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Advance Decision on Life-sustaining Treatment Ordinance

The rapidly ageing of Hong Kong’s population underscores the need to improve end-of-life (“EoL”) care, amidst mounting challenges. The Government’s policy intent is to provide high-quality and comprehensive EoL care services to patients and their families in accordance with their wishes and needs, ensuring that patients receive suitable EoL care. Our aim is to shield patients from enduring ineffective and superfluous treatments in their last days, enabling them to uphold their dignity as they conclude their life’s voyage.

Thus, the Government introduced the Advance Decision on Life-sustaining Treatment Ordinance (“the Ordinance”), with a view to establishing legislative frameworks for advance medical directives (“AMDs”) and do-not-attempt cardiopulmonary resuscitation (“DNACPR”) orders and providing legal protection to patients, medical professionals, as well as rescuers, where terminally-ill patients are empowered with a greater degree of autonomy. The Ordinance was passed at the Council meeting on 20 November 2024 and gazetted on 29 November 2024. The Government plans to allocate an 18-month preparation period for medical institutions, relevant departments and organisations to update their protocols, records and systems, and provide necessary training to their frontline staff.

AMD

An AMD allows an adult patient to make instructions in advance for situations where they are mentally incapable of deciding on a life-sustaining treatment (“LST”), following in-depth discussions with family members and healthcare professionals. In the event of the patient’s health deteriorating, healthcare professionals will adhere to the patient’s AMD regarding the withholding or withdrawal of pertinent LSTs, provided that the specified preconditions in the AMD are met. AMDs made by the public before the commencement of the Ordinance will remain valid, as long as they fulfil the conditions stipulated in the Ordinance. As an illustration, a pre-existing AMD made before the commencement of the Ordinance using [model forms] in Schedule 2 and the Hospital Authority (“HA”) forms should have met the condition of clearly presenting all instructions specified in the Ordinance.

The Government plans to progressively introduce the full electronic route of AMDs, with “eHealth” serving as the designated electronic system to support the making, storage, revocation and retrieval of electronic AMDs. The Government will implement paper AMDs and electronic AMDs by phrases. In the first phase, the paper route of AMDs and electronic storage of such paper AMDs will take effect, whereby the public can decide whether to store their paper AMDs electronically after making one. Once the relevant functions of the designated electronic system are in place, the Government will enable the electronic making of AMDs directly in the system. Both the general public as well as public and private medical institutions will be able to view electronically stored or made AMDs through “eHealth”.

DNACPR Order

To facilitate adherence to instructions in an AMD in situations demanding immediate decisions without the presence of medical professionals (e.g. outside the hospital setting), registered medical practitioners (“RMPs”) may make DNACPR orders for AMD makers who have specified in their AMDs a refusal of cardiopulmonary resuscitation ("CPR"). AMD-based DNACPR orders instruct not to perform CPR on the subject person under applicable circumstances when that person is in a cardiopulmonary arrest. Given that minors and adults who are mentally incapable of deciding on LST cannot make AMDs, RMPs may make a DNCPR order for them if a consensus is reached among the patient’s attending RMPs and family members that CPR would not be in the patient’s best interests. A responsible person (e.g. family members) has to agree with the decision and co-sign the non-AMD-based DNACPR order.

DNACPR orders must be made in writing using a prescribed form for easy identification and verification. Otherwise, the orders will be considered invalid. Before the commencement of the Ordinance, pre-existing DNACPR orders will be gradually replaced by the prescribed forms provided in the Ordinance. In order to facilitate a smooth transition for DNACPR orders made within the HA, the HA will transition to these prescribed forms before the commencement of the Ordinance, ensuring the continued validity of these DNACPR orders after the commencement date.

Download Forms

The model forms of AMD are provided in Schedule 2 of the Ordinance. The Government encourages the members of the public to adopt model forms to make AMDs, ensuring that all instructions in the AMD are clearly presented and comply with legal requirements. The prescribed forms of DNACPR order and continuation sheets for extension of the effective period are included in Schedule 3 of the Bill. These forms and continuation sheets are currently available for download on the Health Bureau website and are listed below for public use -

Frequently Asked Questions:

Q1: What does LST include for the purpose of AMD, which enables patients to refuse LST in certain specified preconditions?

LST refers to a variety of medical treatments that potentially postpone a patient’s death and includes, for example, CPR, artificial ventilation, blood products, pacemakers, vasopressors, specialised treatments for particular conditions such as chemotherapy or dialysis, antibiotics when given for potentially life-threatening infection and artificial nutrition and hydration (i.e. the feeding of food and water to a person through a tube). Through AMD, makers can refuse one or multiple LSTs.

If providing the LST would not be in the terminally-ill patient’s best interest or the patient has expressed his/her wish to refuse the LST, withholding or withdrawing the LST is ethical and legal. However, AMDs do not extend to the refusal of basic care (e.g. offering food and drink to the patient for the patient’s consumption by mouth and assisting the patient in consuming food and drinking by mouth) or palliative care. Healthcare professionals should sustain the provision of basic care and palliative care to patients to address their basic survival needs.

Q2. Who is eligible to make an AMD?

Only adult who is mentally capable of deciding on an LST can make an AMD to indicate his/her wishes for refusing LST (such as CPR) when he/she reaches the specified medical condition (e.g. terminally ill; in a persistent vegetative state and state of irreversible coma; or in other end-stage, irreversible, life-limiting condition).

Given that minors and adults who are mentally incapable of deciding on LST cannot make AMDs, RMPs may make a non-AMD-based DNCPR order for them if a consensus is reached among the patient’s attending RMPs and family members that CPR would not be in the patient’s best interests. A DNACPR order instructs not to perform CPR on the subject person under applicable circumstances when that person is in a cardiopulmonary arrest. A responsible person (e.g. family members) has to agree with the decision and co-sign the order.

Q3. Does AMD have to be made in model forms?

We encourage the members of the public to adopt model forms provided in Schedule 2 of the Ordinance to make AMDs, ensuring that all instructions in the AMD are clearly presented and comply with legal requirements (e.g. the maker is an adult who is mentally capable of deciding on an LST; all instructions in the AMD is presented in a clear way; the maker of the AMD signs the directive in the presence of not less than 2 witnesses; both witnesses, to the best of their knowledge, are not interested persons of the maker; one of the witness is a RMP; the another witness is an adult, etc.)

The model form will provide three specified preconditions for the maker to choose from. AMD will be applicable when the patient falls into the specified precondition(s) specified in the instructions and becomes mentally incapable of deciding on an LST. The three specified preconditions provided in the model form are as follows :

1.	Being terminally ill (i.e. the patient suffers from an advanced, progressive and irreversible medical condition with a short life expectancy in terms of days, weeks or months, where any form of LST would only serve to postpone the person’s death);
2.	Being in a persistent vegetative state and state of irreversible coma; or
3.	Being in other end-stage, irreversible, life-limiting condition (distinct from the above two categories, specifying the medical condition of the patient is progressive and irreversible, has reached its end-stage and limits the survival of the person), for example, a patient with end-stage renal failure, end-stage motor neuron disease, or end-stage chronic obstructive pulmonary disease. Where these patients may receive dialysis treatment or assisted ventilation to prolong life, such conditions are not categorised as the first category. [Note: Patients suffering from end-stage dementia will be categorised as the third category.]

The Ordinance allows members of the public to adopt non-model forms for making AMDs, provided that the instructions in the AMD are clearly presented and comply with legal requirements. Individuals intending to adopt non-model forms are advised to consult RMPs beforehand, ensuring a clear presentation of the specified preconditions in accordance with legal requirements.

Q4. Following the enactment of the Ordinance, is it mandatory for AMDs to be made with RMPs within the HA? Where should the public or elderly look for a RMP to make an AMD?

At present, RMPs in the HA assist patients in making AMDs during advance care planning discussions. If members of the public or the elderly have ongoing follow-up consultations with the HA, they may, where appropriate, take the initiative to express their wishes to make AMD with their RMPs during the consultation sessions.

The Ordinance does not mandate that an AMD must be witnessed by RMPs within the HA. Members of the public can also choose RMPs from private medical institutions who are familiar with their medical history and condition to serve as the RMP witness in the making of AMD. The Ordinance specifies that the witnessing RMPs bear statutory obligations to explain to the maker the nature of the directive and the effect of following each of the instructions in the AMD (i.e. not performing specified LST under the specified precondition) on the maker.

Q5. For pre-existing AMDs and DNACPR orders made before the commencement of the Ordinance, are they required to be remade after the commencement?

Generally, pre-existing AMDs made before the commencement of the Ordinance will continue to be valid, as long as they comply with the requirement as stipulated in the Ordinance. As an illustration, a pre-existing directive made in a HA form should have met the requirements of clearly presenting all instructions specified in the Ordinance.

For pre-existing AMDs which are clearly presented but do not fully comply with all the requirements of the Ordinance, if a RMP agrees that it is not in the patient’s best interests to administer the LST(s) that is/are refused in the AMD, the RMP may withhold LST from the patient on the basis of the patient’s AMD under common law, which is issued by the doctor outside Hong Kong. Nevertheless, we recommend members of the public, who have made an AMD, to regularly review their AMD with RMPs and update or modify the instructions, if appropriate, by using the model form specified in the Ordinance.

Before the commencement of the Ordinance, pre-existing DNACPR orders will be gradually replaced by the prescribed forms in the Ordinance. In order to facilitate a smooth transition for DNACPR orders made within the HA, the HA will transition to these prescribed forms after the enactment and before the commencement of the Ordinance, ensuring the continued validity of these DNACPR orders after the commencement date.

Q6. Is there a limit on the number of times for making AMDs?

Given that AMDs pertain to life-and-death decisions, makers should exercise prudence when making an AMD, and keep records properly if there arises a need to revoke or remake the AMD. This practice helps avoid confusion for healthcare professionals in performing their duties.

Q7. An AMD must be made in the presence and signature of two witnesses. What requirements should such two witnesses meet? Can the patient’s family members or carers serve as a witness?

One of the witnesses must be a RMP registered in Hong Kong and not an interested person of the maker. He/she has to undertake the following three responsibilities:

1.	Explaining to the maker the nature and content of AMD, as well as the effect of following each of the instructions in the AMD on the maker;
2.	Being satisfied that, at the time when the maker signs the directive, the maker is mentally capable of deciding on an LST; and
3.	Declaring in the AMD that he/she meets the two requirements above

Another witness must be an adult and not an interested person of the maker (e.g. a successor to the maker’s estate or a beneficiary under the maker’s insurance). Therefore, family members or carers unknown or unsure of their eligibility should refrain from being witnesses. In such cases, the maker can invite a disinterested adult, such as a friend or a nurse present, to act as a witness.

Alongside the legislation concerning AMDs, thorough advance care planning (“ACP”) discussions between patients and their families stand as a more crucial element of a comprehensive EoL care service. We believe that the companionship, understanding and involvement of family members and friends are integral to patients’ EoL journey. Hence, we suggest that RMPs involve patients’ family members in discussions regarding the patients’ ACP before making an AMD with the patient, providing them with detailed information and guidance. When patients decide to make an AMD, they should share their wishes with family members and friends, and reach a consensus.

Q8. How can the maker revoke an AMD?

The Ordinance follows the “cautious making, easy revoking” principle, ensuring stringent safeguards for making AMDs while facilitating easy revocation, should the maker subsequently change his/her preferences. As long as the maker is mentally capable of deciding on an LST, he/she can revoke an AMD through the following means at any time:

1.	The maker revokes the AMD in writing (whether in paper form or in electronic form);
2.	The maker signs Part 5 of the AMD which was made in the forms prescribed in Schedule 2 of the Ordinance;
3.	The maker (or an adult in the maker’s presence and by the maker’s direction) burns, tears or crosses out the content and signs each page of, the AMD;
4.	The maker, in the presence of one or more witnesses who are adults, revokes the AMD verbally or expresses his/her intention to revoke the AMD by other means (e.g. nodding, shaking head and using sign language);
5.	The maker makes another AMD; or
6.	Once the designated electronic system commences operation, the maker (or an adult in the maker’s presence and by the maker’s direction) revokes the AMD in the electronic system.

Q9. If an AMD is already made, is it necessary to make a DNACPR order? What is the difference between the two instruments?

While both AMD and DNACPR order entail instructions on the refusal of CPR, the two legal documents are slightly different in nature. An AMD is made by an adult who is mentally capable of deciding on an LST, indicating the LST (e.g. CPR) he/she wishes to refuse when he/ she becomes mentally incapable in the future. A DNCPR order is made on the grounds of RMP’s clinical judgements based on the patient’s current clinical condition.

Specifically, at the time of making an AMD, the maker’s condition may not have reached the specified preconditions (e.g., being terminally ill). The treatment provider’s obligations and liabilities relating to subjecting, or not subjecting, the maker of an AMD to an LST are subject to a valid and applicable instruction in the AMD. Irrespective of the patient's location, whether in or outside the hospital setting, treatment providers would not provide LST to the patient when they have notice of the patient’s AMD and the instructions therein are valid and applicable.

On the other hand, a DNACPR order is a clinical decision made by two RMPs during the EoL stage of the patients. The key advantage of a patient having both an AMD and a DNACPR order is to ensure that outside a hospital setting, even in the absence of treatment providers, rescuers can comply with the order and not perform CPR on the patient if they have notice of the DNACPR order.

Considering the patient’s individual circumstances, healthcare professionals will engage in a thorough discussion with the patient and family members to determine the necessity of making the two instruments simultaneously.

Q10. If the patient has a DNACPR order issued by RMPs, and the rescuers cannot locate the validating copy of the order upon arrival at the patient’s residence, will they conduct a search for the order?

The patient has the responsibility of presenting his/her DNACPR order to treatment providers and rescuers. Since DNACPR orders may be followed outside the hospital setting during emergencies, treatment providers and rescuers are required to make split-second decisions. As time is of the essence during rescue operations, the Ordinance will stipulate that treatment providers and rescuers are not required to search the patient’s personal belongings for a validating copy of the DNACPR order. If rescuers do not have notice of any DNACPR order or validating copies, they will administer prompt and proper treatment on the premise of saving lives.

To aid patients in carrying DNCPR orders, the HA will prepare eye-catching designed pouches. The pouches will be clearly labelled as containing a DNACPR order, permitting rescuers (e.g. fire and ambulance personnel of the Fire Services Department) and other relevant individuals to search for the order therein. We advise that DNACPR orders should be positioned in a highly visible location for easy identification and quick access by family members or rescuers.