LPA Advance Decision: How They Work Together

If you have thought about who should make medical decisions for you if you cannot, you may have come across the term LPA advance decision. It can sound as though these are two parts of one document. They are not. A Lasting Power of Attorney and an advance decision are separate arrangements, and getting the relationship between them right can prevent real uncertainty at a difficult time.

Both can form part of sensible later-life planning. One appoints somebody you trust to speak and make decisions for you. The other lets you set out specific treatments you would refuse yourself. The right approach depends on your circumstances, your wishes and how much flexibility you want to leave to those closest to you.

What is an LPA advance decision?

An LPA advance decision usually refers to the interaction between a Health and Welfare Lasting Power of Attorney and an advance decision to refuse treatment. Each has a different role under the Mental Capacity Act 2005 in England and Wales.

A Health and Welfare LPA allows you to appoint one or more attorneys to make decisions for you if you lose mental capacity. These decisions can cover where you live, day-to-day care, contact with other people and medical treatment. You may also give your attorneys authority to give or refuse consent to life-sustaining treatment, but this must be expressly included in the LPA.

An advance decision, sometimes called an advance decision to refuse treatment or ADRT, allows you to refuse particular medical treatment in particular circumstances. For example, a person may state that they do not want life-sustaining treatment if they have a permanent loss of awareness and there is no prospect of recovery.

The key distinction is straightforward. An LPA gives a trusted person authority to decide on your behalf. An advance decision records a decision you have already made for yourself.

Why the order matters

A Health and Welfare LPA and an advance decision can both address medical treatment. Where they overlap, the date on which each document was made can affect which one takes priority.

If you make an advance decision first and later create a Health and Welfare LPA which gives your attorney authority over the same treatment, the later LPA can override the earlier advance decision in relation to that treatment. This may be appropriate if you want your attorney to have the final say, based on the medical facts and circumstances at the time.

If you make a Health and Welfare LPA first, then make a valid advance decision afterwards, your later advance decision can take priority over your attorney's decision about the treatment it covers. This may suit someone with firm views on a particular intervention who wants those views followed, even if family members find the decision emotionally difficult.

This is why documents should never be prepared in isolation. A change in health, family circumstances or personal beliefs may mean that your existing arrangements no longer reflect what you want.

An advance decision must be valid and applicable

For an advance decision to refuse life-sustaining treatment to be legally binding, it must meet specific requirements. It must be in writing, signed by you and witnessed. It must also include a clear statement that the decision applies even if your life is at risk.

It also needs to apply to the situation that has arisen. Vague wording can be difficult for clinicians to rely on. A statement such as “I do not want to be kept alive by machines” may not provide enough detail to establish what treatment you meant or the circumstances in which you intended it to apply.

You must have had mental capacity when making the advance decision, and you can withdraw or amend it while you still have capacity. If there is any doubt about whether a document is valid or applies, medical professionals will need to consider the evidence carefully.

Choosing flexibility or certainty

There is no single answer that is right for every family. An LPA can be particularly helpful where you want someone who knows your values to respond to circumstances that cannot be predicted years in advance. Medical decisions are rarely simple, and a trusted attorney can speak with doctors, ask questions and consider your wider wishes.

An advance decision may be more suitable where you have a clear, settled view about a specific treatment and do not want others to make that choice for you. This is sometimes relevant for people living with a serious diagnosis, although it is not limited to them.

Many people choose a Health and Welfare LPA without an advance decision. Others have both, but make sure the wording is carefully coordinated. What matters is that the people involved understand your intentions and that the documents do not accidentally contradict each other.

A practical conversation with your proposed attorneys is just as valuable as the paperwork. They should know what matters to you: whether remaining at home is a priority, how you feel about life-sustaining treatment, and whether your views are influenced by faith, independence, quality of life or the wish to avoid prolonged suffering.

What an LPA cannot do

A Health and Welfare attorney cannot make decisions while you still have capacity to make them yourself. They cannot simply take over because you are elderly, unwell or making a decision they disagree with.

They must act in your best interests and follow the principles of the Mental Capacity Act. They must also take account of your past and present wishes, beliefs and values where these are known. An attorney cannot demand treatment that clinicians believe is not clinically appropriate, and they cannot make decisions outside the authority you have given them.

This is one reason clear instructions are helpful. You can include preferences and guidance in an LPA to help your attorney understand your wishes. These are different from legally binding instructions, and the distinction needs careful thought. An overly restrictive instruction can create unintended difficulty if circumstances change.

Do not confuse an advance decision with a DNACPR

An advance decision is not the same as a DNACPR decision, meaning “Do Not Attempt Cardiopulmonary Resuscitation”. A DNACPR form is a clinical decision made and recorded by healthcare professionals, usually after discussion with the patient or those close to them where possible.

An advance decision may include a refusal of CPR, provided it is properly expressed and meets the legal requirements. However, it can also cover other treatments, such as artificial ventilation or clinically assisted nutrition and hydration, in defined circumstances.

Nor is an advance decision the same as an advance statement. An advance statement sets out your preferences, values and care wishes. It is not legally binding in the way a valid and applicable advance decision can be, but it can still be extremely useful to those making best-interest decisions for you.

Keeping your plans available when they are needed

A document only helps if the right people can find it. Your Health and Welfare LPA must be registered with the Office of the Public Guardian before your attorneys can use it. Do not wait until a health crisis to check whether registration has been completed.

Your attorneys, close family members and GP should know that you have made an LPA or advance decision and where the current signed documents are stored. If you have an advance decision, consider discussing it with the healthcare professionals involved in your care, particularly if you have an ongoing medical condition.

Review your arrangements after a diagnosis, bereavement, divorce, a change in relationships or any significant shift in your views. Replacing an attorney is possible, but it should be done properly. Crossing out names or adding handwritten changes to a completed LPA can cause serious problems later.

Getting the wording right from the outset

Health and welfare planning asks difficult questions, but postponing them does not remove them. It can leave loved ones trying to interpret your wishes when they are already under pressure.

At Langham Wills, we help clients consider the practical consequences of appointing attorneys and make arrangements that support the people they trust. A personal discussion can help identify whether a Health and Welfare LPA, an advance decision, or a carefully coordinated combination is the most suitable route.

The most reassuring plan is not necessarily the most detailed one. It is the one that clearly reflects your wishes, gives your family appropriate guidance and is in place before anyone needs to use it.