Advance Directive

By planning in advance, the patient can express their treatment preferences. Advance directives help reduce confusion and disagreements on medical care. 

In Hong Kong, a mentally competent patient aged 18 and above can make an AD. This is for the patient to explicitly express their wish to refuse specified life-sustaining treatment (LST) in pre-specified conditions when they are in an end-stage condition and mentally incapable of making health care decisions.

A valid and applicable AD is legally binding under common law.

The life-sustaining treatment (LST) could be very painful to both the patient and the family especially for the advanced cancer patients. For example, the advanced cancer patients who receive Cardiopulmonary Resuscitation (CPR) may have higher risk to experience the rib and sternal fractures and the pain. In this case, the patient and the family may have different views on life as well as LST. If they can manage any disagreement through open communication with the medical clinicians as early as possible, it not only acknowledges the patient’s wish, but also ensures the patient’s right to a peaceful death. This is also the important step to respect and express true love to the patient and their family members.

• Case 1: “Terminally ill” 
  • Suffering from an advanced, progressive and irreversible disease such as advanced cancer. 
  • Having a short life expectancy in terms of days/weeks/few months and the application of LST would only serve to postpone the moment of death.
• Case 2:  “In a persistent vegetative state or a state of irreversible coma” 
• Case 3: “Other end-stage irreversible life limiting condition” 
  • Not belonging to Case 1 or Case 2, but has reached the end stage of the condition, limiting survival of the patient. 
  • Examples include: (i) patients with end-stage renal failure, end-stage motor neuron disease, or end-stage chronic obstructive pulmonary disease who may not fall into the definition of terminal illness in Case 1, because their survival may be prolonged by dialysis or assisted ventilation, and (ii) patients with irreversible loss of major cerebral function and extremely poor functional status who do not fall into Case 2.

• The law of Hong Kong does not require an AD to be made in a specified format. However, an AD form is designed for use by the Hospital Authority (HA) patients. 
• Link of the AD form:
  • Full Advance Directive Form (Appendix 1) 
• Discuss with clinicians first if the patient wants to revise the form/use the other forms/format to express their wish or make the AD form applicable to other conditions.
  • The HA AD form must be signed by the patient and two witnesses.
  • Patient must be at least 18 and competent to make informed decision.
  • One of whom must be a medical practitioner in Hong Kong. Neither witness should have an interest in the estate of the person making the AD. 
  • The patient and family have the responsibility of keeping it, and presenting the original copy to the clinicians on the patient’s admission. 
  • The patient can change his/her mind after making an AD.

Even if the patient has already made an advance directive, they may, as long as remaining mentally competent, alter or revoke the advance directive they made at any time. Once the patient has made a new, valid advance directive, the new one will replace the old one. The patient should keep their healthcare professionals and family informed of any amendment or revocation. 

• For clarity and avoidance of doubt, revocations of advance directives should be made in writing and follow the model form proposed by the Government (click here to download the Government’s proposed revocation form).
• If the revocation is made in writing, it should be made in the presence of a person aged 18 or above and who has no interest in the patient’s estate.
• If the revocation is made verbally, it should be made in the presence of a doctor, a lawyer or other independent person, aged 18 or above, who has no interest in the patient’s estate. If practical, the witness should document the verbal advance directive using the model form proposed by the Government (click here to download the form).
• Once the original advance directive is revoked, a new directive may be made according to the aforementioned procedures.

Note that, even if the patient has not revoked his/her directive, if their subsequent acts give healthcare professionals real reason to doubt the original directive and suggest that they may have changed their mind, they may consider the directive to be revoked.

Hospital Authority: Advance Care Planning (ACP)? Advance Directives (AD)? Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR)? Patients and families should know more!

Videos

▶️ Jockey Club End-of-Life Community Care Project: Hospice Home - Advance Directive (Chinese version only)