Advance decisions, advance statements and DNACPR explained

The difference that matters most is who is speaking. An advance decision and an advance statement are your relative speaking, written down while they can still explain themselves. A lasting power of attorney appoints somebody to speak for them. A DNACPR form or a ReSPECT plan is the clinical team's record of what would be attempted.

All four turn on the same question underneath, which is whether your relative can make the decision in front of them at the time it has to be made. Mental capacity and how it is assessed sets out that test, the legal side of caring for a parent gathers the rest of the paperwork, and elderly care is the wider guide to arranging help at home.

1. 1

   Name the treatments and describe the circumstances

   First

   The Mental Capacity Act asks for the treatment and the circumstances, and says everyday wording is acceptable. Wishes written in general terms are easier to set aside later, so write which treatment is refused and in what situation.
2. 2

   Add the sentence about life being at risk

   The step that gets missed

   A refusal of life-sustaining treatment only counts if the document says it is to apply even if life is at risk. Without that sentence it does not cover the situation it was written for.
3. 3

   Sign it, and have a witness sign it too

   In writing

   A refusal of life-sustaining treatment has to be in writing and signed by your relative, or by somebody else in their presence and at their direction. Your relative acknowledges the signature in front of a witness, who signs as well.
4. 4

   Ask the GP to put it on the record

   Then check

   Take a copy to the surgery and ask for it to be added to your relative's medical record, then ring a few weeks later to confirm it is there. Records do not always move with a person.

There are limits on what an advance decision can do. It refuses treatment and nothing else, so it cannot ask for a treatment, and it cannot ask anyone to end a life, which is illegal in the UK. It also stops applying if the situation turns out to be one your relative did not anticipate and that would have changed their mind, which is why the circumstances matter as much as the treatment.

It cannot refuse the things that keep somebody comfortable, either. The Mental Capacity Act Code of Practice puts warmth, shelter, keeping a person clean and the offer of food and water by mouth outside what an advance decision can turn down, and healthcare staff can carry on with those in a person's best interests whatever the document says. This is the line families most often expect to be somewhere else: an advance decision can refuse artificial nutrition and hydration, the tubes that supply food and fluids when somebody cannot take them by mouth, but it cannot stop a nurse offering a drink, washing somebody or keeping them warm.

None of it is fixed. Your relative can withdraw an advance decision at any time while they have the capacity to do so, and a withdrawal does not have to be in writing, though changing which treatments are refused does have to be written, signed and witnessed again.

A best interests decision under the Mental Capacity Act has to consider your relative's past and present wishes and feelings, and in particular any relevant written statement they made while they had capacity. An advance statement is that written statement. It binds nobody, and it gives the person deciding something concrete from your relative rather than a guess.

There is no form to fill in and no witness needed. A letter in their own words, dated and signed, kept with the rest of their papers, is enough. If the conversation has moved on to the care itself, end of life care covers what that involves and who is in the team explains who would read the statement.

A health and welfare LPA can only be used once your relative is unable to make the decision themselves, and it has to be registered with the Office of the Public Guardian first. Lasting power of attorney covers how one is made, what it costs and how long registration takes.

If your relative has already lost the capacity to understand what they would be signing, an LPA is no longer possible, and am I legally responsible for my elderly parent? explains where that leaves the family. Holding the power brings a duty about money too, and paying for care as an attorney sets out what you can do with your relative's account.

Many parts of England and Scotland use a ReSPECT plan instead, or alongside. ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment, and it records a wider set of recommendations for a future emergency rather than resuscitation alone. It comes out of a conversation between your relative, the family and the clinicians, and the form is not legally binding. Resuscitation Council UK lists the areas that have adopted it; Wales and Northern Ireland have not.

If your relative has a valid advance decision refusing resuscitation, that is the binding document, and the form is how the clinical team records and passes on what it says. The two are meant to agree. If they do not, raise it with the GP, because in an emergency the form is read first.

What happens in an emergencySection titled What%20happens%20in%20an%20emergency

If your relative collapses and nobody can find the paperwork, the ambulance crew will treat them. A crew that cannot see a valid document starts resuscitation and gathers information while they work, because that is the safe thing to do when the position is unclear. Resuscitation Council UK is plain that a plan should be available immediately to the professionals called out to help, so keep the original where it can be found quickly.

What a carer can and cannot doSection titled What%20a%20carer%20can%20and%20cannot%20do

A carer working with your relative through PrimeCarers is self-employed and is not part of the legal arrangement. They do not hold the advance decision, and they should not be asked to witness it, because a witness should have no involvement in the care being paid for. They cannot make or agree a DNACPR decision either, and nor can you.

What a carer does is call 999 if they find your relative unresponsive, and show the crew the document if there is one in the house. Put in the care plan where it is kept and who to telephone, so a carer covering a shift for the first time is not searching an unfamiliar house.

If you are getting the paperwork in order while there is time, it is a sensible moment to look at the practical side too. You can search for carers near you and compare their rates and availability before anybody needs to book. Carers on PrimeCarers charge £18 to £25 an hour with our fee included, against £28 to £35 an hour through an agency. Every carer has interviewed online, and their identity, right to work and enhanced DBS on the Update Service are checked before they appear, and they are insured while they work.