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Advance Decision vs Health LPA: Which Do You Need?

· 24 min

Note: The following scenario is fictional and used for illustration.

Margaret, 68, spent three hours with a solicitor discussing advance care planning. She left with quotes for both an advance decision (£200) and a health LPA (£450), but still couldn't explain the difference between them to her daughter. Six months later, after a stroke left her temporarily unable to communicate, neither document existed—and her family faced agonising decisions about her care with no legal guidance.

According to the Office of the Public Guardian, 687,796 health and welfare LPA applications were submitted in 2023-24, yet many people still don't understand how these differ from advance decisions. The confusion is understandable: both documents relate to healthcare, both only apply when you lack mental capacity, and both are governed by the Mental Capacity Act 2005. But they work in fundamentally different ways—and choosing the wrong one (or creating conflicting documents) can leave your wishes unprotected.

This guide cuts through the legal jargon to explain exactly what each document does, when you need one versus the other, and whether having both makes sense for your situation.

Table of Contents

What Is an Advance Decision to Refuse Treatment?

An advance decision is a legally binding document that allows you to refuse specific medical treatments in advance. Under the Mental Capacity Act 2005, Sections 24-26, it's defined as a decision made by a person aged 18 or older with mental capacity that specifies treatment to be refused if they later lack capacity to consent.

Also called an "advance directive," "living will," or "ADRT (Advance Decision to Refuse Treatment)," this document only covers treatment refusals. You cannot use it to demand treatment, request euthanasia, or refuse basic care like warmth, hygiene, or food offered by mouth.

An advance decision becomes legally binding in England and Wales when it's valid and applicable. In Northern Ireland, advance decisions are also legally binding, though in Scotland they should be taken into account but aren't legally enforceable under the same framework.

Sarah, a Jehovah's Witness, creates an advance decision refusing blood transfusions even if her life is at risk. Because it's written, signed, witnessed, and includes the statement "This decision applies even if my life is at risk," doctors must follow this refusal when Sarah lacks capacity.

Unlike health and welfare LPAs, which require registration with the Office of the Public Guardian, advance decisions have no central registry. This means uptake statistics aren't tracked—while 687,796 health and welfare LPA applications were submitted in 2023-24, we don't know how many people have created advance decisions.

The key limitation: an advance decision is fixed. Once made, it applies only to the specific treatments and circumstances you've described. It cannot adapt to unforeseen medical developments.

What Is a Health and Welfare LPA?

A health and welfare LPA is a legal document that appoints one or more attorneys to make personal welfare decisions on your behalf when you lack mental capacity. Unlike an advance decision where you make the choices in advance, an LPA gives your attorney the power to make healthcare decisions for you based on your best interests.

According to GOV.UK guidance, health and welfare LPAs only apply after registration with the Office of the Public Guardian and when you lack capacity to make decisions yourself. This differs from property and financial affairs LPAs, which can be used while you still have capacity if you permit it.

Your attorney can make decisions about medical treatment, care home placement, daily routine, and accessing your medical records. However, they can only make decisions about life-sustaining treatment if you explicitly grant this authority in Section 7 of the LPA form.

David, 72, appoints his daughter Emma as his health and welfare attorney. When David develops dementia and can no longer make decisions, Emma can consent to medical procedures, choose his care home, and manage his daily care routine—but she cannot refuse life-sustaining treatment unless David specifically granted this power in the original LPA.

Health and welfare LPAs have seen dramatic growth. In 2023-24, 687,796 health and welfare LPA applications were submitted, a 216% increase from previous years. Despite this growth, health LPAs still lag behind property and financial affairs LPAs, which received 807,974 applications in the same period.

One critical detail: 8.9% of LPA applications were rejected in 2024, often due to signature errors, missing certificate provider signatures, or forms completed in the wrong order. Getting the details right matters.

The 7 Key Differences Between Advance Decisions and Health LPAs

Understanding the practical differences helps you choose the right document for your situation. Here's how they compare:

Feature Advance Decision Health & Welfare LPA
Who decides You decide in advance which treatments to refuse Your appointed attorney decides based on your best interests
Scope Can ONLY refuse treatment Can consent to treatment, refuse treatment, and make broader care decisions (placement, daily routine)
Registration No registration required Must be registered with OPG before use (£92 fee)
When it applies When you lack capacity AND the specified treatment is proposed Only when you lack capacity (and LPA is registered)
Cost Free (templates available from charities) to £200 (solicitor-drafted) £92 registration fee + optional solicitor fees (£200-400) or online service fees
Legal requirements Must be written, signed, and witnessed if refusing life-sustaining treatment Must use official OPG forms, include certificate provider, be registered
Flexibility Fixed (cannot adapt to unforeseen circumstances) Flexible (attorney can respond to changing medical situations)

The fundamental difference is who makes the choice. An advance decision is YOUR choice made in advance. A health LPA gives your attorney the power to make choices FOR you based on your best interests and known wishes.

What each document can refuse also differs. An advance decision can refuse ANY treatment, including life-sustaining treatment, if properly documented. A health LPA attorney can only refuse life-sustaining treatment if you explicitly authorised this in Section 7 of the original LPA form.

Timing and registration create another key distinction. Advance decisions take effect immediately when valid and applicable. Health LPAs require registration, which currently takes 8-10 weeks on average, including the mandatory 28-day cooling-off period.

Cost varies significantly. If you use free templates from Compassion in Dying or the Alzheimer's Society, an advance decision costs nothing. A health LPA always costs £92 to register (increased from £82 as of 17 November 2025), plus any professional fees.

James wants to refuse dialysis if he develops severe dementia. An advance decision works perfectly—he can specify this exact refusal. Priya wants someone she trusts to make future medical decisions she can't anticipate. A health LPA is better—her attorney can respond to whatever arises.

With rejection rates at 8.9% for LPAs, getting forms completed correctly matters. Common errors include incorrect signature order, missing sections, and illegible dates—mistakes that cost families time and money.

Which Document Do You Actually Need?

The right choice depends on your specific situation and what type of control you want over future healthcare decisions.

Choose an advance decision if:

You have specific, non-negotiable treatment refusals. This works well for religious objections to blood transfusions, refusal of ventilation in specific circumstances, or clear preferences about end-of-life care. An advance decision gives you complete control over these specific treatment decisions.

You want a free option without registration requirements. Using charity templates means no fees and no 8-10 week wait for registration. Your decision takes effect immediately once properly documented.

You have clear, specific refusals rather than general preferences. The more specific you can be about which treatments you refuse and in what circumstances, the more effective an advance decision becomes.

Choose a health and welfare LPA if:

You want someone you trust to make decisions you can't predict. Medical situations are complex and change rapidly. An LPA gives your attorney flexibility to respond to unforeseen circumstances in your best interests.

You need broader decision-making coverage beyond treatment refusals. Care home choice, daily routine, medical records access, and decisions about where you live all fall under health LPA powers but aren't covered by advance decisions.

You want someone who can CONSENT to treatment, not just refuse it. Advance decisions only refuse treatment. If you want someone able to agree to beneficial treatments on your behalf, you need an LPA.

You trust your attorney to interpret your best interests when circumstances change. This requires confidence that your attorney knows your values and will make decisions aligned with your wishes.

Consider having both if:

You have specific treatment refusals AND want broader decision-making coverage. Many people use an advance decision to document clear refusals while giving an attorney flexibility for everything else.

You want your attorney to have clear guidance. An advance decision can inform your attorney's decisions by documenting your specific wishes about certain treatments.

You have strong preferences about end-of-life treatment but want flexibility for other healthcare decisions. This combination covers both your non-negotiables and unforeseen situations.

Robert, 65, has early-stage Parkinson's. He creates an advance decision refusing artificial nutrition and hydration if he develops severe dementia, PLUS a health LPA appointing his civil partner to make all other healthcare decisions. The advance decision ensures his specific wish is honoured; the LPA covers everything else.

Alison, 58, has no specific treatment refusals but wants her sister to make decisions if she's incapacitated after an accident. She needs a health LPA, not an advance decision.

The growth in health LPAs—216% increase in applications—suggests growing awareness of the need for healthcare planning. While advance decision uptake remains unknown due to no registration requirement, many solicitors report increased interest in both documents.

Can You Have Both an Advance Decision and a Health LPA?

Yes, you can have both documents, and many people do. An advance decision provides specific treatment refusals while an LPA covers broader healthcare decisions your attorney can adapt to changing circumstances.

The key requirement: ensure your documents don't conflict. The best way to coordinate them is to mention your advance decision in Section 7 of your LPA form when you create it.

According to Office of the Public Guardian guidance, if you have an advance decision that you want your attorneys to take into account, you should mention it when completing the LPA form. Include a copy of the advance decision when you send your LPA to the OPG for registration.

Elizabeth, 70, creates an advance decision refusing CPR and ventilation if she has a cardiac arrest. She also creates a health LPA appointing her son to make decisions about care home placement, daily routine, and other medical treatments. In Section 7 of her LPA, she writes: "My attorney must respect my Advance Decision dated 15 March 2024 (copy attached) refusing CPR and ventilation." Both documents now work together.

Creating both documents without referencing the advance decision in the LPA can create confusion. Healthcare professionals need to know both exist and that they're meant to work together rather than compete.

The order in which you create documents matters critically. Whichever document is created LAST takes priority if they conflict—a rule explained in detail in the next section. This means timing is crucial when coordinating these documents.

Attaching a copy of your advance decision when registering your LPA serves two purposes: it informs the OPG that both documents exist, and it creates a record that healthcare professionals can reference when making treatment decisions.

Many people find this combination offers the best of both worlds: specific control over treatments they definitely want to refuse, plus flexible authority for a trusted person to handle everything else. It's not legally required to have both, but it can provide comprehensive protection for your healthcare wishes.

What Happens When an Advance Decision Conflicts with an LPA?

Legal precedence rules are clear but often misunderstood. Under the Mental Capacity Act 2005, Sections 24-26, whichever document was created most recently generally takes priority over the other.

This creates three distinct scenarios:

Scenario 1: Advance decision created FIRST, then LPA

If you create an LPA after an advance decision and the LPA gives your attorney authority over the SAME treatment decisions, the LPA invalidates the advance decision for those specific treatments.

You create an advance decision refusing kidney dialysis in 2022. You then create a health LPA in 2024 giving your attorney authority over "all treatment decisions including kidney dialysis." The LPA overrides the advance decision because it was created later and covers the same treatment.

Scenario 2: LPA created FIRST, then advance decision

The advance decision takes priority over your attorney's decision-making power for those specific treatments. Your attorney cannot consent to treatments you've refused in a later advance decision.

You create a health LPA in 2022. You then create an advance decision refusing chemotherapy in 2024. Your attorney cannot consent to chemotherapy—your advance decision controls that specific treatment decision.

Scenario 3: Both exist, no conflict

When properly coordinated, your advance decision covers specific refusals while your LPA covers everything else. This is the ideal scenario and why referencing your advance decision in your LPA matters so much.

According to NHS guidance on advance decisions, healthcare professionals must follow a valid and applicable advance decision, even if they think it goes against a person's best interests. The Court of Protection has no power to overrule a valid and applicable advance decision to refuse treatment.

How to prevent conflicts:

Reference your advance decision in Section 7 of your LPA form with specific wording like: "My attorney must respect my Advance Decision dated [date] refusing [specific treatments]."

Attach a copy of your advance decision when registering your LPA with the OPG. This creates a clear record that both documents exist and should work together.

Review both documents together with your attorney so they understand your wishes and how the documents interact.

Update both if circumstances change. If you create a new version of either document, review the other to ensure they still work together.

What invalidates an advance decision:

Withdrawal while you have capacity. You can change your mind at any time before losing capacity.

Creating an LPA giving your attorney authority over the same treatment if the LPA is more recent. This is why coordination matters.

Acting inconsistently with the advance decision's terms. If your behaviour contradicts what you wrote, healthcare professionals may question its validity.

Understanding these precedence rules helps you coordinate documents properly. The goal isn't to have documents compete but to work together—your specific refusals documented in an advance decision, with your attorney handling everything else through the LPA.

How to Create an Advance Decision in the UK

Creating a legally valid advance decision requires following specific requirements under the Mental Capacity Act 2005.

Legal requirements:

You must be 18 or older when creating the document.

You must have mental capacity when making the decision—meaning you understand what you're doing and can make the decision freely.

You must specify which treatments you're refusing. You can use lay terms like "breathing machine" instead of "mechanical ventilation," but you need enough detail that healthcare professionals understand what you mean.

For life-sustaining treatment refusals, additional requirements apply:

  • Must be in writing
  • Must be signed by you
  • Must be witnessed by someone independent
  • Must include the statement: "This decision applies to the specified treatment even if my life is at risk"

Step-by-step process:

  1. Decide which treatments to refuse. Be as specific as possible about treatments and the circumstances where your refusal applies. Vague statements like "I don't want treatment" won't work—specify exactly which treatments you refuse and when.

  2. Use a template or create your own. Free templates are available from Compassion in Dying, the Alzheimer's Society, and other reputable charities. These templates guide you through the required information.

  3. Complete the document. Include your full name, date of birth, the specific treatments you refuse, and the circumstances where your refusal applies. Be as detailed as possible.

  4. Sign and date. If refusing life-sustaining treatment, do this in front of a witness. If refusing other treatments, signing without a witness is legally valid but having a witness is best practice.

  5. Witness signature. Your witness must be 18 or older, not a beneficiary in your will, and ideally not a family member. The witness confirms you signed the document, not that they agree with your decision.

  6. Distribute copies. Give copies to your GP, family members who should know about it, and your attorney if you have an LPA. Keep the original in a safe, accessible place.

  7. Review regularly. Update your advance decision if your wishes change or if your circumstances change significantly. An outdated advance decision may not be considered valid.

Cost information:

Free templates are available from Compassion in Dying, Alzheimer's Society, and similar organisations. If you want professional legal advice, solicitors typically charge around £200 for a professionally drafted advance decision. There are no registration fees, unlike LPAs.

Common mistakes to avoid:

Being too vague. "I don't want treatment" doesn't specify which treatments. "I refuse mechanical ventilation if I have irreversible brain damage" is specific enough.

Not signing or witnessing when refusing life-sustaining treatment. Without proper signatures, your refusal of life-sustaining treatment won't be legally valid.

Not updating when circumstances change. If you make the decision at 40 and you're now 75 with different medical conditions, healthcare professionals may question whether it still reflects your wishes.

Not telling anyone where it's kept. An advance decision only works if healthcare professionals know it exists and can find it when needed.

Thomas, 55, downloads the free Compassion in Dying template. He specifies: "I refuse mechanical ventilation, CPR, and artificial nutrition if I have a severe stroke with no reasonable prospect of recovery." He signs in front of his neighbour (witness), gives copies to his GP and daughter, and keeps the original in his bedside drawer where family know to look.

According to NHS guidance, healthcare professionals must follow a valid and applicable advance decision. Getting the details right ensures your wishes are respected.

How to Create a Health and Welfare LPA in the UK

Creating a health and welfare LPA involves more formal requirements and mandatory registration with the Office of the Public Guardian.

Legal requirements:

The donor (person making the LPA) must be 18 or older with mental capacity. Attorneys must also be 18 or older but don't need to be UK residents.

Attorneys must be individuals, not companies. You can appoint one attorney or multiple attorneys to act jointly, jointly and severally, or in a specific order.

You need a certificate provider—an independent person who confirms you understand what you're doing and aren't under pressure. This can be someone who's known you for at least two years or a professional like a solicitor or GP.

The LPA must be registered with the OPG before it can be used. Unlike property LPAs which can sometimes be used before registration, health LPAs only become effective after registration and when you lack capacity.

Step-by-step process:

  1. Choose your attorneys. Select people you trust completely—typically your partner, adult children, or close friends. Consider whether they can make difficult decisions under pressure.

  2. Decide on powers. Will attorneys make decisions jointly (all must agree), jointly and severally (each can act independently), or in a specific order (one acts unless unable, then the next)?

  3. Make the life-sustaining treatment decision. Decide whether your attorneys can refuse life-sustaining treatment on your behalf. This goes in Section 7 of the form and requires careful consideration.

  4. Complete the official LPA form. Use form LP1H from GOV.UK. You can complete it online through the official LPA service or use paper forms.

  5. Certificate provider signs. They confirm you understand the LPA and aren't being pressured to create it. This is a legal safeguard.

  6. You and attorneys sign. Forms must be signed in the correct order—check the form instructions carefully. 8.9% of applications were rejected in 2024, often due to signature errors.

  7. Register with OPG. Submit the completed form with the £92 registration fee (increased from £82 as of 17 November 2025). Fee exemptions are available if you receive certain benefits.

  8. Wait for registration. Current processing time is 8-10 weeks on average, including the mandatory 28-day cooling-off period when people can object.

  9. Receive registered LPA. Only once registered can your attorney act on your behalf when you lack capacity.

Cost breakdown:

OPG registration fee: £92 (mandatory as of 17 November 2025). Fee exemptions are available if you receive certain means-tested benefits. A 50% remission applies if your annual income before tax is less than £12,000.

Solicitor fees: £200-£400 if you use professional help (optional). Online services vary by provider.

Total for DIY approach using the free GOV.UK service: £92.

Common rejection reasons:

According to MoneyWeek reporting on OPG data, common reasons include incorrect signature order, missing certificate provider signature, attorneys who don't meet eligibility requirements, and forms not completed in the correct sequence.

Illegible dates or signatures also cause rejections. Write clearly and ensure all information is complete before submitting.

Important timing note:

Unlike property and financial affairs LPAs which can be used while you have capacity (if you permit it), health and welfare LPAs can ONLY be used after you lose capacity. You can't give your attorney authority to make healthcare decisions while you're still capable of making them yourself.

Plan ahead. Don't wait until a health crisis when you may not have capacity to create an LPA. The 8-10 week registration period means urgent situations can't be addressed with a new LPA.

Frequently Asked Questions

Q: What is the difference between an advance decision and a health LPA?

A: An advance decision allows you to refuse specific medical treatments in advance, whereas a health and welfare LPA appoints someone you trust to make healthcare decisions on your behalf. An advance decision is about your own choices, while an LPA gives decision-making power to your attorney. Both only apply when you lack mental capacity.

Q: Can I have both an advance decision and a health LPA?

A: Yes, you can have both documents. Many people choose to have both because an advance decision refuses specific treatments while an LPA covers broader healthcare decisions like care home placement and daily routine. If you have both, ensure they don't conflict, and mention your advance decision in Section 7 of your LPA form when you create it.

Q: Which takes priority if my advance decision conflicts with my LPA?

A: Whichever document was created most recently takes priority. If you make a health LPA after an advance decision, the LPA will override the advance decision if it gives your attorney authority over the same treatment decisions. Always ensure your documents work together rather than conflict by referencing your advance decision in your LPA.

Q: Does an advance decision need to be registered like an LPA?

A: No, advance decisions do not require registration with the Office of the Public Guardian. However, they must be in writing, signed, and witnessed if they refuse life-sustaining treatment. Health LPAs must be registered with the OPG before they can be used, which costs £92 per document and takes 8-10 weeks.

Q: Can my health LPA attorney override my advance decision?

A: Only if the LPA was created after the advance decision and gives your attorney authority over the same treatment decisions. To prevent this, include a specific instruction in Section 7 of your health LPA referencing your advance decision, and attach a copy when registering the LPA with the Office of the Public Guardian.

Q: How much does it cost to create an advance decision vs a health LPA?

A: Advance decisions can be created for free using templates from charities like Compassion in Dying or Alzheimer's Society. Solicitors typically charge around £200 to draft an advance decision. Health LPAs cost £92 to register with the Office of the Public Guardian (increased from £82 as of 17 November 2025), plus any fees if you use a solicitor (typically £200-400) or an online service.

Q: What can an advance decision refuse that an LPA cannot?

A: This is a misunderstanding of how the documents work. Both can refuse life-sustaining treatment—an advance decision does it directly (your choice in advance), while a health LPA allows your attorney to refuse treatment on your behalf (if you granted this power in Section 7). The key difference is WHO decides: you (advance decision) or your attorney (LPA). Neither document can refuse basic care like warmth, food offered by mouth, or hygiene.

Conclusion

Key takeaways:

  • Advance decisions let you refuse specific treatments in advance (free using charity templates, no registration required, only covers refusals)
  • Health and welfare LPAs appoint someone to make broader healthcare decisions (£92 registration fee, requires 8-10 weeks to register, covers consent and refusals)
  • You can have both—many people do, using an advance decision for specific refusals and an LPA for everything else
  • Timing matters—whichever document is created most recently takes priority if they conflict
  • Coordinate them properly—mention your advance decision in Section 7 of your LPA and attach a copy when registering

The difference between an advance decision and a health LPA comes down to control versus flexibility. If you know exactly which treatments you'd refuse, an advance decision locks in your choice. If you want someone you trust to make decisions you can't predict, a health LPA gives them that power. Most people benefit from both—your specific refusals documented, plus a trusted person to handle everything else.

Need Help with Your Will?

Planning for healthcare decisions through advance decisions and LPAs is only part of estate planning. A legally valid will ensures your assets go to the right people and your guardianship wishes are honoured if you have children.

Create your will with confidence using WUHLD's guided platform. For just £99.99, you'll get your complete will (legally binding when properly executed and witnessed) plus three expert guides. Preview your will free before paying anything—no credit card required.

Legal Disclaimer: This article provides general information only and does not constitute legal or financial advice. WUHLD is not a law firm and does not provide legal advice. Laws and guidance change and their application depends on your circumstances. For advice about your situation, consult a qualified solicitor or regulated professional. Unless stated otherwise, information relates to England and Wales.

Legal Disclaimer:

This article provides general information only and does not constitute legal or financial advice. WUHLD is not a law firm and does not provide legal advice. Laws and guidance change and their application depends on your circumstances. For advice about your situation, consult a qualified solicitor or regulated professional. Unless stated otherwise, information relates to England and Wales.

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