Advance Decision to Refuse Treatment - Template Form

ADVANCE DECISION TO REFUSE TREATMENT

Made pursuant to sections 24 to 26 of the Mental Capacity Act 2005

MADE BY: ________

of ________

Date of Birth: ________

NHS Number (if known): ________

General Practitioner:

________ of

________

To whom it may concern,

1. Purpose and persons addressed

1.1. I make this advance decision to refuse treatment ("this Advance Decision") and it is addressed to any person who may be responsible for my health care in the future, including my family, any attorney or deputy appointed in respect of me, and any healthcare professional.

1.2. This Advance Decision is intended to take effect as a valid and applicable advance decision in accordance with sections 24, 25 and 26 of the Mental Capacity Act 2005 and is intended to bind those treating me to the extent provided by that Act.

2. Capacity and free will

2.1. I have created the contents of this Advance Decision carefully, of my own free will, at a time when I have the mental capacity (within the meaning of sections 2 and 3 of the Mental Capacity Act 2005) to do so.

2.2. I confirm that I have not been subject to any undue influence, duress or pressure in making this Advance Decision.

3. Discussion with my medical adviser

3.1. I have discussed the contents of this Advance Decision with my General Practitioner and/or the following medical or other adviser: ________.

4. When this Advance Decision applies

If at any time after I make this Advance Decision:

4.1. I lack capacity to give or refuse consent to the treatment in question within the meaning of the Mental Capacity Act 2005; AND

4.2. the Specified Circumstances set out in paragraph 6 below have arisen; THEN

4.3. none of the Specified Treatments set out in paragraph 7 below are to be administered to me or, if already commenced, continued.

5. Refusal to apply notwithstanding risk to life

5.1. For the avoidance of doubt, and except where stated to the contrary below, I confirm that the refusal(s) of treatment contained in this Advance Decision are to apply even if my life is at risk or may be shortened as a result. I confirm, as required by section 25(5) of the Mental Capacity Act 2005, that this Advance Decision is to apply to treatment necessary to sustain my life.

5.2. This Advance Decision does not refuse, and shall not be taken to refuse, basic or palliative care or comfort measures intended to keep me comfortable and to relieve pain or distress, the provision of which I expressly wish to continue.

6. Specified Circumstances

The Specified Circumstances are any of the following circumstances, each of which must be confirmed in writing by at least two registered medical practitioners (at least one of whom should be a specialist in the relevant field):

6.1. I am suffering constant, unremitting pain and there is no realistic prospect of improvement or recovery;

6.2. I am physically paralysed and there is no reasonable prospect of a substantial recovery;

6.3. I suffer any serious impairment of the mind or brain such that I cannot take care of myself independently and with dignity, and there is no reasonable prospect of recovery;

6.4. I am in a state of unconsciousness or coma from which it is unlikely that consciousness will ever be regained;

6.5. I am in a persistent or permanent vegetative state, or a minimally conscious state, and it is unlikely that my full cognitive functioning will ever be regained;

6.6. any further circumstances specified by me: ________.

7. Specified Treatments

In this Advance Decision "Specified Treatments" means:

7.1. cardiopulmonary resuscitation;

7.2. clinically assisted (artificial) nutrition and hydration;

7.3. artificial respiration and mechanical ventilation;

7.4. the Specified Treatments shall also include the following:

________

8. Understanding and effect

8.1. I have made this Advance Decision after careful consideration and I understand its nature and implications. I confirm that I wish to refuse the Specified Treatments in the Specified Circumstances, even though this may shorten my life or result in my death.

8.2. I accept responsibility for this decision and I confirm that any healthcare professional who acts in good faith and in reasonable reliance on this Advance Decision, in accordance with section 26 of the Mental Capacity Act 2005, will not incur liability for withholding or withdrawing the Specified Treatments in accordance with my wishes.

9. Validity, revocation and review

9.1. I reserve the right to withdraw, revoke or amend this Advance Decision at any time while I have the capacity to do so. In accordance with section 24(3) of the Mental Capacity Act 2005, any withdrawal (including a partial withdrawal) need not be in writing; however, any amendment relating to life-sustaining treatment must comply with the formalities of section 25(6).

9.2. This Advance Decision will not apply to treatment which is not the treatment specified, to circumstances not specified, or where circumstances exist which I did not anticipate at the time of making it and which would have affected my decision had I anticipated them.

9.3. This Advance Decision shall remain in force until withdrawn or revoked by me. I confirm that I have the capacity to make this Advance Decision at the time of signing it below.

9.4. I confirm that I have not appointed an attorney under a lasting power of attorney with authority to consent to or refuse the Specified Treatments after the date of this Advance Decision, save as follows: ________.

SIGNED by the person making this Advance Decision:

Signature: ____________________________

Name: ________

Dated: ________

Signed in the presence of the witness named below, who confirms that the person making this Advance Decision signed it in their presence and appeared to do so freely and with capacity:

Name of Witness: ________

Signature of Witness: ____________________________

Address of Witness: ________

Occupation of Witness: ________

Dated: ________

RECORD OF REVIEW

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Reviewed by ________ on ________

Signed: ____________________________

Reviewed by ________ on ________

Signed: ____________________________

Reviewed by ________ on ________

Signed: ____________________________

Reviewed by ________ on ________

Signed: ____________________________