Table 2.

Statutory ADMs in England and Wales.

England and Wales – Mental Capacity Act	Purpose	Required Parties Involved (preferable inclusions)	Capacity Assessment Required (MCA)	Legally Binding for MH Services	Point at which effective	Requirements to alter/cancel plan
Advance Decision to Refuse Treatment (ADRT) MCA (S.24–25)	Prospective management of a condition in the long term/future. Made when service user has capacity to make the decision (presumed). Only applies to refusals of treatment.	Service User Witness (MH Services) (Family/Friends) (Independent Advocates)	Service User is presumed to have capacity unless obvious reason to doubt it.	Yes: ADRT is binding on treatment (outside the scope of the MHA) if it (1) exists (i.e. made with capacity, and without duress/undue influence); (2) is valid; and (3) applicable to the treatment. If applies to ECT/other such forms of treatment (S58A MHA) and CTOs, regardless if detained under MHA. Can be overridden as per urgent treatment (S62 for ECT and S64G for CTOs) No: If detained under MHA and ADRT applies to MH care, (For ECT see above).	When a service user is judged not to have capacity to decide on relevant matters (MCA).	If no reason to doubt capacity then can be altered at any time via the same process as creating one. Can be challenged on grounds of existence/validity/applicability (trinity)
				Not binding in relation to Part 4 MHA treatment but Code of Practice and Case law have significant weight. Subsequent LPA covering same medical treatment will override any ADRT (see LPA section below)
LPA – Health and Welfare MCA (S9-14)	Appointment of an individual/s as an attorney to decide on health and welfare matters when the service user lacks capacity to do so. Can Include ‘Preferences’, which Attorneys should bear in mind. Can include ‘Instructions’, which Attorneys MUST adhere to.	Donor Attorney/s Witness Certificate Provider (known to Donor for at least 2 years OR Individual with professional skills to judge understanding) Office of Public Guardian (MH Services) (Replacement Attorney) (Family/Friends) (Independent Advocates)	Donor is presumed to have capacity unless obvious reason to doubt it. Certificate Provider confirms that Donor understands significance of LPA	Yes: LPA is binding on treatment (outside the scope of the MHA) if it (1) exists (i.e. made with capacity, and without duress/undue influence); (2) is valid; and (3) applicable to the treatment. No: If decision related to medical treatment for mental disorder in MHA. Outside the MHA decision to refuse life-sustaining treatment unless expressly authorised by donor.	When a service user is judged not to have capacity (MCA).	If no reason to doubt capacity then can be cancelled by Donor through witnessed deed. Deed then sent to Office of Public Guardian. Can be challenged on grounds of existence/validity/applicability (trinity) Court can override attorney if felt that attorney is not acting in the best interests of donor
				Note: If valid and applicable ADRT exists in advance of LPA, attorney cannot override the ADRT unless LPA specifies attorney has the ability to do so. If LPA covers the same ground as an ADRT it automatically invalidates the ADRT.
Advance Statement (written statement made with capacity) MCA (S.4(6)(a))	Prospective management of a condition in the long term/future made by a service user, usually when they are well Can relate to refusal of matter other than medical treatment (therefore not falling within ADRT). Can relate to request for treatment (or something else). Could be an ADRT which fails on technical grounds but is still a written statement.	Service User (MH Services) (Family/Friends) (Independent Advocates)	Service User is presumed to have capacity unless obvious reason to doubt it.	No However must be particularly considered (as far as reasonably ascertainable).	At any point after the statement has been made when the service user is judged not to have capacity (MCA).	Can be altered at any time when the person has capacity (presumed).