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Introduction
Maintaining patient autonomy is a fundamental aspect of clinical practice, even when individuals lose the capacity to make decisions. Lasting power of attorney (LPA) and advance decision to refuse treatment (ADRT) (also known as an advance decision or advance directive) are useful tools to ensure that wishes are respected in such situations.1
For an LPA or ADRT to take effect, the patient must lack capacity, as defined by the Mental Capacity Act (MCA) 2005.2
The two-stage test of capacity
The MCA outlines a two-stage process for assessing an individual’s mental capacity to make a specific decision. Any assessment of capacity must be decision-specific and time-specific.
Diagnostic test
This determines if the individual has any impairment or disturbance affecting the mind or brain. This can include conditions such as:
- Mental illness: including depression, anxiety, or schizophrenia
- Neurological disorders: including dementia, stroke, or brain injury
- External factors: including temporary impairments caused by alcohol or drug use
If a person has an impairment of the mind or brain, this may affect their capacity and should prompt a decision-specific test, known as the functional test.
Functional test
This determines whether the individual can:
- Understand relevant information
- Retain the information long enough to make a decision
- Use or weigh up the information when making a decision
- Communicate their decision through any means
If the person cannot demonstrate all four components of this test, they lack the capacity to make that decision at the time of assessment.
A person must be supported throughout this process, e.g. by using communication aids, familiar staff, or optimising the timing and surroundings.2
For further information, read the Geeky Medics guide to the mental capacity assessment.
Power of attorney
Adults with capacity can appoint someone to make decisions on their behalf. The person granting this authority is the donor, while the appointed decision-maker is the attorney, who must also be 18 years old.
LPA replaced the enduring power of attorney (EPA) system in 2007, though EPAs created before this date remain valid.3
Different types of power of attorney
Ordinary power of attorney (OPA)
A temporary arrangement that allows someone with capacity to nominate another person to manage their financial affairs. It becomes invalid if the donor loses capacity.
Lasting power of attorney (LPA)
A permanent arrangement that is relevant only if the donor loses capacity. An LPA must be registered with the Office of the Public Guardian (OPG) to be valid.4
There are two types of LPA:
- Health and welfare: includes medical treatment, daily care, and life-sustaining treatment decisions
- Property and financial affairs: includes financial matters, including property and banking
LPAs can be established with a single attorney or multiple attorneys, with the latter being assigned the responsibility to act either “jointly” (requiring consensus on every decision) or “jointly and severally” (allowing for both joint and independent decision-making).
LPAs can be revoked by the donor at any time, provided they retain mental capacity. If revoked, the donor must inform both the attorney and the OPG.
Clinical relevance of an LPA
If a Health and Welfare LPA is in place and the donor later loses capacity, the attorney gains legal authority to make decisions about their care and treatment.
Clinicians must consult with the attorney before making significant medical decisions, provided the LPA is for health and welfare, is legally valid, and has been registered with the OPG.
Rather than acting in an advisory role, the attorney must be consulted, and their consent is legally required for treatment decisions, as if they were the patient themselves. Clinicians cannot proceed with interventions without the attorney’s agreement, except in emergency situations where immediate treatment is necessary to save life or prevent serious deterioration.
If the attorney chooses to exempt themselves from a decision, responsibility then falls to the medical team, who must follow the MCA best interests process.5
Verifying an LPA in practice
Check for the original LPA document embossed with the “validated – OPG” stamp and ensure it confers the necessary powers for healthcare decisions rather than financial matters.
If concerns arise about the attorney’s actions or disputes occur, healthcare professionals should contact the OPG. In complex cases, the Court of Protection may intervene to ensure decisions align with the donor’s best interests.3
Advance decision to refuse treatment (ADRT)
An advance decision to refuse treatment (ADRT) is a legally binding document that allows a person to refuse specific medical treatments in the future, should they lose the capacity to make decisions for themselves. In Scotland, the equivalent term is an advance directive.1, 6
A person must be 18 years or over and have the mental capacity to understand and make decisions at the time of creating an ADRT.1, 6
Key principles and implications
An ADRT only allows a patient to refuse specific treatments; it cannot be used to demand any specific treatments.
Clinically assisted nutrition and hydration (CANH), which includes tube feeding, is considered a recognised form of medical treatment. An ADRT can lawfully refuse CANH, even if this leads to death. However, an ADRT cannot refuse basic comfort and care, including warmth, hygiene, shelter, and oral food and drink.1, 6
Legal aspects of ADRT
For an ADRT refusing life-sustaining treatment to be legally binding, it must:
- Be in writing (if refusing life-sustaining treatment)
- Be signed and witnessed
- Include a statement that explicitly states refusal applies even if life is at risk
- Clearly specify the treatment(s) to be refused and the circumstances under which they apply
If a clinician concludes that an ADRT is not legally binding, they should still consider it as evidence of the patient’s wishes when following the MCA best interests process.1
When is an ADRT invalid?
A person can withdraw their decision at any time while they still have capacity, either verbally or in writing. Additionally, if their actions indicate they have changed their mind, the ADRT may no longer be considered valid.
An LPA for health and welfare can also impact the validity of an ADRT. If an LPA for health and welfare is created after an ADRT, the most recent document takes priority. In such cases, the attorney’s decisions will override the ADRT, unless the ADRT explicitly states otherwise.2
A valid ADRT must also be applicable to the proposed treatment. It does not apply if:
- The specified treatment does not match the required treatment
- Circumstances have changed in a way the patient did not anticipate
- Medical advancements since the ADRT was made may have altered what the patient would likely decide
ADRT in emergencies
In emergency situations, life-saving treatment should not be delayed while searching for an ADRT. If an ADRT is found, its validity and applicability must be assessed as soon as possible.1
If there is genuine doubt about the existence, validity, or applicability of an ADRT, treatment can proceed without legal liability.
ADRT and mental health treatment
An ADRT cannot refuse treatment for a mental disorder if the person is detained under the Mental Health Act 1983. However, an ADRT can refuse treatment for physical illnesses, even if the person is detained.1
Reviewer
Dr Maria McKenna
Consultant in Palliative Medicine
Editor
Dr Jamie Scriven
References
- National End of Life Care Programme. Advance decisions to refuse treatment: A guide for health and social care professionals. 2013. Available from: [LINK].
- HM Government. Mental Capacity Act 2005. 2005. Available from: [LINK].
- NHS. Giving someone power of attorney. 2024. Available from: [LINK].
- Social Care Institute for Excellence (SCIE). Lasting power of attorney – Mental Capacity Act. Available from: [LINK].
- Compassion in Dying. Lasting power of attorney for health and welfare. Available from: [LINK].
- Macmillan Cancer Support. Advance decision to refuse treatment. 2023. Available from: [LINK].
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