Advance Choice Documents (ACDs): Recording Your Mental Health Treatment Wishes

The Mental Health Bill proposes statutory ACDs as a way for people who have experienced mental illness — or are at risk of acute relapse — to record:

• Preferred medications and dosages, and medications to avoid.
• Approaches that have worked or backfired in previous admissions.
• Triggers and early warning signs.
• Preferred family/friend contacts and the role they should play.
• Wishes about admission to specific units, or avoiding specific units.
• Cultural or religious preferences relevant to care.
• Whether they want to be detained in hospital or, where clinically appropriate, treated in the community.

The aim is to give patients greater autonomy and reduce the trauma of compulsory treatment by aligning it more closely with their stated wishes. Research (and the Wessely Review 2018) found that many compulsory admissions go badly because clinical staff do not know patient preferences from previous experiences.

Until ACDs are in force, three existing tools apply:

• Advance Decision to Refuse Treatment (ADRT) under sections 24-26 Mental Capacity Act 2005. Legally binding refusal of specified medical treatments while you have capacity. Must be in writing, signed and witnessed for life-sustaining treatment. ADRTs do not bind compulsory mental health treatment under the MHA 1983 — but they bind physical treatment given to someone admitted under the MHA who has capacity to refuse.
• Advance Statements — statements of wishes and feelings about future treatment. Not legally binding but the clinician must take them into account when making best interests decisions under section 4 MCA 2005.
• Lasting Power of Attorney for Health and Welfare — appointing someone to make health decisions for you when you lose capacity. Can include power to refuse life-sustaining treatment if specifically authorised.

For mental health treatment specifically, ADRTs have limited reach because the MHA gives clinicians power to give treatment without consent. But ADRTs can still bind decisions about physical treatments (surgery, blood products) and end-of-life care.

The Mental Health Bill introduced November 2024 proposes statutory ACDs with key features:

• Statutory recognition — the ACD will be a named document in the MHA framework, with clinicians required to "consider" it when making decisions about admission, treatment, and discharge.
• Reviewability — ACDs can be reviewed and updated at any time with capacity.
• Recorded on NHS systems — ACDs will be added to the patient's electronic record and shared with relevant teams.
• Not binding on the MHA — the Bill does NOT make ACDs binding on compulsory treatment. Clinicians can still detain and treat under the MHA framework. But they must take ACD wishes into account and document their reasons for departing.
• Capacity assessment — the ACD must be made while the person has capacity to make it. This is a deliberate safeguard.
• Nominated Person involvement — the new Nominated Person (replacing the Nearest Relative) can help interpret and apply the ACD.

As at May 2026 the Bill is in committee stage in Parliament. Commencement of the substantive provisions is expected in late 2026 or 2027 after Royal Assent and consultation on implementing regulations.

Even before the statutory ACD framework, you can:

• Discuss your preferences with your care team — community mental health team, GP, psychiatrist. Ask them to record your wishes on your NHS record.
• Make an Advance Statement — informal but written document setting out your wishes. Templates are available from Mind, Rethink Mental Illness, and the Royal College of Psychiatrists.
• Make an Advance Decision to Refuse Treatment (ADRT) if there are specific medications or treatments you want to refuse. Use the MCA 2005 framework — written, signed, witnessed.
• Make an LPA for Health and Welfare — appointing a trusted person to make decisions if you lose capacity. £82 OPG fee.
• Carry a wallet card or wristband — flagging that you have an Advance Statement and where to find it.
• Talk to your Nominated Person (or under current law, your Nearest Relative) about your preferences so they can advocate for you.

It is important to understand the limits:

• Neither ACDs nor ADRTs can prevent compulsory admission and treatment under the MHA where the clinical and legal criteria are met. The clinical professional and AMHP can detain you and the treatment provisions of the MHA still apply.
• An ADRT for life-sustaining treatment must specifically state it applies even where life is at risk, and must be in writing, signed and witnessed.
• Capacity at the time of making the document is essential. An ADRT made while psychotic or severely depressed without capacity is invalid.
• Specific situations not anticipated in the document fall back on best interests decision-making.
• Family disputes about the ACD's meaning can lead to Court of Protection involvement.

Despite the limits, ACDs and existing advance tools give clinicians real information about your preferences. Treatment that respects past wishes is usually less traumatic for everyone involved.