Advance Care Planning in Hong Kong Care Homes

What advance care planning means in a care home

Advance care planning is a series of conversations, not a form. It begins with what matters to the resident — how much treatment they would want, what they would most want to avoid, who should speak for them — and it continues as their health changes. A care home meets it in the ordinary course of work: at admission, after a hospital discharge, when a diagnosis changes, and on the afternoon a daughter asks a question that nobody has answered.

The documents that come out of those conversations do different jobs, and staff who treat them as one thing give the wrong answer at the wrong moment.

Two boundaries are worth stating plainly, because families raise them. An advance medical directive is not euthanasia and cannot ask for anything that ends life; it refuses treatment, and it cannot refuse basic care — food and drink offered by mouth, and help with eating and drinking — or palliative care. Nor is it a permission to stop caring: a named treatment is withheld while comfort care continues. The financial document is a different instrument altogether, and registering an enduring power of attorney is a separate process before a different court.

For scale: the Hospital Authority recorded 1,788 advance medical directives and 4,876 DNACPR orders in 2024, according to a Legislative Council reply of 30 April 2025. Which is why the conversation, and not the form, is where a home starts.

What Hong Kong law requires, and since when

Hong Kong legislated in 2024 and switched the law on in 2026. The Advance Decision on Life-sustaining Treatment Ordinance (Cap. 651) was passed by the Legislative Council on 20 November 2024, gazetted on 29 November, and its main provisions came into operation on 31 July 2026, as the commencement announcement records. Before that date an advance directive rested on the common law and on Hospital Authority practice; the HA has been facilitating them for its patients since 2010.

Under the Ordinance a directive may be made only by an adult who is mentally capable of deciding on life-sustaining treatment. It names the treatments refused — cardiopulmonary resuscitation, artificial ventilation, dialysis, antibiotics given for a life-threatening infection, artificial nutrition and hydration, among others — and the clinical condition in which the refusal operates: terminal illness, persistent vegetative state or irreversible coma, or another end-stage, irreversible, life-limiting condition described in the document. The Health Bureau publishes the forms and a set of questions and answers on exactly these points.

The making requirements are formal, and a home should know them because families ask. The directive must be signed in the presence of two witnesses, neither of whom may be an interested person, and one of whom must be a registered medical practitioner. That doctor must be satisfied the maker is mentally capable, must have explained the nature of the directive and the effect of each instruction, and must declare in the document that both were done. The Ordinance supplies model forms in Schedule 2 but does not require them: a directive in another format can be valid where its instructions are clear and the statutory conditions were met. Hospital Authority forms signed before commencement are grandfathered.

It applies narrowly. A directive has effect only when the maker has lost the mental capacity to decide on life-sustaining treatment and the specified precondition in the directive is met. It does not apply where there are reasonable grounds for believing that circumstances have arisen which the maker did not anticipate and would probably not have made that instruction had they foreseen them. It cannot refuse basic care or palliative care, and it cannot request anything that ends life.

A do-not-attempt cardiopulmonary resuscitation order is a separate instrument with separate formalities. It must be on the prescribed form in Schedule 3, and an order in any other form is invalid; there is no electronic version. An order that rests on a directive must be issued by two doctors, at least one a specialist. An order that does not rest on one is for a minor or a mentally incapable adult, is made by the attending doctor when the doctor and the family agree that CPR would not be in the patient's best interests, and must be co-signed by a responsible person.

Who is in the room, and who decides

Four parties, four different jobs, and the Ordinance gives the decision to only one of them.

The resident decides. The directive is the resident's own instrument, made while they are capable, and it is not a family agreement. A son or a daughter cannot sign it, cannot sign it on the resident's behalf, and cannot overrule it afterwards.

The doctor certifies and witnesses. Because one witness must be a registered medical practitioner, the home's nurse or health worker cannot take that role, however well they know the resident and however long they have cared for them. What the home can do is make sure the doctor has what the statutory judgement needs: the recent changes, the resident's own words, what the family has been told, and an interpreter if the conversation is not in a shared language.

The family supports, and is not a party to the signature. That does not make them spectators. The Ordinance's safeguards assume the maker has discussed the decision with the people who will live with it, and a family that has been in the conversation from the start is far easier to work with at three in the morning than one that meets the document for the first time in a crisis.

The home arranges and records. The Social Welfare Department's reference guideline on end-of-life care in residential care homes expects a multi-disciplinary process with each discipline's role written down, a care plan built with the resident and the family, and staff trained in the legal provisions and in talking about dying. In practice the home contributes the room, the time, the continuity and the note afterwards. One boundary: a decision to use restraint, or to stop using it, is a different decision recorded on a different form, and the restraint guidance is the place for it, not this article.

The document set, and where it is kept

A directive that nobody can find is not a directive. The Ordinance is explicit that a directive is not valid where the treatment provider does not have notice of it. Notice means a validating copy — the original paper directive, a certified true copy, or a copy stored in eHealth — and for a DNACPR order, the original or a certified true copy only, because there is no electronic version of the order.

For a care home, that turns filing into a clinical act. The Hospital Authority provides a standard pouch for the directive, the order and the care plan, and its current clinical guidelines expect patients and families to present the copies rather than rely on anyone searching for them; they state that treatment providers are generally under no obligation to search a patient's belongings. A home that keeps the documents in one known folder, flags them at every handover, and sends a validating copy with the resident to hospital is doing the part of this that belongs to it.

The rest of the record is already required. The current edition of the Code requires an individual care plan within one month of admission and a first review six months later, then reviews at least annually or when the care needs change (paragraphs 12.3.1 and 12.3.2). It lists what the plan must contain (12.3.3) and requires a personal health and nursing record covering hospital admissions and discharges and medical consultations (12.5). What the Code does not contain is an advance directive procedure; that comes from Cap. 651 and the department's end-of-life guideline. The obligations chapter by chapter, and how an inspection uses them, are set out in the care home Code of Practice in Hong Kong; the wider record set is in care home documentation.

And nobody annotates the directive on the resident's behalf. A resident may revoke by crossing out the contents and signing each page; that is a revocation, and it is recorded as one. What the Ordinance treats as an offence is a third party obstructing or misleading: altering, concealing or replacing a page so that a treatment provider does the opposite of what the resident decided, and the HA guidelines list tampering and falsification among that conduct. If a document looks wrong, the answer is to preserve it as it is and escalate, not to tidy it.

When the directive is reviewed, and when it is revoked

A directive does not expire, but it can go stale. Nothing in Cap. 651 requires a care home to review one on a timetable, and nothing in the Code of Practice mentions directives at all; the discipline has to come from the home. The obvious place to attach it is the review cycle the Code already imposes on the care plan: made within a month of admission, first reviewed six months later, then at least annually or whenever the care needs change.

A home that reviews the care plan without opening the directive has done half the job, because the two documents answer the same question from opposite directions: what are we trying to achieve for this resident, and what has the resident already refused? Record the review even when nothing changes. The date, who was present, what was asked and what the resident said are worth more than a blank space in a file, and they are the only evidence that the document was looked at rather than inherited. Where the resident no longer has capacity, the review is a check that the named condition still matches the clinical picture, and the note should say so.

Revocation is deliberately easy, and this is where care staff matter most. A resident may revoke in writing, by destroying the document, by making a new one, through eHealth, or orally in front of one or more adult witnesses. A sentence in a corridor, heard by two care workers, can revoke a directive that a doctor signed. The HA guidance asks patients to tell their doctor as soon as practicable so that records and the electronic copy can be updated, and where a family reports a revocation only after the resident has lost capacity, the doctor is advised to presume it was made while the resident was capable unless the contrary is proved. Staff who write down the words, the time and who was present are not creating paperwork; they are preserving the only evidence there will ever be.

One thing a directive is not: a medication order. Medication management continues on its own record, and a refusal of antibiotics for a life-threatening infection does not touch the eye drops, the laxative or the antihypertensive on the drug round.

The events that make a directive stale are, in a care home, ordinary ones:

• Admission to the home, when the resident's circumstances and the people around them change.
• Any hospital admission or discharge, because the discharge summary may carry a new prognosis, a new order or a new directive.
• A change of diagnosis or prognosis, or a decline that brings the named condition closer than it was.
• A loss of mental capacity, or a recovery of it.
• A new DNACPR order, or the revocation of one.
• A request from the resident, at any time, for any reason at all.

When a directive is questioned, or a resident dies in the home

When a directive is questioned, the staff role is to stop and escalate, not to adjudicate. The HA guidelines set the presumptions plainly: in an emergency, and where there is doubt, life-sustaining treatment should be provided until proof of the directive or the order is available. A valid and applicable directive cannot be overruled by family members, significant others or an appointed guardian. Where the doubt concerns the document itself — a page that looks altered, a signature that does not match, an instruction typed over — the guidelines list wilful obstruction, tampering and falsification among conduct that may amount to an offence. Preserve the document, do not copy it further, and report it.

Dying in the home has become a simpler event than it was, and the detail matters at three in the morning. Since 3 June 2024, a death in a residential care home for the elderly is not a reportable death to the Coroner where three conditions are met: the resident was diagnosed with a terminal illness while alive, was attended by a registered medical practitioner within the 14 days before death, and the certificate of cause of death states a natural cause. The Government set that out when it gazetted the commencement of the two notices; the SWD guideline describes the arrangement as applying to care homes other than nursing homes.

The department's guideline also sets the sequence for the night itself: arrange for a registered medical practitioner to attend and certify, arrange direct transfer to a funeral parlour rather than calling an ambulance, support the family, and give staff the chance to debrief. None of that is a treatment decision, and all of it depends on the papers being where the night staff can find them.

Nothing in this article is a product recommendation, and no device changes whether a directive is honoured. Two things in our own group touch the edges of this work: Easikin is an SI（Superintelligence）· AI（artificial intelligence）assistant for adult children coordinating a parent's care, which is often where these conversations begin, and Steadicore is room-level sensing that leaves a timestamped record of movement — a record, not a clinical judgement.