Living Will / Advance Healthcare Directive (Pakistan)

A Living Will / Advance Healthcare Directive in Pakistan records a person's wishes about future medical treatment for use if they later lose capacity to decide, resting on the common-law right to refuse treatment and informed-consent principles rather than a dedicated statute.

Pakistan does not yet have a dedicated Advance Healthcare Directive Act or Living Will legislation comparable to the statutes enacted in the United Kingdom (Mental Capacity Act 2005), Australia, or Canada. The legal framework for living wills in Pakistan is derived from the general principles of the Contract Act 1872 (governing voluntary, freely given declarations), the common law principle of informed consent developed through Pakistani courts, the Code of Medical Ethics issued by the Pakistan Medical and Dental Council (PMDC) established under the Pakistan Medical and Dental Council Ordinance 1962, and the ethical guidelines of the College of Physicians and Surgeons Pakistan (CPSP).

The Pakistan Medical and Dental Council (PMDC) — now restructured as the Pakistan Medical Commission (PMC) under the Pakistan Medical Commission Act 2020 — issues ethical guidelines for registered medical practitioners in Pakistan regarding patient autonomy, informed consent, and end-of-life care. The PMC's Code of Ethics requires doctors to respect patients' previously expressed wishes regarding treatment, to the extent consistent with medical ethics, Islamic principles, and Pakistani law. The Islamic Medical Association of Pakistan (IMAP) and the Islamic Fiqh Academy have addressed issues of end-of-life care from an Islamic jurisprudence (Fiqh) perspective, with particular guidance on the distinction between actively ending life (which is prohibited) and withdrawing futile treatment (which may be permissible under certain interpretations).

The Islamic perspective on end-of-life care is central to any living will in Pakistan, where the vast majority of the population is Muslim. Muslim scholars and Islamic bioethicists generally hold that withdrawing futile life-sustaining treatment from a terminally ill patient who has no reasonable prospect of recovery may be permissible under the principle of la darar (no harm) and the prohibition on excessive medical intervention. However, active euthanasia — intentionally accelerating death — remains prohibited under Islamic law and under Section 302 of the Pakistan Penal Code 1860 (PPC), which makes culpable homicide amounting to murder a capital offence. A Living Will in Pakistan must therefore be carefully worded to address treatment preferences (withholding or withdrawing futile treatment) rather than requesting active intervention to end life.

The designation of a healthcare proxy (also called a healthcare agent or medical power of attorney) in a Living Will is an important aspect of advance healthcare planning in Pakistan. The healthcare proxy is authorised to make medical decisions on behalf of the incapacitated person in accordance with the wishes expressed in the Living Will and the proxy's knowledge of the person's values and preferences. The healthcare proxy's authority derives from a Power of Attorney — specifically a healthcare or medical power of attorney — executed under the general law of agency in the Contract Act 1872. Where no healthcare proxy is designated, medical decisions for incapacitated patients in Pakistani hospitals are typically made by the closest available family member (spouse, adult child, or parent) in consultation with the treating physician.

A Living Will and Advance Healthcare Directive in Pakistan is needed by any adult who wishes to document their healthcare preferences and confirm that their wishes are respected if they become unable to communicate or make decisions in the future.

A Living Will is needed when a person is diagnosed with a serious, progressive, or terminal illness — such as cancer, advanced heart disease, chronic kidney disease requiring dialysis, amyotrophic lateral sclerosis (ALS), or advanced dementia — and wishes to record their preferences about specific treatments, resuscitation, mechanical ventilation, and palliative care while they are still capable of making and expressing decisions. Hospitals affiliated with the Pakistan Medical Association (PMA) and major teaching hospitals in Lahore, Karachi, and Islamabad increasingly recognise advance directives in their patient management protocols.

A Living Will is needed when a person is planning for major surgery or a high-risk medical procedure and wishes to record their wishes regarding post-operative care, including preferences regarding mechanical ventilation, CPR, and aggressive treatment in case of surgical complications that leave them incapacitated. Submitting a Living Will to the hospital before elective surgery confirms that the surgical team and anaesthesiologist are aware of the patient's preferences.

A Living Will is needed when an elderly person wishes to address end-of-life care preferences before cognitive decline — such as Alzheimer's disease or vascular dementia — affects their capacity to make decisions. The Living Will records the person's wishes while they retain full legal capacity, providing guidance to family members, healthcare proxies, and medical teams when the person can no longer speak for themselves.

A Living Will is needed when family members disagree about medical treatment decisions for an incapacitated relative, creating conflict in hospitals and distress for the patient. A previously executed Living Will that clearly records the patient's own wishes helps resolve family disagreements by providing a documented record of the patient's autonomous choices, reducing the burden on family members who might otherwise have to make agonising decisions without guidance.

A Living Will is needed when a person appoints a healthcare proxy — an adult they trust to make medical decisions on their behalf — and wishes to give that proxy clear written instructions about their treatment preferences, values, and the circumstances in which specific treatments should or should not be pursued. The healthcare proxy should receive a signed copy of the Living Will and be familiar with its contents before any medical crisis arises.

A valid and effective Living Will and Advance Healthcare Directive in Pakistan under the general principles of the Contract Act 1872 and the PMC Code of Ethics must contain the following essential elements.

Declarant's Identity and Capacity: The Living Will must state the full name, CNIC number, date of birth, and address of the declarant. It must include a declaration that the declarant is an adult (18 years or over under the Majority Act 1875), of sound mind, and acting voluntarily without coercion or undue influence under the Contract Act 1872. The declaration should be made before the declarant develops any condition that could affect their legal capacity.

Statement of Values and Beliefs: A Living Will in Pakistan should begin with a statement of the declarant's personal, religious, and ethical values — including their religious beliefs (Muslim, Christian, Hindu, etc.) and how these beliefs inform their views on medical treatment, suffering, and death. For Muslim declarants, a reference to Islamic principles of medical ethics and the guidance of Islamic scholars on end-of-life care (including fatawa from the Federal Shariat Court or established Islamic scholars) is appropriate.

Specific Treatment Instructions — CPR: The declarant should state their preference regarding cardiopulmonary resuscitation (CPR) — whether they wish CPR to be attempted in the event of cardiac or respiratory arrest, or whether they prefer a Do Not Resuscitate (DNR) order to be entered in their medical records. The declarant should understand that CPR is often unsuccessful in patients with advanced illness and may cause distress.

Specific Treatment Instructions — Mechanical Ventilation: The declarant should state their preference regarding mechanical ventilation (breathing machines) — whether they consent to a trial period of ventilation, whether ventilation should be continued indefinitely if they cannot breathe independently, or whether they prefer ventilation to be withdrawn if they have no reasonable prospect of recovery. This is a particularly important instruction for patients in Pakistani intensive care units (ICUs).

Specific Treatment Instructions — Artificial Nutrition and Hydration: The declarant should state whether they consent to artificial nutrition (feeding through a nasogastric tube or PEG tube) and artificial hydration (intravenous fluids) if they cannot eat or drink independently. Many terminally ill patients in Pakistan are maintained on artificial nutrition for extended periods — the Living Will gives the declarant the opportunity to express whether this is consistent with their wishes.

Palliative Care and Pain Management: The declarant should state their preference for palliative care — comfort-focused care aimed at managing pain and symptoms rather than curing the underlying disease. The declarant may instruct that adequate pain relief is provided even if high doses of medication are required, consistent with palliative care principles endorsed by the World Health Organization (WHO) and the Pakistan Palliative Care Society.

Healthcare Proxy Designation: The Living Will should designate a named adult as the declarant's healthcare proxy (medical attorney) with authority to make medical decisions on the declarant's behalf consistent with the instructions in the Living Will. The proxy's full name, CNIC number, relationship to the declarant, and contact details must be stated. An alternate proxy should also be designated in case the primary proxy is unavailable or unwilling to act.

Witnesses and Attestation: The Living Will must be signed by the declarant in the presence of two adult witnesses who are not family members and who are not healthcare providers of the declarant. Witnesses confirm that the declarant signed voluntarily and appeared to be of sound mind. Attestation by a Notary Public under the Notaries Ordinance 1961 or an Oath Commissioner is recommended to strengthen the document's authenticity.

Distribution: The declarant should provide copies of the Living Will to their healthcare proxy, their primary physician (registered with the PMC), and the hospital where they receive treatment. Forms-legal.com provides this Living Will (Pakistan) template as a practical guide. Declarants should discuss their wishes with their physician and with a scholar of Islamic jurisprudence (for Muslim declarants) before executing this document.

Under the Succession Act 1925, the High Courts of Pakistan have jurisdiction over probate and administration. The Powers of Attorney Act 1882 governs appointment of attorneys. For Muslims, Islamic inheritance law (Faraid) applies — sons receive double the share of daughters. The Waqf Properties Ordinance 1979 governs Islamic endowments. The Trusts Act 1882 governs creation and administration of private trusts.