End of life care: Assessing the validity of advance refusals

1. 70. If you are the clinician with lead responsibility for the patient’s care, you should assess both the validity and the applicability of any advance refusal of treatment that is recorded in the notes or that has otherwise been brought to your attention. The factors you should consider are different in the four UK countries, reflecting differences in the legal framework (see the legal annex). However, in relation to validity, the main considerations are that:
   1. (a) the patient was an adult when the decision was made (16 years old or over in Scotland, 18 years old or over in England, Wales and Northern Ireland)
   2. (b) the patient had capacity to make the decision at the time it was made (UK wide)
   3. (c) the patient was not subject to undue influence in making the decision (UK wide)
   4. (d) the patient made the decision on the basis of adequate information about the implications of their choice (UK wide)
   5. (e) if the decision relates to treatment that may prolong life it must be in writing, signed and witnessed, and include a statement that it is to apply even if the patient’s life is at stake (England and Wales only²⁷)
   6. (f) the decision has not been withdrawn by the patient (UK wide)
   7. (g) the patient has not appointed an attorney, since the decision was made, to make such decisions on their behalf (England, Wales and Scotland)
   8. (h) more recent actions or decisions of the patient are clearly inconsistent with the terms of their earlier decision, or in some way indicate they may have changed their mind.