Hong Kong’s end-of-life law raises concerns over emergency care, affordability

Formal legal framework will empower Hongkongers to specify in advance which life-sustaining treatments they wish to refuse when terminally ill The Hospital Authority's Doris Tse says ambulance workers have clear guidelines on how to handle emergencies under the new law. Photo: Dickson Lee Hong Kong’s new legislation on end-of-life directives could create significant operational challenges, including verifying patients’ wishes in emergencies and affordability barriers for low-income families, according to frontline responders and patient advocates. The warnings come a week before the Advance Decision on Life-sustaining Treatment Ordinance takes effect next Friday. Under the law, a formal legal framework will empower Hongkongers to specify in advance which life-sustaining treatments they wish to refuse when terminally ill. Sherman Wong Chun-man, chairman of the Hong Kong Fire Services Department Ambulance Officers Association, warned that frontline workers may encounter practical difficulties in implementing the ordinance. He noted that ambulance crews often faced split-second, life-or-death decisions upon arrival at emergency sites, with limited or incomplete information. “Even when the relevant documents are present on site, ambulance personnel must still assess whether they apply based on the patient’s actual clinical condition at that moment,” he said. He added that if a patient has executed the relevant documents, families should present the originals or valid proof to enable quicker verification of their validity and applicability. An advance medical directive allows a mentally capable adult to refuse specified life-sustaining treatments in the future, such as cardiopulmonary resuscitation (CPR), artificial ventilation, pacemakers or other interventions. It takes effect only when the patient loses their mental capacity and reaches a defined clinical condition, such as a persistent vegetative state. A directive must be signed in the presence of two witnesses, one of whom must be a doctor. It can be presented in paper form or electronically via eHealth, the official health record mobile application. It remains valid unless the patient revokes it while he or she still possesses the mental capacity to do so. Directives made before the law takes effect will continue to be valid if they meet legal requirements and clearly present all instructions. However, patients are advised to review them regularly with their doctors. Tim Pang of the Society for Community Organization says low-income families may struggle to afford advance directives outside public hospital settings. Photo: Karma Lo Tim Pang Hung-cheong, a patients’ rights advocate with the Society for Community Organization, said that low-income families may struggle to afford advance directives outside public hospital settings. Unhandled type: inline-plus-widget {"type":"inline-plus-widget"} “It is difficult for low-income families to afford such directives as the fees can reach several thousand dollars,” he said. He suggested the government provide subsidies, stressing that this would be a form of social service. Pang also noted that older people – particularly those living alone or in elderly-only households – may find it difficult to use digital systems and continue to rely on paper documents. However, physical copies can be hard to locate in emergencies, creating practical challenges in real-life situations, he said. Under the law, advance directives can only be revoked by the mentally capable adults who made them. Healthcare professionals, family members, cohabitants, guardians and friends are not permitted to do so. Meanwhile, overseas studies, such as in Germany, have shown that relatives find it challenging to align their own wishes with those of patients who signed advance directives. Dr Doris Tse Man-wah, chairwoman of the Hospital Authority’s clinical ethics committee, said healthcare professionals could honour advance directives or do-not-attempt cardiopulmonary resuscitation (DNACPR) orders only if three strict conditions were met. First, medical staff must be aware of the document’s existence, and second, the file itself must be intact and properly executed. Finally, the patient must have lost mental capacity while simultaneously meeting specified clinical criteria, such as being terminally ill. “If healthcare professionals are in doubt, their priority should be saving lives,” Tse said. “There is no time to be a detective in an emergency.” She said ambulance workers had clear guidelines on how to handle the emergencies. “I’m not worried that they will take shortcuts and pretend not to see any [signed directives],” she said. “If they intentionally ignore the directives and perform CPR, they are also legally liable.” Jang Chun-kit, chairman of the Hong Kong Fire Services Department Ambulancemen’s Union, welcomed the ordinance and said the authorities had launched internal training as early as July last year. He said that the programme went beyond simply explaining legal clauses and procedures to incorporate situational simulations and case discussions to complement the guidelines. Jang added that the department had disseminated updated information and used real-life cases as teaching material to reinforce understanding, ensuring frontline workers not only knew “what to do,” but also “how to do it” and “how to execute it accurately and efficiently.” He said clear guidelines were in place for frontline staff, and if there was any uncertainty, saving lives would always come first.