Hong Kong’s Advance Decision on Life-Sustaining Treatment Ordinance: Preserving Dignity at Life’s End

Hong Kong, a city renowned for its longevity, took a groundbreaking step on 20 November 2024 by enacting the Advance Decision on Life-Sustaining Treatment Ordinance. This legislation addresses the uncertainties surrounding end-of-life care for its aging population, providing legal clarity and safeguarding individual autonomy during critical medical decisions.

The Significance of the Ordinance

Previously, Advance Directives (ADs) in Hong Kong existed under common law but lacked statutory enforceability. Medical professionals often faced dilemmas when original documents were unavailable or family disputes arose, compelling them to proceed with life-sustaining treatments like resuscitation. The new Ordinance codifies these directives into law, ensuring that Advance Medical Directives (AMDs) are legally binding and streamlining processes for healthcare providers, patients, and families.

Key Provisions of the Ordinance

1. When Does an AMD Take Effect?

An AMD becomes applicable under two conditions (*Section 17*):

- Mental Incapacity: The person is unable to make informed decisions due to impaired mental function (*Section 3(2)*).

- End-of-Life Preconditions: The individual must be in one of three states (*Sections 4–6*):

  - Terminally ill (e.g., late-stage cancer).

  - Persistent vegetative state or irreversible coma (characterized by unresponsiveness despite wakefulness).

  - Other irreversible, end-stage conditions (e.g., motor neuron disease or end-stage organ failure).

2. Scope of Refusable Treatment

The Ordinance permits refusal of life-sustaining treatments, defined as interventions necessary to sustain life, such as mechanical ventilation, dialysis, or artificial nutrition/hydration. However, it explicitly excludes basic care (oral food/water, hygiene) and palliative care (pain relief), which must always be provided (*Section 14*). Importantly, the law prohibits euthanasia, rejecting directives that seek active assistance in ending life.

3. Creating a Valid AMD

- Formal Requirements: AMDs must be written, signed by a mentally capable adult (18+), and witnessed by two individuals, including a registered medical practitioner. Witnesses must not be beneficiaries of the maker’s estate (*Section 10*).

- Flexibility: While prescribed forms are recommended for clarity, they are not mandatory.

4. Storage and Enforcement

Healthcare providers can act on a validating copy of an AMD, including certified physical or electronic versions stored in a designated system (*Section 19*). The law shields providers from liability if they act in good faith based on a duly notified AMD (*Section 22*).

5. DNACPR Orders: Clarity in Emergencies

The Ordinance formalizes Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) Orders:

- For AMD holders, a paper DNACPR Order (issued by two doctors, including a specialist) instructs paramedics and clinicians to withhold CPR during cardiac arrest (*Sections 40, 43*).

- For incapacitated adults without an AMD, immediate family or cohabitees (including same-sex partners in enduring relationships) can request a DNACPR Order, reflecting Hong Kong’s progressive recognition of diverse family structures (*Sections 25, 32*).

6. Revocation: Simplicity Over Rigidity

AMDs can be revoked through written declaration, destruction of the document, or verbal revocation in the presence of one witness (*Section 13*). DNACPR Orders linked to AMDs follow similar revocation rules, while standalone Orders require annotation by two doctors.

7. Transitional Recognition

Existing ADs and DNACPR Orders created before the Ordinance are recognized if they meet new criteria, with Hospital Authority forms presumed valid (*Schedule 1*).

Beyond AMDs: Gaps in Incapacity Planning

While the Ordinance marks progress, it focuses narrowly on end-of-life treatment. Broader incapacity planning—such as appointing someone to manage daily care, finances, or housing—remains unaddressed. Hong Kong lacks legislation for Enduring Powers of Attorney (EPA), which would authorize trusted individuals to make decisions during incapacity. Experts urge citizens to consider complementary tools like EPAs and lifetime trusts to protect their interests and dependants.

Conclusion: A Step Forward, Yet More to Do

The Ordinance empowers Hong kong citizens to assert control over their final moments, balancing patient autonomy with medical ethics. By recognizing cohabitees and modernizing DNACPR protocols, the law reflects societal evolution. However, comprehensive incapacity legislation is still needed. For now, individuals are advised to combine AMDs with estate planning tools to ensure holistic protection. As the population ages, this law is not just about dying with dignity—it’s about living with the assurance that one’s wishes will prevail, even in incapacity.

This article summarizes key aspects of the Ordinance and does not constitute legal advice. Readers should consult professionals for personalized guidance.

香港《維持生命治療的預作決定條例》：守護生命終章的尊嚴

作為全球最長壽的城市，香港於2024年11月20日通過的《維持生命治療的預作決定條例》（下稱《條例》），為應對人口老化需求邁出重要一步。這項立法不僅填補了過往法律空白，更為市民在生命末期的醫療自主權提供了明確保障。

條例的背景與意義

過去，香港雖有「預設醫療指示」（Advance Directives，ADs）的概念，並由醫院管理局（HA）提供特定表格供市民表達拒絕特定維生治療的意願，但其法律效力僅依賴普通法原則，存在模糊地帶。例如，若家屬質疑指示適用性或文件正本無法及時提供，醫護人員仍需繼續急救措施（包括心肺復甦）。新《條例》將普通法原則成文化，明確界定何時可停止治療、保護醫護人員的法律責任，並規範「預設醫療指示」（AMD）的格式與執行程序。

條例核心內容解析

1. AMD何時生效？

根據《條例》第17(1)條，AMD生效需滿足兩大條件：

- 喪失心智決策能力：例如因腦部功能受損而無法權衡治療選擇（第3(2)條）。

- 符合三類「末期狀況」之一（第4–6條）：

  - 晚期絕症（如癌症末期）；

  - 持續植物人狀態或不可逆轉昏迷（定義包含「雖有睡眠覺醒週期，但無法對周遭環境作出有目的反應」）；

  - 其他末期不可逆轉的疾病（如末期腎衰竭、運動神經元疾病）。

2. 可拒絕的治療範圍

《條例》允許拒絕所有「維持生命治療」，即維持生命的醫療措施（如人工營養及水分）。但**基本護理**（如經口餵食、清潔）與**紓緩治療**（如止痛）不得拒絕（第14(1)(a)條）。同時，AMD不可用於要求安樂死或協助自殺（第14(1)(b)–(c)條）。

3. AMD的簽署與存檔

- 簽署要求：須由18歲以上具心智能力者以書面形式訂立，並由兩人見證，其中一人須為註冊醫生，且見證人不得為潛在遺產受益人或保險受益人（第10條）。

- 格式彈性：雖建議使用《條例》附表範本，但非強制性。

4. 執行保障與醫護責任豁免

醫護人員只要知悉「有效副本」（包括實體或電子存檔於指定系統的版本），即可按AMD指示行事（第19條）。若基於合理確信AMD有效而停止維生治療，醫護可免除民事或刑事責任（第22條）。

5. 不作心肺復甦術命令（DNACPR）

- AMD持有者：兩名醫生（其中一名為專科）可簽發紙本DNACPR命令，作為救護員或醫護人員不施行心肺復甦的依據（第40、43條）。

- 無AMD的無行為能力者：其家屬或**同居伴侶**（無論同性或異性，只要為親密關係共同生活者）可與醫生共同簽署DNACPR命令（第25、32條）。此規定被視為香港法律對多元家庭權益的重要認可。

6. 撤銷機制

AMD可透過書面聲明、銷毀文件，或在一名見證人在場下口頭撤銷（第13條）。基於AMD的DNACPR命令撤銷方式相同；非基於AMD的命令則需兩名醫生簽署註銷（第34條）。

7. 過渡安排

《條例》附表1規定，過往的ADs或DNACPR命令若符合新法條件（尤其使用HA表格者），將被推定為有效。

未竟之議：自主權的延伸需求

儘管《條例》賦予市民拒絕維生治療的權利，但其僅適用於特定末期階段。對於更廣泛的「無行為能力規劃」——例如指定代理人決定住所、一般醫療選擇或財務管理——香港尚未立法承認「持久授權書」（Enduring Power of Attorney, EPA）。專家建議市民結合「家族信託」等工具，提前規劃資產與受養人照顧事宜。

結語：尊嚴善終的起點

《條例》的通過，標誌著香港在生命倫理與個人自主權之間取得平衡。通過承認同居伴侶權益、明確醫護責任，法律既呼應社會多元現狀，亦為高齡化挑戰提供解方。然而，完整的無行為能力保障機制仍需完善。對市民而言，訂立AMD僅是第一步，結合遺產規劃與法律諮詢，方能真正實現「生有所護，終有所安」。

本文僅概述條例要點，不構成法律意見。具體情況請諮詢專業人士。

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