How does Hong Kong’s new end-of-life law affect patients and medical staff?

A new law allowing patients in Hong Kong to reject life-sustaining treatments when they are terminally ill will take effect on Friday. The South China Morning Post looks into how the law will affect patients and healthcare professionals. What is the new law about? The Advance Decision on Life-sustaining Treatment Ordinance will come into effect on July 31, following its passage by the Legislative Council in November 2024. The law gives patients the power to reject certain life-sustaining treatments when they are terminally ill and mentally incapable of making decisions. It also provides legal protection to healthcare professionals and rescuers who honour these medical directives. What is an advance medical directive and DNACPR order? Both documents are key instruments in end-of-life care, and have been in place in public hospitals since 2010 under common law. An advance medical directive allows a patient to make instructions in advance on what life-sustaining treatments - such as CPR, blood transfusion, artificial nutrition and hydration - they do not wish to receive when their health deteriorates. The ordinance specifies three conditions that could trigger the directive to come into effect. It applies when the patient is terminally ill after an advanced and irreversible medical condition and is expected to live for days, weeks or months. It also applies when the patient is in a persistent vegetative state or an irreversible coma. A third situation is when the patient has other end-stage, irreversible and life-limiting conditions, such as end-stage renal failure or dementia. However, accidents such as car crashes and other acute illnesses do not fall within the criteria for triggering the directive, according to Dr Doris Tse Man-wah, chairwoman of the Hospital Authority's clinical ethics committee. A do-not-attempt cardiopulmonary resuscitation (DNACPR) order specifically covers the refusal of CPR for patients who meet the three specified conditions and suffer cardiopulmonary arrest. The order aims to give clear instructions to rescuers in non-hospital settings when healthcare professionals are not present. An advance medical directive can be made in paper form and stored electronically on the city's eHealth platform. The government also plans to allow people to sign the directive directly on the electronic platform at a later stage. The maker of the directive must sign it in the presence of at least two witnesses, one of whom must be a registered doctor. A DNACPR order can also be made for people who have specified that no CPR should be given as their death approaches. In this case, the order must be signed by two doctors, one of whom must be a specialist. Adults who are mentally incapable and children cannot make advance medical directives. However, doctors may issue a DNACPR order for such patients if they and the patient's family members agree that attempting CPR would not be in the patient's best interests. For a child or a mentally incapable adult, the DNACPR order must be signed by two doctors, including a specialist. It also requires a responsible adult, such as a family member, neighbour, or close friend, to agree with the decision and co-sign. A DNACPR order must be issued in a statutory form and is valid for a maximum of one year. An advance medical directive does not have an expiry date unless it is amended or revoked by the maker. What if family members do not agree? Patients can revoke their advance directive when they are mentally capable. Other people, such as healthcare professionals, family members, cohabitants or friends, cannot revoke the order. "We hope that following discussions on advance care planning, patients can clearly express their wishes and family members will also understand," Tse said. She said that even if a patient's decision in the directive might not be in their best interests, instructions made in a valid directive should be followed. Can patients revoke the directive or the order? Mentally capable patients can revoke the directive at any time. They may destroy the paper document, revoke it in writing, sign the revocation section in the directive, cross out the relevant content and sign on each page or verbally revoke the directive in the presence of an adult witness. "It is OK to change your mind, but patients should let healthcare professionals know as early as possible," Tse said. "If you want to revoke the directives, better destroy everything … or else you cannot rule out that someone might use fragmented documents [as your directive]." Are healthcare professionals liable for non-compliance? The legislation will protect healthcare professionals from legal liabilities if they comply with a valid directive. Tse said they would also be held liable if they intentionally ignored the directive. "If you know that a patient has a valid directive and still proceed to perform CPR, you would bear legal responsibility," she said. The Fire Services Department, which operates the city's emergency ambulance service, said that if paramedics could not verify the documents on-site, they would carry out life-saving measures based on the "if in doubt, rescue first" principle. According to the ordinance, a person who wilfully obstructs a healthcare worker in following another person's advance directive is liable to a fine of HK$50,000 (215,000 baht) and imprisonment for six months. Related story: Choice at life's end