Hong Kong’s Advance Decision on Life-sustaining Treatment Ordinance will take effect on July 31. The law allows patients to refuse certain life-sustaining treatments in advance if they become terminally ill and lose the mental capacity to make decisions. The Legislative Council approved the measure in November 2024.

The legislation covers two separate instruments: advance medical directives and do-not-attempt cardiopulmonary resuscitation orders, known as DNACPR orders. Both have been used in Hong Kong’s public hospitals under common law since 2010. The ordinance now establishes a specific legal framework and protects healthcare professionals and emergency responders who comply with valid patient instructions.

Through an advance directive, individuals can specify in writing which treatments they do not wish to receive if their condition deteriorates to the point that they can no longer decide for themselves. These treatments may include cardiopulmonary resuscitation, blood transfusions, artificial nutrition and artificial hydration. An advance directive does not constitute a general refusal of medical care and may be activated only in circumstances defined by law.

The first qualifying circumstance involves a patient in the terminal stage of an advanced and irreversible medical condition, with an estimated life expectancy of days, weeks or months. The second covers a persistent vegetative state or irreversible coma. The third applies to other irreversible, end-stage conditions that limit life expectancy, including end-stage renal failure and dementia.

Loss of decision-making capacity alone is therefore insufficient to activate a directive. Dr Doris Tse Man-wah, chairwoman of the Hospital Authority’s clinical ethics committee, told the South China Morning Post that car accidents and other acute illnesses do not meet the criteria established by the legislation. Advance instructions apply only when at least one of the three qualifying conditions is present.

A DNACPR order has a narrower scope than an advance medical directive. It instructs healthcare personnel not to attempt cardiopulmonary resuscitation if a qualifying patient experiences cardiopulmonary arrest. The document is also intended to give emergency responders clear instructions outside hospitals, where a doctor or other healthcare professional may not be present.

Only mentally capable adults may prepare an advance directive. It must be made in writing, and patients may use government-recommended forms designed to provide clear instructions and ensure compliance with legal requirements. The document must be signed in the presence of at least two witnesses, one of whom must be a registered doctor.

Directives may remain on paper and can also be stored electronically through Hong Kong’s eHealth platform. The government plans to allow users to sign them directly through the digital system at a later stage, although no implementation date or technical procedure has yet been announced.

The ordinance also addresses the responsibilities of care providers. Doctors, other healthcare professionals and emergency responders will receive legal protection when acting in accordance with valid directives. This is particularly important for DNACPR orders applied outside hospitals, where responders must be able to establish quickly whether a patient’s instructions exist and are legally valid.

When the ordinance takes effect on July 31, Hong Kong will place practices already used for years in its public healthcare system on a statutory footing. Attention will now turn to how directives are applied during out-of-hospital emergencies and integrated with eHealth, as well as to any additional operating protocols for healthcare facilities, doctors and emergency response teams.