Advance Medical Directives

Aims:

An advance medical directives (AMD) allows an adult patient to make instructions in advance for situations where they are mentally capable 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.

Requirements:

The person must be mentally capable and must volunteer to make the advance medical directive.

Constitutionality:

The Advance Decision on Life-sustaining Treatment Ordinance (The Ordinance) was gazetted on 29 November 2024

Formality:

The maker (the person with dementia) should make the advance medical directive in writing, and in front of two witnesses. The witnesses have to sign the advance medical directive. One of the witnesses should be a registered medical practitioners (RMP) who registered in Hong Kong.

1. An advance medical Directive allows an adult patient to make instructions in advance for situations where they are mentally capable 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.
2. 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.
3. 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
   • artificial nutrition and hydration (i.e. the feeding of food and water to a person through a tube)
4. 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).
5. Given that minors and adults who are mentally incapable of deciding on LST cannot make AMDs, registered medical practitioners (RMPs) may make a non-AMD-based do-not-attempt cardiopulmonary resuscitation (DNACPR) 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.
6. Model forms are provided to make AMDs, ensuring that all instructions in the AMD are clearly presented and comply with legal requirements. 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.
7. 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 :
   • 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);
   • Being in a persistent vegetative state and state of irreversible coma; or
   • 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.]
8. As long as the maker is mentally capable of deciding on an LST, he/she can revoke an AMD at any time.

• Everyone has the right to experience natural death with dignity.
• Quality of life, such as feeling at ease and comfortable, is often more important than the length of life to people with terminal illness. However, health care professionals have to provide operations or other treatments in the person's best interests, which may include life-sustaining treatments that are medically futile, possibility resulting in more pain for the person and his or her family members.
• Health care professionals must provide life-sustaining treatments to anyone who is incapable of making decisions for himself or herself if no attorney is appointed and there are conflicting opinions among immediate family members, possibility resulting in more pain for the person and a number of family members.

• You can click here to download the model form of advance medical directive
• An AMD must be made in the presence and signature of two witnesses
• One of the witnesses must be a RMP registered in Hong Kong and not an interested person of the maker
• 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).
• 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.

• 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 at any time
• 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.