Subject: health services, end-of-life care

Recent policy developments of advance directives in Hong Kong

Policy developments of advance directives in the United States


  • ADs in Hong Kong are implemented through administrative measures at present, while the legislative approach in the US provides more certainty to the legal status of ADs made by the general public on end-of-life care before medical crises. As a complementary measure in the US, POLST can meet the specific needs of terminally-ill patients due to the endorsement of treating doctors. Also, POLST provides legal immunity to paramedics for withdrawing resuscitation under emergency.

Prepared by Germaine LAU
Research Office
Information Services Division
Legislative Council Secretariat
6 June 2019


1.Centre for Health Protection (2019).

2.In some places, the AD may refer to a document which includes various decisions related to end-of-life care (most notably the appointment of a substitute decision maker and donation of organs) on top of the decision to refuse life-sustaining treatments. However, official documents in Hong Kong usually use the narrow definition (i.e. treatment refusals), which was commonly known as a "living will" in America. See Law Reform Commission (2006).

3.GovHK (2012).

4.Legislative Council Secretariat (2018).

5.Legislative Council Secretariat (2019).

6.As at 2018, at least 17 out of 28 member states of European Union had specific legislation on ADs. Other advanced countries with such legislation include Australia, Canada, Singapore and the United States. See Irish Hospice Foundation (2016), Nys et al. (2013) and Sulmasy (2018).

7.Most Western European countries reported the prevalence of advance directives in the range of 10%-20% among the general population. For English-speaking countries, the uptake rates were 4% for England in 2013 and 14% for Australia in 2014. See Government Accountability Office (2019), Kitzinger et al. (2016) and White et al. (2014).

8.Centre for Health Protection (2019).

9.Chung et al. (2017) and Luk (2018).

10.Chinese University of Hong Kong (2018).

11.Hospital Authority (2016).

12.A shorter AD form containing only the refusal of cardiopulmonary resuscitation ("CPR"), a common and invasive life-sustaining treatment, was introduced in 2014 to "help reducing the psychological stress that may arise from signing the more complex full AD form". See Hospital Authority (2015b).

13."Other end-stage irreversible life-limiting conditions" include (i) end-stage renal failure, end-stage motor neuron disease, and end-stage chronic obstructive pulmonary disease which do not fall into the category "terminally ill" because life can be prolonged by dialysis or assisted ventilation; and (ii) irreversible loss of major cerebral function and extremely poor functional status. See Hospital Authority (2014).

14.The Hospital Authority ("HA") revised its Guidelines on Life-sustaining Treatment in the Terminally Ill to include the concept of advance care planning to engage patients and their families in discussion of end-of-life decisions in 2015. See Hospital Authority (2015a).

15.GovHK (2019).

16.Chung et al. (2017).

17.Legislative Council Secretariat (2018) and Tse (2018).


19.Hospital Authority (2016).

20.GovHK (2012).

21.Institute of Medicine of the National Academies (2014).

22.The percentage of Medicare expenditures spent on patients in their last year of life increased from 26.5% in 1994 to 27.9% in 1999. See Calfo et al. (2004).

23.Massachusetts, Michigan, and New York chose to legislate only for appointment of substitute decision-makers, but advance directives can still be valid under common law. See Sabatino (2007).

24.On top of that, the Act directed the Department of Health and Human Services to conduct a public awareness campaign for ADs and oversee compliance by health facilities. See Department of Health and Human Services (2008).

25.While ADs in different formats may also be recognized, the statutory standard form is widely perceived as the safe way to ensure the validity of ADs. In addition, some states impose limitations on implementing the AD if the patient is pregnant. See Hannibal (2019) and Sabatino (2007).

26.Most states require two adult witnesses while the qualifications vary. Most commonly disqualified as witnesses are the appointed substitute decision-maker and the treating health care provider. See Sabatino (2007).

27.Many statutory forms also cover donation of organs and designation of a primary doctor. See California Department of Justice (2019).

28.Government Accountability Office (2019) and Pew Research Centre (2006 and 2013).

29.Department of Health and Human Services (2008) and Government Accountability Office (2015 and 2019).

30.National POLST Paradigm (2019).

31.Office of National Coordinator for Health Information Technology (2018).

32.Oregon Health and Science University (2014).


Hong Kong

1.Centre for Health Protection. (2019) Number of Deaths by Leading Causes of Death, 2001 - 2018.

2.Chinese University of Hong Kong. (2018) CUHK Pioneers in Developing Standardised Tests for Screening Cognitive Impairment in the Ageing Population in Hong Kong.

3.Chung, R. et al. (2017) Knowledge, Attitudes, and Preferences of Advance Decisions, End-of-Life Care, and Place of Care and Death in Hong Kong. A Population-Based Telephone Survey of 1067 Adults. Journal of the American Medical Directors Association, 18(4), April, pp. 367.e19-367.e27.

4.Food and Health Bureau. (2009) Introduction of the Concept of Advance Directives in Hong Kong.

5.GovHK. (2012) LCQ1: Advance directives.

6.GovHK. (2019) LCQ15: Advance directives in relation to medical treatment.

7.Hospital Authority. (2014) Full HA AD Form.

8.Hospital Authority. (2015a) Guidelines on Life-Sustaining Treatment in the Terminally Ill.

9.Hospital Authority. (2015b) Q&A on DNACPR.

10.Hospital Authority. (2016) Guidance for HA Clinicians on Advance Directives in Adults.

11.Law Reform Commission. (2006) Report on Substitute Decision-making and Advance Directives in Relation to Medical Treatment.

12.Legislative Council Secretariat. (2018) Report of Joint Subcommittee on Long-term Care Policy. LC Paper No. CB(2)852/17-18 Annex I.

13.Legislative Council Secretariat. (2019) Panel on Health Services - List of outstanding items for discussion (position as at 10 April 2019). LC Paper No. CB(2)1167/18-19(01).

14.Luk, JK. (2018) End-of-life services for older people in residential care homes in Hong Kong. Hong Kong Medical Journal, 24(1), February, pp. 63-67.

15.Tse, CY. (2018) Advance Care Planning and Advance Directives in Hong Kong: Concepts and Developments.


United States

17.Calfo, S. et al. (2004) Last Year of Life Study.

18.California Department of Justice. (2019) Advance Health Care Directive Form.

19.Department of Health and Human Services. (2008) Advance Directives and Advance Care Planning: Report to Congress.

20.Government Accountability Office. (2015) Advance Directives: Information on Federal Oversight, Provider Implementation, and Prevalence.

21.Government Accountability Office. (2019) Advance Care Planning - Selected States' Efforts to Educate and Address Access Challenges.

22.Hannibal, B. (2019) State Laws on Pregnancy and Health Care Directives.

23.Institute of Medicine of the National Academies. (2014) Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.

24.National POLST Paradigm. (2019) About POLST.

25.Office of National Coordinator for Health Information Technology. (2018) Electronic Access to POLST Documentation through HIE.

26.Oregon Health & Science University. (2014) POLST orders successfully guide end of life medical treatment.

27.Pew Research Center. (2006) Strong Public Support for Right to Die.

28.Pew Research Center. (2013) Views on End-of-Life Medical Treatments.

29.Sabatino, C. (2007) Advance Directives and Advance Care Planning: Legal and Policy Issues.


30.Irish Hospice Foundation. (2016) Advance healthcare directives.

31.Kitzinger, J. et al. (2016) Increasing understanding and uptake of Advance Decisions in Wales.  

32.Nys, H. et al. (2013) Rights, autonomy and dignity of people with dementia: competence assessment and advance directives.

33.Sulmasy, D.P. (2018) Italy's New Advance Directive Law: When in Rome. JAMA Intern Med, 178(5), May, pp. 607-608.

34.White, B. et al. (2014) Prevalence and predictors of advance directives in Australia. Internal Medicine Journal, 44(10), October, pp. 975-980.

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