Portugal's Living Will Gap: Why Nearly All Citizens Lack End-of-Life Legal Protection

Portugal's National Ethics Council has issued a stark warning about advance healthcare directives: fewer than 45,247 active living wills were registered by the end of 2025—representing less than 0.5% of the entire population. This negligible uptake leaves the overwhelming majority of Portuguese citizens without legal protection for medical decisions should they become incapacitated, a situation the ethics council calls both preventable and urgent.

Why This Matters:

• Your medical autonomy is unprotected: Without a living will registered in the RENTEV national system, doctors and family members—not you—will decide your end-of-life care if you become unable to communicate.

• Bureaucratic barriers persist: Most Portuguese hospitals lack an on-site RENTEV counter, making it nearly impossible to register directives while hospitalized.

• The form is deliberately confusing: The current registration document mixes negative and positive phrasing in ways that can trick applicants into selecting the opposite of their intentions.

• Only 22% of Portuguese adults recognize what a living will is, according to national surveys, and among those, barely half understand how to complete one.

The Scale of the Problem

Among Portugal's population of roughly 10 M people, the 45,247 registered directives translate to a participation rate that lags dramatically behind European peers. Most subscribers fall between 50 and 80 years old, suggesting younger residents remain entirely disengaged from advance care planning. The Conselho Nacional de Ética para as Ciências da Vida (CNECV), chaired by Maria do Céu Patrão Neves, released its position statement on February 23, 2026, calling the situation both preventable and urgent.

The living will—testamento vital in Portuguese—is a legally binding document that instructs healthcare teams whether to pursue life-prolonging interventions, resuscitation, or palliative-only care when a patient can no longer speak for themselves. It also allows the designation of a healthcare proxy. While the framework has existed since the Law 25/2012 was enacted and RENTEV went live in July 2014, uptake remains anemic more than a decade later.

What's Blocking Adoption?

The CNECV acknowledged it lacks definitive research into why Portuguese residents avoid the system but pointed to three structural barriers: widespread ignorance of the directive's existence, procedural friction, and a poorly designed registration form. National polling data supports this assessment—only 22% of Portuguese adults recognize what a living will is, and among those, barely half understand how to complete one.

Cultural factors also influence the issue. The CNECV noted in its February 2026 statement that awareness remains limited and that residents often defer advance care planning until crisis moments, if they consider it at all. The absence of mandatory medical counseling during registration raises informed-consent concerns.

The RENTEV form itself is a documented obstacle. The ethics council's report criticized its inconsistent linguistic patterns, noting that the document alternates between affirmative and negative constructions within the same section, creating scenarios where users may inadvertently authorize treatments they wish to refuse—or vice versa. This lack of clarity compounds adoption barriers.

Hospital Access Remains a Fiction

One of the most damning revelations in the CNECV statement is that most Portuguese hospitals do not operate a RENTEV service desk. While the directive is supposed to be accessible during moments of acute care—precisely when patients confront life-altering medical decisions—the infrastructure does not exist to facilitate registration in clinical settings. RENTEV counters are scattered across primary care health centers (centros de saúde) and select local health units (Unidades Locais de Saúde), but hospitalized patients have little recourse unless they already registered before admission.

The bureaucratic path is equally cumbersome. To register, a resident must either appear in person at a RENTEV counter—many of which require prior appointment—or mail a notarized document via registered post. Though the registry itself is free, the practical barriers and time investment deter participation, especially among older or mobility-limited individuals who would benefit most.

What the Ethics Council Wants Fixed

The CNECV's February 2026 position paper delivered six core recommendations, targeting both systemic infrastructure and user experience:

Simplify the RENTEV form immediately: The council called for a complete rewrite to impose uniform phrasing, eliminate ambiguous double negatives, and improve readability for non-specialist users.

Embed directive information in hospital intake protocols: All admissions packets, discharge instructions, and continuing-care facility welcome guides should include a plain-language explainer about living wills and healthcare proxies.

Credential at least two RENTEV-trained staff per institution: Every public and private health facility should have designated professionals with system access authorized to assist inpatients with on-the-spot registration when requested.

Enable authenticated online registration: The current system requires physical presence or notarized mail. The council urged development of a secure digital portal using Portugal's Chave Móvel Digital authentication framework to allow remote completion.

Integrate RENTEV counters into municipal health kiosks: Local government health service points (balcões de saúde autárquicos) should offer directive registration alongside vaccinations and prescription renewals, without eliminating the option for physician consultation.

Mobilize primary care physicians as educators: General practitioners and family doctors are positioned to normalize living-will conversations during routine appointments, especially with patients over 50 or those managing chronic conditions.

What This Means for Residents

If you live in Portugal and have not registered a living will, you currently have no legal mechanism to control medical interventions if you suffer a stroke, severe accident, or degenerative illness that robs you of decision-making capacity. In such scenarios, attending physicians consult with family members, but familial consensus is not guaranteed, and relatives may impose preferences that contradict your values—particularly around resuscitation, feeding tubes, or ventilator support.

The directive also allows you to appoint a procurador de cuidados de saúde—a healthcare proxy who speaks on your behalf if you cannot. Without this designation, Portuguese medical teams default to next-of-kin hierarchies, which may exclude partners in non-married relationships or prioritize relatives you are estranged from.

Living wills in Portugal are valid for five years from the date of signature and can be revoked or updated at any time. However, the renewal process requires the same cumbersome steps as initial registration, and the RENTEV system does not send automatic reminders when directives approach expiration.

Healthcare professionals can access your registered directive through the Portal do Profissional on the national health data platform, while patients can view their own documents via the SNS 24 app. But these digital integrations are meaningless if fewer than 1 in 200 residents have anything on file.

The International Context

Portugal's uptake rate sits below that of other European countries with more established advance directive frameworks. Many international healthcare systems have achieved broader engagement through institutional infrastructure and professional training, emphasizing that legislative frameworks alone are insufficient—implementation requires active professional engagement and user-friendly systems.

Practical Next Steps

If you wish to register a living will, you must either visit a RENTEV counter in person or submit a notarized form by mail. The Serviços Partilhados do Ministério da Saúde (SPMS) website maintains a list of available counters, primarily located in health centers rather than hospitals. Examples include the Unidade Local de Saúde do Alentejo Central in Évora, the Hospital José Joaquim Fernandes in Beja, and various ACES facilities in Coimbra, Sintra, and Madeira.

Appointments are recommended but not universally required; contact your nearest facility to confirm hours and documentation requirements. You will need a valid Portuguese identification card (Cartão de Cidadão) and, ideally, a clear written summary of your care preferences before arriving, as on-site counseling is inconsistent.

For those unable to travel, notarizing your signature and mailing the completed form to any RENTEV counter is the alternative, though this involves notary services at additional cost. The CNECV has urged the government to enable digital authentication as an alternative to notarization, but no legislative timeline exists yet.

The Institutional Accountability Gap

The CNECV, an independent advisory body operating under the Assembleia da República since 2009, does not have enforcement authority. Its recommendations are non-binding, meaning the Ministry of Health and SPMS can choose whether and when to act on the proposed reforms. The council was established in 1990 to address ethical dilemmas arising from advances in biology, medicine, and life sciences, and this living-will audit represents one of its most direct critiques of administrative barriers.

The lack of urgency is puzzling given Portugal's aging demographic profile. By 2030, nearly 30% of the population will be over 65, and the demand for end-of-life care planning will intensify. Without streamlined directive infrastructure, hospitals will face recurring ethical conflicts, and families will endure preventable legal disputes over incompetent patients' treatment wishes.

The ethics council's statement appealed to professional duty and systemic efficiency rather than recommending penalties for non-compliance or mandatory directive discussions. Whether that approach will yield measurable improvement remains uncertain, but the 0.5% baseline leaves considerable room for progress—or continued neglect.