end-of-life care. canada health canada – canada's federal health agency – has acknowledged the need for a greater investment in palliative and hospice care as the country faces a rapidly growing population of elderly and terminally ill citizens. much of the current focus in canada is on advance care planning which involves encouraging individuals to reflect on and express their wishes for future care, including end-of-life care, before they become terminally ill or incapable of making decisions for themselves. a number of publicly funded initiatives exist to promote advance care planning and to encourage people to appoint "substitute decision makers" who make medical decisions and can give or withhold consent for medical procedures according to the patient's pre-expressed wishes when the patient becomes incapable of doing so themselves in 2008, the advance care planning in canada: a national framework and implementation project was founded. the goal was to engage healthcare professionals and educate patients about the importance of advance care planning and end of life care. polling indicates that 96% of canadians think that having a conversation with a loved one about planning for the end of life is important. however, the same polls show that only about 13% have actually done so, or have created an advance care plan for themselves. a 2014 ipsos reid survey reveals that only about a third of canadian doctors and nurses working in primary care feel comfortable discussing end of life issues with their patients. end-of-life issues in canada have recently been highlighted due to the ongoing related debate about physician-assisted death in canada. former federal health minister rona ambrose (july 15, 2013 to november 4, 2015) has stated: "i think the starting point for me is that we still don't have the best elderly care and palliative care yet… so let's talk about making sure we have the best end-of-life care before we start talking about assisted suicide and euthanasia." european union country reports on advance directives is a 2008 paper summarizing advance health care legislation on each country in the european union with a shorter summary for the u.s.; a 2009 paper also provides a european overview. england and wales in england and wales, people may make an advance directive or appoint a proxy under the mental capacity act 2005. this is only for an advance refusal of treatment for when the person lacks mental capacity; to be legally binding, the advance decision must be specific about the treatment that is being refused and the circumstances in which the refusal will apply. to be valid, the person must have been competent and understood the decision when they signed the directive. where the patient's advance decision relates to a refusal of life-prolonging treatment this must be recorded in writing and witnessed. any advance refusal is legally binding providing that the patient is an adult, the patient was competent and properly informed when reaching the decision, it is clearly applicable to the present circumstances and there is no reason to believe that the patient has changed their mind. if an advance decision does not meet these criteria but appears to set out a clear indication of the patient's wishes, it will not be legally binding but should be taken into consideration in determining the patient's best interests. in june 2010, the wealth management solicitors, moore blatch, announced that research showed demand for living wills had trebled in the two years previous, indicating the rising level of people concerned about the way in which their terminal illness will be managed. according to the british government, every adult with mental capacity has the right to agree to or refuse medical treatment. to make their advance wishes clear, people can use a living will, which can include general statements about wishes, which are not legally binding, and specific refusals of treatment called "advance decisions" or "advance directives". germany on 18 june 2009 the bundestag passed a law on advance directives, applicable since 1 september 2009. such law, based on the principle of the right of self-determination, provides for the assistance of a fiduciary and of the physician. italy on 14 december 2017, italian senate officially approved a law on advance healthcare directive that came into force on 31 january 2018. controversy over end-of-life care emerged in italy in 2006, when a terminally ill patient suffering from muscular dystrophy, piergiorgio welby, petitioned the courts for removal of his respirator. debated in parliament, no decision was reached. a doctor eventually honored welby's wishes by removing the respirator under sedation. the physician was initially charged for violating italy's laws against euthanasia, but was later cleared. further debate ensued after the father of a 38-year-old woman, eluana englaro, petitioned the courts for permission to withdraw feeding tubes to allow her to die. englaro had been in a coma for 17 years, following a car accident. after petitioning the courts for 10 years, authorization was granted and englaro died in february 2009. in may 2008, apparently as a result of the recent court of cassation's holding in the case of englaro, a guardianship judge in modena, italy used relatively new legislation to work around the lack of the advance directive legislation. the new law permitted a judicially appointed guardian ("amministratore di sostegno") to make decisions for an individual. faced with a 70-year-old woman with end-stage lou gehrig's disease who was petitioning the court (with the support of her family) to prevent any later use of a respirator, the judge appointed her husband as guardian with the specific duty to refuse any tracheotomy and/or respirator use if/when the patient became unable to refuse such treatment herself. the netherlands in the netherlands, patients and potential patients can specify the circumstances under which they would want euthanasia for themselves. they do this by providing a written euthanasia directive. this helps establish the previously expressed wish of the patient even if the patient is no longer able to communicate. however, it is only one of the factors that is taken into account. apart from the will in writing of the patients, at least two physicians, the second being totally unrelated to the first physician in a professional matter (e.g. working in another hospital, no prior knowledge of the medical case at hand), have to agree that the patient is terminally ill and that no hope for recovery exists. japan advance healthcare directives are not legally recognized in japan. according to a 2017 survey by the ministry of health, labor and welfare (mhlw), 66% of surveyed individuals supported the idea of such directives, but only 8.1% had prepared their own. the private organization nihon songenshi kyōkai (japan society for dying with dignity) offers members a semi-standardized "living will" (ribingu uiru) form that is registered with the organization, though it holds no legal weight. israel in 2005, the knesset passed a law allowing people to write advanced care directives. right to refuse care is only recognized if the patient is considered terminally ill and their life expectancy is less than six months. switzerland in switzerland, there are several organizations which take care of registering patient decrees, forms which are signed by the patients declaring that in case of permanent loss of judgement (e.g., inability to communicate or severe brain damage) all means of prolonging life shall be stopped. family members and these organizations also keep proxies which entitle their holder to enforce such patient decrees. establishing such decrees is relatively uncomplicated. in 2013 a law concerning advanced healthcare directives has been voted. every adult with testamentary capacity can redact a legal binding document declaring a will in the event of loss of judgement. they may also designate a natural person to discuss medical procedures with the attending doctor and make decisions on their behalf if they are longer capable of judgment. united states aggressive medical intervention leaves nearly two million americans confined to nursing homes, and over 1.4 million americans remain so medically frail as to survive only through the use of feeding tubes. of u.s. deaths, about a third occur in health care facilities. as many as 30,000 persons are kept alive in comatose and permanently vegetative states. cost burdens to individuals and families are considerable. a national study found that: "in 20% of cases, a family member had to quit work", 31% lost "all or most savings" (even though 96% had insurance), and "20% reported loss of major source of income". yet, studies indicate that 70-95% of people would rather refuse aggressive medical treatment than have their lives medically prolonged in incompetent or other poor prognosis states. as more and more americans experienced the burdens and diminishing benefits of invasive and aggressive medical treatment in poor prognosis states – either directly (themselves) or through a loved one – pressure began to mount to devise ways to avoid the suffering and costs associated with treatments one did not want in personally untenable situations. the first formal response was the living will. in the united states, all states recognize some form of living wills or the designation of a health care proxy. the term living will is not officially recognized under california law, but an advance health care directive or durable power of attorney may be used for the same purpose as a living will. in pennsylvania on november 30, 2006, governor edward rendell signed into law act 169, that provides a comprehensive statutory framework governing advance health care directives and health care decision-making for incompetent patients. as a result, health care organizations make available a "combined living will & health care power of attorney example form from pennsylvania act 169 of 2006." several states offer living will "registries" where citizens can file their living will so that they are more easily and readily accessible by doctors and other health care providers. however, in recent years some of these registries, such as the one run by the washington state department of health, have been shuttered by the state government because of low enrollment, lack of funds, or both. on july 28, 2009, barack obama became the first united states president to announce publicly that he had a living will, and to encourage others to do the same. he told an aarp town meeting, "so i actually think it's a good idea to have a living will. i'd encourage everybody to get one. i have one; michelle has one. and we hope we don't have to use it for a long time, but i think it's something that is sensible." the announcement followed controversy surrounding proposed health care legislation that included language that would permit the payment of doctors under medicare to counsel patients regarding living wills, sometimes referred to as the "infamous" page 425. shortly afterwards, bioethicist jacob appel issued a call to make living wills mandatory. india supreme court of india on march 9, 2018, permitted living wills and withholding and withdrawing life sustaining treatments. the country's apex court held that the right to a dignified life extends up to the point of having a dignified death.