Advance Medical Directives- A Compassionate Approach to Planning Ahead for End-of-Life Treatment
Advance medical directives (“AMDs”) enable adults who are mentally capable of deciding on life-sustaining treatment to state in advance which treatments they wish to refuse if they later lose that capacity and specified clinical conditions arise. AMDs safeguard patient autonomy and help protect patients from ineffective or unnecessary treatment that would merely prolong the dying process. Hong Kong previously relied primarily on the common law. The Advance Decision on Life-sustaining Treatment Ordinance (Cap. 651) (“the Ordinance”), which came into operation on 31 July 2026, establishes a clear statutory framework for making and implementing AMDs and for issuing do-not-attempt cardiopulmonary resuscitation orders.
A. What Treatments May an AMD Cover?
Under the Ordinance, a maker may refuse one or more forms of life-sustaining treatment—that is, treatment that has the potential to postpone death. Examples include cardiopulmonary resuscitation (“CPR”), artificial ventilation, blood products, pacemakers, vasopressors, chemotherapy, dialysis, antibiotics used for a potentially life-threatening infection, and artificial nutrition and hydration.
An AMD cannot be used to refuse basic care, such as offering food or drink by mouth and helping the patient to eat or drink, or palliative care. Nor does it authorise the administration or prescription of a substance for the purpose of ending the patient’s life.
B. When Does an AMD Apply?
An AMD does not take effect immediately upon being made. It applies only when the maker is mentally incapable of deciding on life-sustaining treatment and the specified precondition or preconditions selected in the AMD have been met. The model form in Schedule 2 to the Ordinance covers the following preconditions:
(1) Terminal illness: the patient has an advanced, progressive and irreversible medical condition, with a short life expectancy measured in days, weeks or months, and any form of life-sustaining treatment would only postpone death.
(2) Persistent vegetative state or irreversible coma: the patient has suffered severe brain damage resulting in persistent unawareness and an inability to make any purposeful response. A patient in a persistent vegetative state retains wakefulness and sleep-wake cycles; a patient in an irreversible coma does not. In either case, there is no prospect of regaining the relevant awareness or wakefulness.
(3) Other end-stage, irreversible, life-limiting condition: the patient has a progressive and irreversible condition that has reached its end stage and limits survival, but does not fall within the categories above. Examples may include end-stage renal failure, motor neurone disease, chronic obstructive pulmonary disease or dementia.
C. How Is an AMD Made?
The Government’s model forms are set out in Schedule 2 to the Ordinance and may be downloaded from the Health Bureau website. A non-model form may also be used, provided that its instructions are clearly presented and all statutory requirements are satisfied. In summary:
- The maker must be at least 18 years old.
- At the time of signing, the maker must be mentally capable of deciding on life-sustaining treatment. This means that the maker must be able to understand, retain and use or weigh the relevant information, and communicate the decision.
- The maker must sign in the presence of at least two witnesses. One witness must be a registered medical practitioner in Hong Kong; the other must be an adult. To the best of each witness’s knowledge, neither may be an interested person of the maker.
- The witnessing registered medical practitioner must explain the nature of the AMD and the effect of following each instruction, and must be satisfied that the maker has the requisite mental capacity when signing.
Patients are encouraged to consider an AMD as part of advance care planning and to discuss their wishes with their family and healthcare professionals. Hospital doctors or private registered medical practitioners familiar with the patient’s medical history and condition may assist with the process.
D. How May an AMD Be Revoked?
Consistent with the principle of “cautious making, easy revoking”, a maker who remains mentally capable of deciding on life-sustaining treatment may revoke an AMD at any time by:
- revoking it in writing, whether on paper or in electronic form;
- signing Part 5, if the AMD was made using a model form in Schedule 2;
- personally burning or tearing the AMD, or crossing out its contents and signing each page—or directing an adult, in the maker’s presence, to do so;
- revoking it verbally, or expressing an intention to revoke it by another means (such as nodding, shaking the head or using sign language), in the presence of one or more adult witnesses;
- making another AMD; or
- revoking it through the designated electronic system, personally or through an adult acting in the maker’s presence and at the maker’s direction.
E. Do-not-Attempt Cardiopulmonary Resuscitation Orders
A do-not-attempt cardiopulmonary resuscitation (“DNACPR”) order directs that CPR is not to be performed if the patient suffers cardiopulmonary arrest. It is a clinical order issued only after the patient has reached the relevant clinical condition, and it assists treatment providers and rescuers—including those acting outside a hospital—to identify and follow the decision promptly.
An AMD-based DNACPR order may be issued for an adult whose AMD refuses CPR. It must be issued by two registered medical practitioners, at least one of whom is a specialist. A non-AMD-based DNACPR order may be issued for a minor or an adult who lacks capacity to decide on life-sustaining treatment if the attending doctor and the patient’s family agree that CPR would not be in the patient’s best interests; a responsible person, such as a family member or guardian, must co-sign the order.
Every DNACPR order must be made in writing using the prescribed paper form in Schedule 3 to the Ordinance. There is no electronic DNACPR order. Orders issued before the Ordinance commenced must be replaced using the prescribed form in order to remain valid.
Further Information
Health Bureau:
https://www.healthbureau.gov.hk/en/press_and_publications/otherinfo/241100_adlto/index.html
Jockey Club End-of-Life Community Care Project:
https://foss.hku.hk/jcecc/publication/維持生命治療的預作決定條例/
