Advance decisions in psychiatry: England and Wales

'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.

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