Replies to LegCo questions

LCQ1: Advance directives

Following is a question by the Hon Mrs Sophie Leung and a reply by the Secretary for Food and Health, Dr York Chow, in the Legislative Council today (July 8):

Question:

On August 16, 2006, the Law Reform Commission released its report on Substitute Decision-making and Advanced Directives in Relation to Medical Treatment (the Report). The Report examined, inter alia, the giving of instructions by a patient, while he is still competent in making medical decisions, as to the healthcare or medical treatment he wishes to receive if he later becomes incompetent to do so (advance directives). In this connection, will the Government inform this Council:

(a) whether it knows how many patients have, since the release of the Report, made advance directives on their own initiatives, and how many of these directives have been executed by hospitals or doctors; and

(b) whether the Government has, since the release of the Report, allocated resources to help patients and their families understand the rights and responsibilities involved in making advance directives; if it has, of the amount of money spent on such promotional work, as well as the relevant details; if not, the reasons for that, as well as whether it will allocate resources in the foreseeable future to educate the public?

Reply:

President,

Let me first explain the concept of advance directives.

In order to provide patients with the most appropriate treatment that is in their best interests, it is imperative to establish mutual trust and maintain good communication among doctors, patients and their family members throughout the whole treatment process. In case of conflict, a patient's right of self-determination should prevail over the wishes of his relatives, and a doctor's professional decision should always be guided by the best interest of the patient. However, when a patient is terminally ill, in a state of irreversible coma or in a persistent vegetative state, and by medical judgment, all treatment will be futile in improving the condition, the healthcare professionals and family members caring for the patient often encounter the problem of providing the patient with suitable forms of health care or medical treatment.

The Code of Professional Conduct for the Guidance of Registered Medical Practitioners (the Code of Professional Conduct) of the Medical Council of Hong Kong has provided guidelines on the care for the terminally ill. Where death is imminent, it is the doctor's responsibility to take care that a patient dies with dignity and with as little suffering as possible. Withholding or withdrawing life-sustaining treatment taking into account the patient's benefits, wish of the patient and family, and the principle of futility of treatment for a terminal patient, is legally acceptable and appropriate. It is important that the right of the terminally ill patient be respected. The view of his relatives should be solicited where it is impossible to ascertain the views of the patient. The decision of withholding or withdrawing life support should have sufficient participation of the patient himself, if possible, and his immediate family, who should be provided with full information relating to the circumstances and the doctor's recommendation.

Under the common law, an individual may, while mentally competent to make decisions or take actions, give directions as to the future medical treatment that he wishes to receive when he is no longer mentally competent to make such decisions. Such directions are known as "advance directives". An individual who makes an advance directive usually makes a written statement to specify that, when he is terminally ill, in a state of irreversible coma, or in a persistent vegetative state, save for basic and palliative care, he can choose not to receive any life-sustaining treatment or any other treatment he has specified, such as cardiopulmonary resuscitation, or to specify the withholding or withdrawal of futile treatment which merely postpones his death, such as artificial ventilation, so as to minimise distress or indignity that he may suffer and to spare the healthcare professionals or relatives or both from the burden of making difficult decisions on his behalf. The concept of advance directive is derived from the belief in a person's autonomy in healthcare decisions and the principle of informed consent.

I must emphasise that advance directives and euthanasia are two distinct concepts. Advance directives concern the principle of a patient's autonomy which allows him to decide, when being conscious, the form of health care he would like to have in a future time when he is no longer mentally competent. Euthanasia involves a third party's unlawful acts of intentional killing, manslaughter, or aiding, abetting, counselling or procuring the suicide of another, or an attempt by another to commit suicide, which are unlawful in Hong Kong. The Code of Professional Conduct of the Medical Council of Hong Kong defines euthanasia as "direct intentional killing of a person as part of the medical care being offered". Euthanasia is neither medically ethical nor legal in Hong Kong. Hence, no one in Hong Kong can indicate a wish to perform euthanasia in his advance directive. Even if a person expressly requests for such an illegal behaviour to be conducted, healthcare professionals should in no way act as instructed. Any person who is involved in euthanasia will be suspected to have committed the above offences.

I now proceed to reply each part of the question:

(a) The Hospital Authority (HA) issued the Guidelines on Life-sustaining Treatment in the Terminally Ill (the Guidelines) in 2002 based on the Code of Professional Conduct with a view to assisting frontline doctors, nurses and other healthcare professionals caring for the terminally ill in making decisions with respect to life-sustaining treatment for the terminally ill. The healthcare professionals of HA have all along followed the Guidelines and maintain communication with the terminally ill patients and their family members having regard to the development of the health conditions of the patients. When a doctor considers that withholding or withdrawing life support is in the best interest of the patient, the doctor will involve the patient, if possible, and his immediate in making the decision. According to the information provided by HA, so far no patient treated or received healthcare services in hospitals under HA have shown advance directives to the healthcare professionals, nor has there been any patient initiated the making of an advance directive.

(b) We share the view of the Legal Reform Commission (LRC) in its report entitled Substitute Decision-making and Advanced Directives in Relation to Medical Treatment (the Report) published in August 2006 that Hong Kong people are not yet familiar with the concept of advance directives. As such, it is not the appropriate time to implement advance directives at this stage through any form of legislation. Having considered the Report's recommendation to promote advance directives through non-statutory means, we plan to work with HA and the Department of Health to promote the concept of advance directives and consult healthcare sector (including the Medical Council of Hong Kong), legal profession, patient groups and non-government organisations providing healthcare-related services for patients this year. Information materials on advance directives will be prepared and distributed to the public through these bodies and organisations. Relevant information will also be made available to the public at hospitals, healthcare institutions, etc. Moreover, we will consult the healthcare and legal sectors on the need to issue guidelines on the making and handling of advance directives. The relevant work will be done by the existing staff of the Food and Health Bureau, and we have not yet estimated the resources required at this juncture.


Ends/Wednesday, July 8, 2009
Issued at HKT 13:23

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