discuss these with patients) 


  • illustrate the practicalities of advance decision-making with some case examples


  • set out the criteria for when an ADRT may be invalid.


Start the module


If you like this module, you may also be interested in:


Advance statements and the law in Scotland by Dr Stephen Anderson


Competence, capacity and decision-making ability in mental disorder by Dr Justine McCulloch and Dr Mark Taylor


Irish Mental Health Act 2001 by Dr Larkin Feeney and Dr Brendan Kelly


Psychiatric aspects of terminal care by Dr John Mitchell


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