Advance decisions in psychiatry: England and Wales

by Dr Lisa Williams and Dr John Rigby


Last updated: October 2020


'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 end-of-life care by Dr Christian Hosker and Dr Wendy Neil


BJPsych Advances: related articles for CPD Online



Related Advances articles


Download take-home notes to print and annotateDownload take-home notes to print and annotate


© 2021 Royal College of Psychiatrists