Key Facts
- A Health and Welfare LPA is a legal document that allows you to appoint one or more trusted people (called attorneys) to make health and welfare decisions on your behalf.
- An Advance Decision to Refuse Treatment (sometimes called a living will or advance directive) is a legal statement in which you document specific medical treatments you wish to refuse in advance.
- Several important legal distinctions separate these two documents under the Mental Capacity Act 2005.
- Understanding the timing of when each document becomes relevant is essential for healthcare planning.
- Whether you need a Health and Welfare LPA, an ADRT, both, or neither depends on your personal circumstances and wishes.
Planning for future healthcare decisions is one of the most important aspects of estate planning in England and Wales. Two key documents help you maintain control over your medical care when you cannot make decisions yourself: a Health and Welfare Lasting Power of Attorney (LPA) and an Advance Decision to Refuse Treatment (ADRT). However, many people are uncertain about what each document does and whether they need both.
What Is a Health and Welfare Lasting Power of Attorney?
A Health and Welfare LPA is a legal document that allows you to appoint one or more trusted people (called attorneys) to make health and welfare decisions on your behalf. These attorneys can make decisions about your medical care, treatment options, and personal welfare if you lose mental capacity and cannot decide for yourself.
The Health and Welfare LPA covers a broad range of decisions, including decisions about medical treatment, where you live, what you eat, and personal care. Your attorneys have authority to consent to or refuse most types of medical treatment, though some restrictions apply.
The LPA comes into effect only when you lack mental capacity to make a specific decision. Until that point, you retain full control over your own healthcare choices. Learn more in the Health and Welfare LPA complete guide.
What Is an Advance Decision to Refuse Treatment?
An Advance Decision to Refuse Treatment (sometimes called a living will or advance directive) is a legal statement in which you document specific medical treatments you wish to refuse in advance. Unlike an LPA, an ADRT does not give another person authority to make decisions for you. Instead, it is your own predetermined instruction about future medical care.
An ADRT allows you to say, for example, that you do not wish to receive cardiopulmonary resuscitation (CPR) or that you refuse artificial nutrition and hydration if you develop terminal dementia. Your healthcare providers must respect these wishes even after you lose capacity, provided the ADRT is valid and applies to your circumstances.
The ADRT is particularly useful for clearly stating your values and wishes about specific treatments you find unacceptable, regardless of your prognosis or the medical team’s recommendations.
What Is Key Legal Differences?
Several important legal distinctions separate these two documents under the Mental Capacity Act 2005.
Scope of Authority
A Health and Welfare LPA grants broad decision making power to your attorneys across multiple healthcare matters. Your attorneys can make decisions about treatments, consent to or refuse options, and respond to new medical situations as they arise. They have flexibility to make judgments based on your best interests and any preferences you expressed.
An ADRT, by contrast, applies only to the specific treatments you refuse. It does not grant power to make other decisions. Your healthcare providers must follow your refusal, but they may still need to make other decisions through your LPA attorney or in accordance with the Mental Capacity Act if no LPA exists.
When They Take Effect
A Health and Welfare LPA takes effect only when you lack mental capacity in relation to a specific decision. Before that point, you make your own choices. Once registered, your LPA attorney can step in whenever you lose capacity.
An ADRT takes effect immediately upon execution if it is valid, but it only becomes relevant when a healthcare decision arises that falls within its scope. For example, an ADRT refusing CPR becomes relevant only if your medical team considers CPR. Until that situation occurs, the ADRT remains dormant.
What Happens If You Regain Capacity
If you regain capacity after your LPA attorney has been making decisions, you resume decision making authority immediately. Your attorney’s powers are suspended while you have capacity.
Similarly, if you regain capacity and a treatment covered by your ADRT is proposed, you can change your mind and consent to that treatment. Your advance refusal no longer applies once you have capacity.
Not sure where to start with your LPA?
Download our free Lasting Power of Attorney checklist to see exactly what’s involved — or book a free consultation and we’ll walk you through it.
When Each Document Takes Effect
Understanding the timing of when each document becomes relevant is essential for healthcare planning.
Health and Welfare LPA Timeline
After you create a Health and Welfare LPA and it is registered at the Office of the Public Guardian, your attorney can act only if you lose mental capacity in relation to a specific decision. Healthcare providers will assess whether you have capacity to make the decision in question. If you do, your attorney has no authority. If you do not, your attorney can step in.
This means your LPA attorney may have authority over some decisions but not others, depending on whether you retain capacity for each specific choice.
Advance Decision to Refuse Treatment Timeline
An ADRT can be made when you have full capacity and understanding. It is valid immediately but remains in the background until a relevant medical situation arises. When healthcare professionals consider a treatment you have refused in your ADRT, they must check the document and comply with your refusal, provided the ADRT is valid and clearly applies to the treatment in question.
An ADRT remains valid indefinitely unless you revoke it or a significant change in circumstances suggests your wishes may have altered.
Do You Need Both Documents?
Whether you need a Health and Welfare LPA, an ADRT, both, or neither depends on your personal circumstances and wishes.
The Case for Both
Many people benefit from having both documents. An LPA gives your attorney broad authority to make healthcare decisions and respond to medical situations flexibly, considering your best interests. An ADRT reinforces specific refusals that are important to you, such as decisions about life-sustaining treatment.
Together, they provide a comprehensive plan: your attorney can make most healthcare decisions using the LPA framework, whilst your ADRT ensures certain treatments are never imposed against your clearly stated wishes. This combination offers maximum protection and clarity.
LPA Alone
You might choose only an LPA if you trust your attorney to make decisions in line with your values and you do not feel the need to refuse specific treatments in advance. Your attorney can then make decisions flexibly as medical situations arise. However, see more details about whether an attorney can refuse medical treatment under a Health LPA.
ADRT Alone
An ADRT alone is appropriate if you have clear, specific wishes to refuse certain treatments but do not wish to appoint an attorney to make broader healthcare decisions. For example, you might refuse life prolonging treatment but be content for healthcare professionals to make other decisions in your best interests if you lose capacity.
Neither Document
If you do not create either document, healthcare professionals will make decisions in your best interests according to the Mental Capacity Act if you lose capacity. Whilst this provides some protection, it does not reflect your personal wishes or preferences.
How They Interact If You Have Both
If you create both a Health and Welfare LPA and an ADRT, they work together to provide comprehensive healthcare planning.
Your ADRT refusals take absolute priority: if you have refused a treatment in a valid ADRT, your attorney cannot consent to that treatment, even if they believe it is in your best interests. The ADRT is a veto that cannot be overridden.
For all other healthcare decisions and treatments not covered by your ADRT, your attorney uses the LPA to make decisions. They should consider your preferences, values, and any instructions you gave them when creating the LPA. See the guide to LPA instructions and preferences for more detail.
This structure ensures your clearest wishes (expressed in the ADRT) are always respected, whilst giving your attorney flexibility to make other healthcare decisions.
Which Document Takes Precedence?
If you have both documents and a conflict arises, the ADRT takes precedence for the specific treatments it covers. Your attorney cannot override an ADRT refusal because the ADRT represents your own direct instruction, not delegated authority to another person.
However, for decisions outside the scope of your ADRT, your attorney’s decisions under the LPA prevail (assuming your attorney is acting in good faith and in your best interests).
In practice, conflicts are rare if your LPA and ADRT are drafted together and reflect a consistent set of values about your healthcare.
What Is Mental Capacity Act 2005 Framework?
Both the Health and Welfare LPA and the ADRT are governed by the Mental Capacity Act 2005, which sets out the legal rules for decision making when someone lacks capacity.
The Act establishes that a person is presumed to have capacity unless proven otherwise, and that decisions must be made in the person’s best interests if capacity is lacking. Both the LPA and ADRT operate within this framework, helping to uphold your autonomy and wishes even when you cannot communicate them directly.
The Act also requires healthcare professionals to consider any statements about preferences and beliefs you made when you had capacity, whether in an ADRT, LPA instructions, or other documents.
What Is Practical Considerations?
Storage and Access
Both your LPA and ADRT should be stored safely and your healthcare providers should know where to find them. Keep copies with your GP, hospital medical records, and with your LPA attorney. Some people also register ADRTs on the NHS Advance Decisions Register to ensure healthcare professionals can locate them quickly in an emergency.
Regular Review
Review both documents periodically, especially after major life changes. Your views on treatment may evolve, your chosen attorney may no longer be suitable, or changes in medical science might make some refusals less relevant. A periodic review ensures your documents reflect your current wishes.
Communicating Your Wishes
Do not assume your healthcare providers, family, or attorney know what your ADRT or LPA instructions contain. Discuss your wishes openly with your GP, your attorney, and close family members. Clear communication prevents confusion and helps ensure your choices are understood and respected.
The feeling clients consistently describe after completing the process is relief. The knowledge that if something happens and they lose capacity, someone they trust has the legal authority to step in and manage their affairs, and that their care and finances will be handled in the way they would want. At Elwyn & Mabel, we manage the full process: initial advice, drafting, signing, all liaison with certificate providers and attorneys, review before submission, and registration with the Office of the Public Guardian. To see the process in more detail, you can download the Lasting Power of Attorney Checklist:
Frequently Asked Questions
Can my Health and Welfare LPA attorney override my Advance Decision to Refuse Treatment?
No. If you have a valid ADRT refusing a specific treatment, your attorney cannot consent to that treatment, even if they believe it would be in your best interests. The ADRT is an absolute refusal that takes priority over the LPA.
Do I need to register my Advance Decision to Refuse Treatment with the NHS?
Registration is not legally required, but it is strongly recommended. Registering your ADRT with the NHS Advance Decisions Register or ensuring your GP has a copy means healthcare professionals can locate your wishes quickly during medical emergencies, reducing the risk that treatment you have refused will be administered.
What happens if I create a Health and Welfare LPA but later change my mind about healthcare decisions?
You can modify or revoke your LPA at any time while you have capacity. If you wish to change your healthcare wishes, you can create a new ADRT, update your LPA instructions, or revoke your LPA entirely. Communicate any changes to your attorney, GP, and hospital without delay.
Is an Advance Decision to Refuse Treatment the same as a Do Not Resuscitate order?
No. A Do Not Resuscitate (DNR) order is a clinical decision made by healthcare professionals in consultation with you (or your attorney or ADRT if you lack capacity). An ADRT is a legal document you create in advance that can include a refusal of CPR and other treatments. Your ADRT informs the DNR decision, but they are distinct.
Can I refuse all medical treatment in my Advance Decision to Refuse Treatment?
You can refuse specific treatments, but you cannot validly refuse all treatment in all circumstances. An ADRT that is too vague or that purports to refuse basic care such as washing or comfort measures may not be valid. ADRTs are most legally robust when they specify the treatments you refuse, the circumstances in which the refusal applies, and are made with careful thought and legal advice.
TL;DR: Health and Welfare LPA vs Advance Decision to Refuse Treatment:
A Health and Welfare Lasting Power of Attorney appoints an attorney to make healthcare decisions for you if you lose capacity. An Advance Decision to Refuse Treatment is your own direct statement refusing specific medical treatments in advance.
- A Health and Welfare LPA gives broad healthcare decision making power to a trusted attorney.
- An ADRT is your own direct refusal of specific treatments, not delegated authority.
- If you have both documents, your ADRT refusals take absolute priority over the LPA.
- Both documents are governed by the Mental Capacity Act 2005 and uphold your autonomy.
- Having both an LPA and an ADRT provides the most comprehensive healthcare planning.
More From Elwyn & Mabel
Creating a Lasting Power of Attorney is one of the most important steps in planning for the future. Download the free Lasting Power of Attorney Checklist for a step by step guide to getting your LPA in place, explained in plain language.
For personalised guidance on creating a Lasting Power of Attorney or any aspect of estate planning, book a free consultation with Elwyn & Mabel. The team will answer questions, review individual circumstances, and help put the right plan in place.