01Purpose and principlesWhat the treatment does and how it fits into care.
Advance care planning helps a person prepare for decisions that may arise if serious illness progresses. It can record communication preferences, values, important relationships, acceptable outcomes, preferred care, people to consult and views about treatments. The conversation should be offered sensitively and can stop, continue later or remain informal. Refusing to plan does not reduce entitlement to clinically appropriate care.
Different records do different jobs. A values or advance statement informs future best-interests decisions. An emergency-care plan gives clinical recommendations for foreseeable crises. A DNACPR entry addresses cardiopulmonary resuscitation only. In England and Wales, an advance decision to refuse treatment can be legally binding when valid and applicable, while a health-and-welfare attorney may make authorised decisions after capacity is lost. These instruments must not be collapsed into a single 'ceiling' label.
The Mental Capacity Act 2005 applies in England and Wales. Scotland uses the Adults with Incapacity (Scotland) Act 2000 and distinct welfare-attorney and intervention principles; advance directives operate within Scottish law and professional guidance rather than the MCA's ADRT provisions. Northern Ireland's Mental Capacity Act (Northern Ireland) 2016 has had phased implementation, so clinicians must use current local policy and legal advice rather than assume every provision is operational.
A plan is useful only when discoverable and current. Record the conversation in language the patient recognises, distinguish preferences from refusals and recommendations, document capacity and any authorised proxy, and share with consent across primary, community, ambulance and hospital services. Provide the patient with a copy and instructions for amendment. Review the plan when circumstances change rather than treating a signature as permanent evidence of present wishes.
Documentation should identify the author and professional role, date, decision-specific capacity, participants, interpreter, the person's own wording and which items carry legal force. Scan or upload the complete signed instrument rather than a cropped summary, flag its location in the clinical record and reconcile local electronic alerts. When the patient crosses a service boundary, include the plan in the structured handover and confirm that the receiving team can open it.
Planning should also address foreseeable practical transitions: loss of an oral route, who may collect controlled medicines, care of dependants, access to the home, device deactivation, and who to call when symptoms change. These arrangements do not replace treatment decisions, but missing logistics can defeat a well-reasoned preference. The responsible team should make each task explicit and avoid placing unagreed coordination work on relatives.
Key points
- Advance care planning is a voluntary process of exploring and recording what matters if health worsens or communication becomes difficult.
- Start first-line with values, understanding, worries and preferred decision support; introduce legal forms only after establishing what the person is trying to achieve.
- Capacity is presumed, specific to the decision and time, and must be supported with accessible information, interpretation and treatment of reversible impairment.
- In England and Wales, an advance statement guides best-interests reasoning but does not have the same binding force as a valid applicable advance decision to refuse treatment.
- An advance decision refusing life-sustaining treatment in England and Wales must be written, signed, witnessed and explicitly state that it applies even if life is at risk.
- A registered health-and-welfare lasting power of attorney acts only after loss of capacity and only within the instrument's authority; 'next of kin' has no automatic decision power.
- A DNACPR recommendation concerns CPR, while an emergency treatment plan such as ReSPECT describes broader recommendations and priorities during crisis.
- The practical gold standard is a current, specific, accessible and shared record whose legal status and authorship can be understood by clinicians under time pressure.
- Review after diagnosis progression, admission, treatment change, altered capacity, relationship change or patient request, and withdraw or amend plans while capacity remains.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
A new serious diagnosis, progressive decline, repeated admission or major treatment decision offers a natural opportunity before crisis limits reflection.
Descriptions of important abilities, relationships, fears and acceptable burdens guide interpretation but do not automatically refuse a named treatment.
A clear refusal identifies the intervention and circumstances in which it applies; formal requirements increase when life-sustaining treatment is covered.
A health-and-welfare attorney's registered powers and restrictions must be examined rather than inferred from family relationship or possession of paperwork.
New treatment options, recovery, separation, bereavement or changed values may alter applicability and should prompt direct review with the capable person.
Reluctance to speak alone, language mirroring another person or unexplained pressure about treatment or inheritance warrants private and safeguarding assessment.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
First-line values and readiness conversationFirst stepFirst line - Why
- Establish whether the person wants to plan, what matters, what they fear and which future decisions feel relevant.
- Interpretation and limitations
- Permission and values determine pace and content; reluctance means offer another opportunity and information, not complete a form by default.
- 02
Decision-specific capacity assessment - Why
- Confirm the person can understand, retain, use or weigh and communicate the particular planning decision after support.
- Interpretation and limitations
- Capacity for one element does not prove capacity for every complex legal act, and an unwise preference does not establish impairment.
- 03
Advance-decision validity and applicability check - Why
- Verify authorship, absence of withdrawal, treatment specificity, circumstances and additional formalities for life-sustaining refusal in England and Wales.
- Interpretation and limitations
- A valid refusal applies only to the decision described; inconsistency, later attorney appointment or changed circumstances may require expert examination of legal effect.
- 04
Attorney authority verification - Why
- Inspect registration, jurisdiction, health-and-welfare scope, restrictions and power concerning life-sustaining treatment.
- Interpretation and limitations
- Authority begins only when the person lacks relevant capacity; a property-and-finance attorney does not thereby gain healthcare powers.
- 05
Document reconciliation - Why
- Compare advance statement, refusal, attorney instrument, DNACPR entry and emergency treatment plan for dates, contradictions and accessibility.
- Interpretation and limitations
- Clarify discrepancies with the capable person; never assume the newest document automatically cancels a legally distinct earlier refusal without analysis.
- 06
Jurisdiction and local-policy check - Why
- Identify where the decision is being made and which statutory, common-law and documentation framework governs it.
- Interpretation and limitations
- England-and-Wales terminology should not be exported to Scotland or Northern Ireland; consult current local guidance for cross-border or phased-law uncertainty.
04Treatment approachPreparation, options, escalation and aftercare.
01Voluntary planningBuild from values to usable recordsFirst stepA person with capacity is willing to discuss possible future deterioration or loss of communication.+
- 1PreferredExplore understanding, priorities, feared outcomes, trusted people and preferred communication before discussing specific forms or treatments.
- 2Explain separately the roles and limits of an advance statement, advance refusal, attorney, DNACPR and broader emergency-care recommendation in the relevant jurisdiction.
- 3Document capacity and choices precisely, provide copies, share with consent across services and agree events that should trigger review.
02Using a planVerify authority before actingThe person lacks capacity and a previous plan, refusal or proxy is available during a current decision.+
- 1Define the exact treatment decision and urgency, support any remaining communication and check whether capacity may recover within a safe timeframe.
- 2Verify the instrument's identity, validity, applicability, jurisdiction and proxy powers, while gathering current clinical evidence and prior values.
- 3Follow a binding applicable refusal or authorised decision; otherwise complete and record a best-interests process and seek senior or legal help for material uncertainty.
03Plan revisionUpdate without erasing historyThe patient requests change or illness, relationships, treatment options or residence materially alters the previous context.+
- 1Assess capacity for the revision, explore the reason for change and ensure freedom from coercion with appropriate communication support.
- 2Amend or revoke the relevant instrument using its required formal process and mark superseded copies clearly without destroying the audit trail.
- 3Distribute the updated version to holders, confirm electronic and paper accessibility and explain which prior records no longer represent current wishes.
04Cross-border careRecheck legal effect after jurisdiction changeA patient with planning documents moves or receives urgent treatment in another UK nation.+
- 1Identify the jurisdiction governing the current decision and obtain the complete original records, including proxy registration and any relevant court order.
- 2Ask local legal or governance support how the earlier refusal, attorney or emergency recommendation is recognised and whether replacement documentation is advisable.
- 3Continue supported involvement and necessary care, record the analysis and help the capable patient create locally intelligible records before another crisis.
05Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Review plans after clinical progression, acute admission, new treatment availability, cognitive change, relationship change or relocation across jurisdiction.
- Check that primary care, community teams, ambulance services and relevant hospitals can locate the same current documents when consent permits.
- Confirm continuing capacity and voluntariness whenever a major amendment or treatment refusal is made.
- Reconcile dates and wording across DNACPR, emergency plan, attorney and advance-decision records and resolve contradictions early.
- Ask whether the person's priorities and information preferences still feel accurately represented rather than reviewing signatures alone.
- Audit whether plans are offered equitably and not used to pressure disabled, older or care-home residents away from beneficial treatment.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Values survive novel scenarios
A clear account of acceptable function and treatment burden can guide best interests when a future crisis was impossible to predict specifically.
Specificity creates legal effect
A broad wish not to be kept alive is different from a refusal naming treatment and the circumstances in which it applies.
Current capacitous choice wins
A person who can decide now may accept or refuse treatment regardless of an older plan or an attorney's different opinion.
Accessibility is clinical safety
A legally robust document locked in an unavailable record may fail at the moment it was intended to guide emergency care.
Cross-border moves matter
When a patient changes UK nation, clinicians should review terminology, proxy powers and recognition under the receiving jurisdiction before crisis.
07Common pitfallsFrequent interpretation and management errors.
- 01
Starting with forms before asking what matters to the person.
- 02
Treating advance care planning as mandatory or irreversible.
- 03
Calling an advance statement a legally binding treatment refusal.
- 04
Assuming next of kin automatically has healthcare decision authority.
- 05
Using a DNACPR entry as a refusal of antibiotics, fluids or hospital care.
- 06
Applying Mental Capacity Act language unchanged throughout the United Kingdom.
- 07
Failing to verify life-sustaining-treatment wording, signature and witness requirements.
- 08
Keeping updated plans in one record that emergency clinicians cannot access.