(2) israelmost, halforal+notes,(2) notes japanmost, halforal, notes lebanonmostoral+notes+electronic malaysiararelynotes maltamostnotes new zealandalwayspre-printed netherlandshalfelectronic (3) norwayalways, rarelyoral, notes+electronic pakistanalwaysnotes+electronic polandalways, mostoral+notes, notes+pre-printed puerto ricoalwayspre-printed saudi arabiaalways, mostpre-printed, notes+electronic, oral singaporealways, most, halfpre-printed (2), oral+notes+pre-printed, oral+notes+electronic, oral+pre-printed south africararelyoral+notes south koreaalwayspre-printed spainalways, mostpre-printed, oral+notes+electronic, oral+notes+pre-printed sri lankamostnotes swedenmostoral+notes+pre-printed+electronic switzerlandmost, halforal+notes+pre-printed, oral+notes+other taiwanhalf, rarelynotes+pre-printed+other, oral uaehalforal+notes ugandaalwaysnotes, usaalways, mostnotes, electronic, oral+electronic, oral+notes+electronic, oral+notes+pre-printed+electronic australia in australia, do not resuscitate orders are covered by legislation on a state-by-state basis. in victoria, a refusal of medical treatment certificate is a legal means to refuse medical treatments of current medical conditions. it does not apply to palliative care (reasonable pain relief; food and drink). an advanced care directive legally defines the medical treatments that a person may choose to receive (or not to receive) in various defined circumstances. it can be used to refuse resuscitation, so as avoid needless suffering. in nsw, a resuscitation plan is a medically authorised order to use or withhold resuscitation measures, and which documents other aspects of treatment relevant at end of life. such plans are only valid for patients of a doctor who is a nsw health staff member. the plan allows for the refusal of any and all life-sustaining treatments, the advance refusal for a time of future incapacity, and the decision to move to purely palliative care. brazil there is no formally recognized protocol for creating and respecting dnr orders in brazil's healthcare delivery system. the legality of not administering resuscitation procedures for terminally ill patients has not been clearly defined, leading many providers to practice caution around withholding cpr. although dnr orders have not been institutionalized in brazil there has been a significant amount of dialogue around the ethical question of whether or not to withhold resuscitation interventions. in the past two decades the federal medical board of brazil published two resolutions, cfm 1.805/2006 and cfm 1.995/2012, which address therapeutic limitations in terminally ill patients as well as advanced directives. a recent study also showed that in brazil's healthcare system cpr is being withheld in scenarios of terminal illness or multiple comorbidities at rates similar to those in north america. canada do not resuscitate orders are similar to those used in the united states. in 1995, the canadian medical association, canadian hospital association, canadian nursing association, and catholic health association of canada worked with the canadian bar association to clarify and create a joint statement on resuscitative interventions guideline for use to determine when and how dnr orders are assigned. dnr orders must be discussed by doctors with the patient or patient agents or patient's significant others. unilateral dnr by medical professionals can only be used if the patient is in a vegetative state. france in 2005, france implemented its "patients' rights and end of life care" act. this act allows the withholding/withdrawal of life support treatment and as well as the intensified usage of certain medications that can quicken the action of death. this act also specifies the requirements of the act. the "patients' rights and end of life care" act includes three main measures. first, it prohibits the continuation of futile medical treatments. secondly, it empowers the right to palliative care that may also include the intensification of the doses of certain medications that can result in the shortening the patient's life span. lastly, it strengthens the principle of patient autonomy. if the patient is unable to make a decision, the discussion, thus, goes to a trusted third party. hong kong starting in 2000, the medical council of hong kong has taken the position that advance directives should be recognized. a law reform commission consultation from 2004 to 2006 resulted in a recommendation that legislation be passed in support of advance directives. however, as of 2019 no consensus had been reached on legislation. the hong kong hospital authority has adopted a set of forms which its doctors will recognize if properly completed. however, their recognition at private hospitals is less clear. israel in israel, it is possible to sign a dnr form as long as the patient is at least 17 years of age, dying, and aware of their actions. italy in italy dnr is included in the italian law no. 219 of december 22, 2017 "disposizioni anticipate di trattamento" or dat, also called "biotestamento". the law no.219 "rules on informed consent and advance treatment provisions", reaffirm the freedom of choice of the individual and make concrete the right to health protection, respecting the dignity of the person and the quality of life. the dat are the provisions that every person of age and capable of understanding and wanting can express regarding the acceptance or rejection of certain diagnostic tests or therapeutic choices and individual health treatments, in anticipation of a possible future inability to self-determine. to be valid, the dats must have been drawn up only after the person has acquired adequate medical information on the consequences of the choices he intends to make through the dat. with the entry into force of law 219/2017, every person of age and capable of understanding and willing can draw up his dat. furthermore, the dats must be drawn up with: public act authenticated private writing simple private deed delivered personally to the registry office of the municipality of residence or to the health structures of the regions that have regulated the dat due to particular physical conditions of disability, the dat can be expressed through video recording or with devices that allow the person with disabilities to communicate. the dats do not expire. they can be renewed, modified or revoked at any time, with the same forms in which they can be drawn up. with the dat it is also possible to appoint a trustee, as long as he is of age and capable of understanding and willing, who is called to represent the signatory of the dat who has become incapable in relations with the doctor and health facilities. with the decree of 22 march 2018, the ministry of health established a national database for the registration of advance treatment provisions. without the expression of any preference by the patient, physicians must attempt to resuscitate all patients regardless of familial wishes. japan in japan, dnr orders are known as do not attempt resuscitation (dnar). currently, there are no laws or guidelines in place regarding dnar orders but they are still routinely used. a request to withdraw from life support can be completed by the patient or a surrogate. in addition, it is common for japanese doctors and nurses to be involved in the decision-making process for the dnar form. jordan dnrs are not recognized by jordan. physicians attempt to resuscitate all patients regardless of individual or familial wishes. nigeria there is no formally accepted protocol for dnrs in nigeria's healthcare delivery system. written wills may act as a good guide in many end of life scenarios, but often physicians and/or patients' families will act as the decision makers. as quoted in a 2016 article on advanced directives in nigeria, "…everything derives from communal values, the common good, the social goals, traditional practices, cooperative virtues and social relationship. individuals do not exist in a vacuum but within a web of social and cultural relationships." it is important to note that there are vast cultural differences and perspectives on end of life within nigeria itself between regions and communities of different ancestry. saudi arabia in saudi arabia patients cannot legally sign a dnr, but a dnr can be accepted by order of the primary physician in case of terminally ill patients. taiwan in taiwan, patients sign their own dnr orders, and are required to do so to receive hospice care. however, one study looking at insights into chinese perspectives on dnr showed that the majority of dnr orders in taiwan were signed by surrogates. typically doctors discuss the issue of dnr with the patients family rather than the patient themselves. in taiwan, there are two separate types of dnr forms: dnr-p which the patient themselves sign and dnr-s in which a designated surrogate can sign. typically, the time period between signing the dnr and death is very short, showing that signing a dnr in taiwan is typically delayed. two witnesses must also be present in order for a dnr to be signed. dnr orders have been legal in taiwan since june 2000 and were enacted by the hospice and palliative regulation. also included in the hospice and palliative regulation is the requirement to inform a patient of their terminal condition, however, the requirement is not explicitly defined leading to interpretation of exact truth telling. united arab emirates the uae have laws forcing healthcare staff to resuscitate a patient even if the patient has a dnr or does not wish to live. there are penalties for breaching the laws. united kingdom dnacpr form as used in scotland england in england, cpr is presumed in the event of a cardiac arrest unless a do not resuscitate order is in place. if they have capacity as defined under the mental capacity act 2005 the patient may decline resuscitation. patients may also specify their wishes and/or devolve their decision-making to a proxy using an advance directive, which are commonly referred to as 'living wills', or an emergency care and treatment plan (ectp), such as respect. discussion between patient and doctor is integral to decisions made in advance directives and ectps, where resuscitation recommendations should be made within a more holistic consideration of all treatment options. patients and relatives cannot demand treatment (including cpr) which the doctor believes is futile and in this situation, it is their doctor's duty to act in their 'best interest', whether that means continuing or discontinuing treatment, using their clinical judgment. if the patient lacks capacity, relatives will often be asked for their opinion in order to form a 'best interest' view of what the individual's views would have been (prior to losing capacity). evaluation of respect (an ectp) found that resuscitation status remained a central component of conversations, and that there was variability in the discussion of other emergency treatments. in 2020 the care quality commission found that residents of care homes had been given inappropriate orders of do not attempt cardiopulmonary resuscitation (dnacpr) without notice to residents or their families, causing avoidable deaths. in 2021, the mencap charity found that people with learning disabilities also had inappropriate dnacpr orders. medical providers have said that any discussion with patients and families is not in reference to consent to resuscitation and instead should be an explanation. the uk's regulatory body for doctors, the general medical council, provides clear guidance on the implementation and discussion of dnacpr decisions, and the obligation to communicate these decisions effectively was established by legal precedent in 2015. scotland in scotland, the terminology used is "do not attempt cardiopulmonary resuscitation" or "dnacpr". there is a single policy used across all of nhs scotland. the legal standing is similar to that in england and wales, in that cpr is viewed as a treatment and, although there is a general presumption that cpr will be performed in the case of cardiac arrest, this is not the case if it is viewed by the treating clinician to be futile. patients and families cannot demand cpr to be performed if it is felt to be futile (as with any medical treatment) and a dnacpr can be issued despite disagreement, although it is good practice to involve all parties in the discussion. as in england and wales, inappropriate orders have been given to individuals who had no medical reason for them, such as a deaf man who received a dnacpr order in 2021 due to "communication difficulties." wales wales has its own national dnacpr policy, 'sharing and involving'. they use the term 'do not attempt cardiopulmonary resuscitation' or 'dnacpr'. they also have an active public information campaigns, which includes the website 'talkcpr' united states in the united states the documentation is especially complicated in that each state accepts different forms, and advance directives also known as living wills may not be accepted by ems as legally valid forms. if a patient has a living will that specifies the patient requests dnr but does not have a properly filled out state-sponsored form that is co-signed by a physician, ems may attempt resuscitation. the dnr decision by patients