LPA vs Advance Decision: The Difference Nobody Explains

You will meet at least four documents when you plan for a moment you can't decide for yourself. Most people don't realise they exist. Fewer realise they do different jobs. Almost nobody is told to have more than one of them.

This is what they actually are and how they work together.

The four documents

Health & Welfare LPA (LP1H) A Lasting Power of Attorney for health and welfare decisions. You appoint one or more people, your attorneys, to make decisions about your care and treatment when you can't. It's the OPG's form LP1H, it's registered with the Office of the Public Guardian, and once registered it sits in the drawer waiting.

It only kicks in when you've lost the mental capacity to make the specific decision that's in front of you. Capacity is decision-specific under the Mental Capacity Act 2005, you might have capacity to choose what to eat but not to decide whether to accept an operation. The LPA switches on, decision by decision, only where capacity is missing.

Your attorneys can decide where you live (including a move into residential care), day-to-day care arrangements, medical treatment, refusal of specific treatments, contact with family and friends, and diet. They can't override an Advance Decision you've validly made, force treatment on you against a capacitous refusal, or authorise anything unlawful.

The one thing everyone forgets: Section 5 of the LP1H asks whether your attorneys can consent to or refuse life-sustaining treatment on your behalf. You choose Option A (yes, they can) or Option B (no, doctors decide, in your best interests, with your attorneys consulted but not deciding). If you leave Section 5 blank, the LPA is rejected by the OPG. It's the hardest decision in the whole form, and it's not one you can skip.

Advance Decision to Refuse Treatment (ADRT), sometimes called a "living will" An Advance Decision is you, in writing, refusing specific treatments in advance. Not an attorney, not a family member, you. It has statutory force under sections 24-26 of the Mental Capacity Act 2005 when it is valid and applicable.

Two conditions for validity: - It must be made while you have capacity. - If it refuses life-sustaining treatment, it must be in writing, signed by you, signed by a witness in your presence, and must expressly state that it is to apply "even if life is at risk". Those exact words matter.

Two conditions for applicability: - The specific treatment being contemplated must be the treatment you refused. - The circumstances now must be the circumstances you had in mind.

An ADRT does not need lawyers, the OPG, or the Court of Protection. It just needs to be properly drafted. Doctors are legally bound to follow it, refusing to do so where it is valid and applicable is potentially a criminal battery.

DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) A clinical decision recorded by a doctor, refusing cardiopulmonary resuscitation specifically. It is not a legal document made by you. A doctor can enter one on their own clinical judgement (with a duty to consult you if you have capacity, or those close to you if you don't), and a valid ADRT that refuses CPR can also produce the same clinical effect.

DNACPR is narrow: it says nothing about ventilation, artificial nutrition, antibiotics, dialysis, or anything else. Only CPR.

ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) A clinical care-planning document, produced with your clinical team, that summarises your preferences and clinical recommendations for emergency situations. Widely used across the NHS. Combines your voice with clinical judgement. Guides emergency clinicians about what should and shouldn't be attempted.

Not legally binding by itself. A ReSPECT plan that reflects a valid ADRT will effectively bind clinicians because the ADRT does; a ReSPECT plan that only reflects clinical preferences does not.

How they fit together

Most people who plan properly hold two of these documents: an LP1H and an ADRT. Some also have a DNACPR or ReSPECT in their clinical records, entered by their GP or hospital team.

The LP1H is your general answer for the many decisions you can't predict. You cannot write down in advance every possible treatment scenario. An attorney you trust can weigh new information, a fresh diagnosis, an experimental option, a change in your quality of life, and decide.

The ADRT is your specific answer for treatments you already know you would refuse. Someone with a strong faith position on blood transfusions; someone who has watched a parent through a specific illness and has decided what they don't want; someone with a chronic condition who has thought carefully about limits. The ADRT locks that in.

The DNACPR and ReSPECT are what your clinical team writes down about you, informed by both.

When they conflict

This is the bit the kits don't explain.

LP1H Option A + ADRT covering the same treatment: the ADRT wins for the specific treatment covered, but only if the ADRT is valid and applicable. If your ADRT refuses "life-sustaining treatment in the event of terminal illness with less than six months to live" and you are now in that state, the ADRT applies. If it refuses treatment in circumstances you didn't foresee, or is silent on this treatment, your attorney under LP1H Option A can decide.

LP1H Option A + later ADRT: the ADRT is later in time and reflects your current voice. It generally wins for the specific treatment covered.

LP1H Option A + earlier ADRT: trickier. Section 25(2)(b) MCA 2005 says an ADRT is invalid if you did anything clearly inconsistent with the ADRT remaining your fixed decision. Signing an LP1H granting your attorney Option A after the ADRT might be treated as inconsistent, depending on whether you knew about the ADRT when you signed the LPA. The safest rule: if you have both, make sure the drafting is coherent, that one specifically defers to the other where they overlap, and that the dates make the sequence clear.

LP1H Option B + ADRT: no conflict. Doctors decide in your best interests, respecting your ADRT for the specific treatment it covers.

LP1H (either option) + DNACPR: DNACPR is clinical, entered by doctors, and can be reviewed at any time. If your attorney disagrees with a DNACPR entry, they can raise it with the clinical team, who will reconsider, and, if capacity is missing, the attorney's view is a substantial factor in the best-interests assessment for that decision under s.4 MCA 2005.

The mistakes we see

• "I signed a living will, so I don't need an LPA." No: the ADRT only covers the specific treatments it names. Everything else falls into best-interests decision-making, in which your attorney has statutory standing under a valid LPA and your family without one does not.
• "I signed an LPA, so I don't need a living will." No: the LPA gives someone else the pen; the ADRT keeps some decisions in your own words. Both are useful.
• "I've told my family what I want." Legally, your family has no standing to make decisions for you without an LPA or a Court of Protection deputyship. Doctors will consult them under s.4 MCA 2005, but the final call is the treating clinician's best-interests judgement, not your family's.
• "I have a DNACPR, so I'm covered." No: DNACPR covers CPR only.
• "My ADRT will apply to anything terminal." Only if it is drafted to. ADRTs must be specific enough to be applicable. "I refuse life-sustaining treatment if I am dying" is too vague for many clinicians to act on with confidence. Specificity matters.

What we recommend

Most Bonsai clients end up with:

• An LP1H with attorneys they trust, usually spouse plus one child, jointly and severally with replacement attorneys.
• An ADRT for the specific treatments they've already decided about, properly worded, life-sustaining sections signed and witnessed, cross-referenced to the LP1H.
• An LP1F alongside, because financial decisions matter too.
• A Business Owner LPA if they run a company.
• A note in their care plan (ReSPECT or equivalent) that both documents exist and where to find them.

The whole set can be built through our tokenised questionnaire in one sitting. The pair goes into the drawer together. Your clinical team can find them when it matters.

The one thing that isn't optional

You need mental capacity to make any of these documents. Once capacity is gone, none of them can be created for you, an application to the Court of Protection for a Deputyship is the only route, and Deputies have narrower powers than attorneys, higher supervision costs, and take 6-12 months to appoint.

The whole point of these documents is that they exist before you need them. That's why we called this page what we called it.

Related reading on this site: - How our LPAs work, the tokenised questionnaire → - The Business Owner LPA, the succession document your accountant forgot → - Five reasons the OPG rejects LPAs →

Sources: - Mental Capacity Act 2005 ss.24-26 (Advance Decisions), s.4 (best interests), Chapter 9 Code of Practice (legislation.gov.uk) - NHS England Advance Decisions to Refuse Treatment guidance - LP1H form and LP12 guide (gov.uk) - Resuscitation Council UK, ReSPECT - BMA, best-interests decision-making for adult patients toolkit

This post is marketing material and general information. It is not legal advice. Speak to a solicitor before making or relying on any of these documents.